Low-back pain

Acute effect of dry needling on trunk kinematics and balance of patients with non-specific low back pain

BACKGROUND

Limited knowledge exists about the effectiveness of dry needling (DN) concerning the torso kinematics in patients with non-specific low back pain (NS-LBP). Acute effects of DN in NS-LBP patients from a functional perspective were investigated.

METHODS

Sixteen NS-LBP patients and 11 healthy individuals (HG) were examined. NS-LBP patients received a single session of DN at the lumbar region. Baseline and immediate post-treatment measurements during flexion-extension and lateral bending of the trunk were conducted for the NS-LBP patients. HG were measured only at baseline to be used as a reference of NS-LBP patients' initial condition. Algometry was applied in NS-LBP patients. Centre of pressure, range of motion of the trunk and its' derivatives were obtained.

FINDINGS

HG performed significantly faster, smoother and with greater mobility in the performed tasks compared to the pre intervention measurements of the NS-LBP patients. For the NS-LBP patients, significant greater angular velocity in frontal plane and significant lower jerk in the sagittal plane were demonstrated post intervention. DN alleviated pain tolerance significantly at the L5 level. Regarding the effectiveness of the DN upon spine kinematics, their derivatives were more sensitive.

INTERPRETATION

It appeared that the pathological type of torso movement was acutely affected by DN. NS-LBP patients showcased smoother movement immediately after the intervention and better control as imprinted in the higher derivative of motion although range of motion did not improve. This quantitative variable may not be subjected to acute effects of DN but rather need additional time and training to be improved.

The Pace of Biological Aging Predicts Nonspecific Chronic Low Back Pain Severity

This study aimed to determine if and how the pace of biological aging was associated with nonspecific chronic low back pain (cLBP) and compare what measure of epigenetic age acceleration most strongly predicts cLBP outcomes. We used the Dunedin Pace of Aging from the Epigenome (DunedinPACE), Horvath's, Hannum's, and PhenoAge clocks to determine the pace of biological aging in 69 cLBP, and 49 pain-free controls (PFCs) adults, ages 18 to 85 years. On average, participants with cLBP had higher DunedinPACE (P < .001) but lower Horvath (P = .04) and Hannum (P = .02) accelerated epigenetic age than PFCs. There was no significant difference in PhenoAge acceleration between the cLBP and PFC groups (P = .97). DunedinPACE had the largest effect size (Cohen's d = .78) on group differences. In univariate regressions, a unit increase in DunedinPACE score was associated with 265.98 times higher odds of cLBP than the PFC group (P < .001). After controlling for sex, race, and body mass index (BMI), the odds ratio of cLBP to PFC group was 149.62 (P < .001). Furthermore, among participants with cLBP, DunedinPACE scores positively correlated with pain severity (rs = .385, P = .001) and interference (rs = .338, P = .005). Epigenetic age acceleration from Horvath, Hannum, and PhenoAge clocks were not significant predictors of cLBP. The odds of a faster pace of biological aging are higher among adults with cLBP, and this was associated with greater pain severity and disability. Future interventions to slow the pace of biological aging may improve cLBP outcomes. PERSPECTIVE: Accelerated epigenetic aging is common among adults with nonspecific cLBP. Higher DunedinPACE scores positively correlate with pain severity and interference, and better predict cLBP than other DNA methylation clocks. Interventions to slow the pace of biological aging may be viable targets for improving pain outcomes.

Notochordal cells: A potential therapeutic option for intervertebral disc degeneration

Intervertebral disc degeneration (IDD) is a prevalent musculoskeletal degenerative disorder worldwide, and ~40% of chronic low back pain cases are associated with IDD. Although the pathogenesis of IDD remains unclear, the reduction in nucleus pulposus cells (NPCs) and degradation of the extracellular matrix (ECM) are critical factors contributing to IDD. Notochordal cells (NCs), derived from the notochord, which rapidly degrades after birth and is eventually replaced by NPCs, play a crucial role in maintaining ECM homeostasis and preventing NPCs apoptosis. Current treatments for IDD only provide symptomatic relief, while lacking the ability to inhibit or reverse its progression. However, NCs and their secretions possess anti-inflammatory properties and promote NPCs proliferation, leading to ECM formation. Therefore, in recent years, NCs therapy targeting the underlying cause of IDD has emerged as a novel treatment strategy. This article provides a comprehensive review of the latest research progress on NCs for IDD, covering their biological characteristics, specific markers, possible mechanisms involved in IDD and therapeutic effects. It also highlights significant future directions in this field to facilitate further exploration of the pathogenesis of IDD and the development of new therapies based on NCs strategies.

Inhalation of Pelargonium graveolens Essential Oil Alleviates Pain and Related Anxiety and Stress in Patients with Lumbar Spinal Stenosis and Moderate to Severe Pain

Pain in lumbar spinal stenosis (LSS) patients is closely associated with psychological factors, including anxiety, stress, and depression, and is a critical determinant of patient daily functionality and overall quality of life. The present study evaluated the effects of inhalation of Pelargonium graveolens (geranium) essential oil (GEO) on pain and related psychological factors in LSS patients. Fifty-nine patients, categorized as having mild or moderate to severe pain based on pain visual analog scale (VAS) scores, were randomly assigned to inhalation of 1% GEO or placebo control (PC). No significant differences between GEO and PC were observed in patients with mild pain, whereas differences in anxiety-VAS and stress-VAS scores were observed in patients with moderate to severe pain. Anxiety-VAS and stress-VAS scores decreased significantly after GEO but not after PC inhalation. Regardless of the severity of pain, post-intervention pain-VAS scores were significantly lower in the GEO group than in the PC group. In summary, GEO reduced pain and improved anxiety and stress, particularly among patients with moderate to severe pain. These findings suggest that GEO inhalation may have potential as an adjunct therapy for improving pain management and alleviating anxiety and stress in LSS patients with insufficient responses to pharmacological pain control.

Trunk stability in fatiguing frequency-dependent lifting activities

BACKGROUND

Work-related low-back disorders (WLBDs) are one of the most frequent and costly musculoskeletal conditions. It has been showed that WLBDs may occur when intervertebral or torso equilibrium is altered by a biomechanical perturbations or neuromuscular control error. The capacity to react to such disturbances is heavily determined by the spinal stability, provided by active and passive tissues and controlled by the central nervous system.

RESEARCH QUESTION

This study aims to investigate trunk stability through the Lyapunov's maximum exponent during repetitive liftings in relation to risk level, as well as to evaluate its ability to discriminate these risk levels.

METHODS

Fifteen healthy volunteers performed fatiguing lifting tasks at three different frequencies corresponding to low, medium, and high risk levels according to the National Institute for Occupational Safety and Health (NIOSH) equation. We investigated changes in spinal stability during fatiguing lifting tasks at different risk levels using the maximum Lyapunov's index (λ_Max) computed from trunk accelerations recorded by placing three IMUs at pelvis, lower and upper spine levels. A two-way repeated-measures ANOVA was performed to determine if there was any significant effect on λ_Max among the three risk levels and the time (start, mid, and end of the task). Additionally, we examined the Pearson's correlation of λ_Max with the trunk muscle co-activation, computed from trunk sEMG.

RESULTS

Our findings show an increase in trunk stability with increasing risk level and as the lifting task progressed over time. A negative correlation between λ_Max and trunk co-activation was observed which illustrates that the increase in spinal stability could be partially attributed to increased trunk muscle co-activation.

SIGNIFICANCE

This study highlights the possibility of generating stability measures from kinematic data as risk assessment features in fatiguing tasks which may prove useful to detect the risk of developing work-related low back pain disorders and allow the implementation of early ergonomic interventions.

Endoscopic Rhizotomy for Facetogenic Back Pain: A Review of the History, Financial Considerations, Patient Selection Criteria, and Clinical Outcomes

BACKGROUND

Chronic back pain (CBP) is a condition that places a considerable burden on society, with several million people affected in the United States alone. Treatment options to address this problem and relieve CBP are constantly evolving, and one of the most promising treatment modalities for CBP that is refractory to conservative treatment options is endoscopic rhizotomy (ER).

METHODS

A thorough search of the PubMed (MEDLINE) database was conducted to assess the full progression of ER from its earliest uses to present day in a historical narrative review of ER, with treatment of facetogenic pain as a model pathology.

RESULTS

ER allows for direct visualization and ablation of sensory branches of the dorsal ramus to provide pain relief in up to 80% of patients faced with refractory CBP. This technique has been built upon since the early 20th century, and the novel endoscopic approach continues to gain popularity among physicians. Benefits of ER include superior postoperative median pain-free duration compared with traditional percutaneous radiofrequency ablation, as well as direct visualization of regional anatomy. Patient selection criteria for the procedure and a modest list of contraindications allow the use of ER as a viable treatment option for a significant population of patients suffering from CBP. Potential barriers to ER include high cost of the procedure, longer intraoperative time, and expensive proprietary equipment.

CONCLUSIONS

ER is an effective treatment for refractory CBP with notable advantages. As the technology and popularity of this procedure progress, improvements in the cost, training, and intraoperative time may make it a favorable alternative to the current standard of care.

A Review on Treatment Approaches for Chronic Low Back Pain via Mulligans Movement With Mobilization and Physical Therapy

Low back pain is a leading cause of functional disability. Low back pain is a problem that every one of all age groups faces and there are various methods used to correct low back pain. Manual therapy is a specialized area in physiotherapy which manages neuromuscular pain. Manual therapy techniques include the Maitland mobilization technique, Kaltenborn mobilization technique, Mulligan technique, Active release technique, and many more. Manual therapy mainly works on arthrokinematics and osteokinematics of the joint. It is one of the main strategies used to manage low back pain. Low back pain can be because by spinal dysfunction, Sacroiliac dysfunction, muscle pathology, or any ligamentous strain. The cause of the low back pain should be identified and treated accordingly. Articles using keywords - chronic low back pain, Mulligan, and non-specific low back pain were searched on the database of Pubmed and Scopus a total of 30 articles from the timeframe of 2011 to 2021 were included in the study. From this review, we can conclude that Mulligan mobilization with movement is an effective way to reduce low back pain. Further studies need to be conducted to check the effectiveness of manual therapy techniques in chronic low back pain.

Effectiveness of Negative Pulsed-Pressure Myofascial Vacuum Therapy and Therapeutic Exercise in Chronic Non-Specific Low Back Pain: A Single-Blind Randomized Controlled Trial

Non-specific low back pain is defined as pain located in the lumbar region; this condition is the most frequent musculoskeletal disorder. Negative pulsed-pressure myofascial vacuum therapy (vacuum treatment (VT)) devices mobilize tissue according to previously programmed parameters of force, time and frequency. The purpose of this study was to compare the effects of VT combined with core therapeutic exercise versus a physical therapy program (PTP) based only on core therapeutic exercise. Fifty participants with chronic non-specific low back pain were randomly assigned to two treatment groups, the VT group (n = 25) or the PTP group (n = 25). Pain, pressure-pain threshold, range of motion, functionality and quality of life were measured before treatment, at the end of treatment, and at one-month and three-month follow-ups. Both groups received 15 therapy sessions over 5 weeks. Statistically significant differences in favor of the VT group were shown in the results. In conclusion, the intervention based on myofascial vacuum therapy improved pain, mobility, pressure pain threshold, functionality and quality of life.

Lower Back Pain as an Occupational Hazard Among Ugandan Health Workers

Background: Lower back pain is a public health concern affecting 70–85% of the world's population. There is paucity of published data on the prevalence, disability and risk factors for lower back pain among health workers in Uganda.

Objective: To determine the frequency rate (note that is it implicit that frequency is a rate like incidence so including rate seems redundant here. This is bounded by zero and infinity. In contrast, prevalence is bounded by 0 and 1 and is thus a proportion not a rate) of lower back pain and its associated risks amongst health professionals in the Arua District of Uganda.

Methods: Cross-sectional descriptive study of 245 consecutive participants conducted during February-April 2020. We stratified risks as individual or work related and analyzed the data using IBM SPSS version 25. Chi-square was used to measure the significance of association between categorical variables at 95% confidence interval, regarding a p ≤ 0.05 as significant.

Results: The mean age of participants was 40.87 years ± 8.74 (SD), with female predominance (69.8%). Majority were either general nurses or midwives (64.9%) and more than half had practiced for over 6–10 years. The frequency rate of lower back pain was 39.6% (n = 97). Individual factors associated with LBP were; cigarette smoking (X² = 33.040; P ≤ 0.001), alcohol consumption (X² = 13.581; P ≤ 0.001), age (X² = 14.717; P = 0.002), and female gender (X² = 4.802; P = 0.028). The work related factors significantly associated with lower back pain were: being a nurse/midwife (X² = 9.829; P = 0.007), working in the outpatient department (X² = 49.752; P ≤ 0.001), bending (X² = 43.912; P ≤ 0.001), lifting (X² = 33.279; P < 0.001), over standing (X² = 40.096; P ≤ 0.001), being in awkward positions (X² = 15.607; P= < 0.001), and pushing patients (X² = 21.999; P ≤ 0.001).

Conclusion: The frequency rate of low back pain was high amongst health workers and its main associated individual and work related factors could have been prevented. Health workers should strike a balance between caring for their personal back-health and meeting clients' needs while manually handling patients. Ergonomic structuring, job organization, back health care courses and use of assistive equipment could reduce such occupational hazards in our low resourced settings.

The influence of low back pain on health – related quality of life and the impact of balneal treatment

Introduction. Low back pain has a direct and proportional impact on function and a general one on the quality of life. The present study aims to evaluate the functional impact of low back pain using specific self-assessment tools as indexes of appreciation and epidemiological correlations of potential risk factors involved. The conceptual model of our research is based on the importance of correlating symptoms with clinical assessment, using scales of pain, disability, quality of life, and determination of epidemiological correlations of these areas and the determined factors of the pathology. Material and method. The study group is made up of 106 cases with clinical diagnostic of low back pain, admitted from 28 September 2020 to 28 March 2021, at Balneal and Rehabilitation Sanatorium of Techirghiol. After performing anamnesis, general clinical examination, specific neuro-musculo-skeletal examination, the patients filled the surveys highlighting the impact of their low back pain on functionality and disability deriving from it. The survey included the Oswestry Disability Index, the Functional Independence Measure (FIM) instrument and the Visual analog scale (VAS) score evaluated at the moment of hospitalization and at discharge. Statistical analysis of data was carried out and correlations between variables resulting from study were highlighted. The study was conducted according to the norms of deontology and medical ethics. The authors declare no conflict of interest. Results and discussions. Lumbar pathology is common in patients who are hospitalized for a complex balneary-physical-kinetic treatment at Balneal and Rehabilitation Sanatorium of Techirghiol. About 80% of patients who have addressed to our unit in which the study was conducted, have presented low back pain. The majority of patients were females, representing 57,55% of the total number. Regarding the patients’ age, 58,5% of them were in the 50-70 years interval. The study reveals a major positive impact of our treatment on spinal symptomatology, an effect pointed out by the relevant statistical differences between the admittance and discharge VAS scores(p<0.001). Reporting the investigated disability with the Oswestry questionnaire of painful lumbar syndrome, and functional evaluation scale (FIM) demonstrates the impact of this pathology on the patient's social life, once again emphasizing the special attention to be paid to axial pathology, both as curative treatment and the importance of prophylactic treatment. Statistical analysis of identified risk factors, reveals the importance of prophylaxis and patient’s education in this area. A strong and important statistical correlation was found between the Oswestry total score and the walking and standing items, and a moderate, but strong correlation with the other items. Regarding the sex life item, the correlation is existent, but at a modest level. Conclusions. The study reveals the importance of correlation of the data obtained from anamnesis, the general clinical examination and the specific examination neuromioarthrokinetic with assessment tools that determine the level of functional independence, the functional impact on social life in high-frequency pathologies treated in medical facilities that provide healthcare in the field of medical recovery. It is necessary to quantify the therapeutic results obtained, in order to assess the level of improvement in quality of life. Keywords: low back pain, balneal, functional indicators, quality of life,

Effect of RUSI-based core stability exercise on chronic non-specific low back pain patients: study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is one of the most highly prevalent pain both in developed countries and low-income and middle-income countries. Despite increasing healthcare resources and numerous treatment methods for LBP, the efficacy of these therapeutic strategies is still uncertain. Recently, core stability exercise (CSE) is popularly applied as a preventive or rehabilitative method in the treatment of LBP. However, the adequate activation of the local muscle systems of CSE needs further optimisation and quantification. This trial aims to investigate the feasibility and efficacy of CSE monitored by real-time ultrasound image (RUSI) on LBP individuals.

METHODS AND ANALYSIS

Forty subjects with chronic non-specific LBP (CNLBP), aged from 20 to 50 years, will be randomly allocated into two groups using sealed, consecutively numbered opaque envelopes: (1) study group (SG): CSE monitored by RUSI and (2) control group (CG): identical CSE without monitoring. Interventions will last 30 mins, two times a week for 8 weeks. The primary outcomes include pain intensity, disability and quality of life, and the secondary outcomes will be the postural control static stability, onset timing of trunk muscles activation, ultrasound images of muscle thickness and surface electromyography (sEMG) signal of muscle activities. Outcome measures will be collected at baseline, 4 and 8 weeks during training, and at 6 months follow-up. Data will be collected and analysed by an assessor blinded to group allocation. Effect sizes and mixed-model repeated measures analysis of variance (2 groups×4 time points) will be calculated.

ETHICS AND DISSEMINATION

This protocol and informed consent has been approved by the Institutional Research Ethics Committee of the First Affiliated Hospital, Sun Yat-sen University (Approval number: [2020] 254-1). The findings of this study will be disseminated to participants through social networks and will be submitted to peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2000034498).

Artificial intelligence X-ray measurement technology of anatomical parameters related to lumbosacral stability

PURPOSE

To develop a deep learning-based model for measuring automatic lumbosacral anatomical parameters from lateral lumbar radiographs and compare its performance to that of attending-level radiologists.

METHODS

A total of 1791 lateral lumbar radiographs were collected through the PACS system and used to develop the deep learning-based model. Landmarks for the four used parameters, including the lumbosacral lordosis angle (LSLA), lumbosacral angle (LSA), sacral horizontal angle (SHA), and sacral inclination angle (SIA), were identified and automatically labeled by the model. At the same time, the measurement results were obtained through landmarks on the test set compared to manual measurements as the reference standard. Statistical analyses of the Percentage of Correct Key Points (PCK), intra-class correlation coefficient (ICC), Pearson correlation coefficient, mean absolute error (MAE), root mean square error (RMSE), and Bland-Altman plots were performed to evaluate the performance of the model.

RESULTS

The mean differences between the reference standard and the model for LSLA, LSA, SHA, and SIA, were 0.39°, 0.09°, 0.13°, and 0.12°, respectively. A strong correlation and consistency between the four parameters were found between the model and reference standard (ICC = 0.92-0.98, r = 0.92-0.97, MAE = 1.35-1.84, RMSE = 1.82-2.51), while with statistically significant difference for LSLA (p = 0.02).

CONCLUSIONS

The presented model revealed clinically equivalent measurements in terms of accuracy, while superior measurements were obtained in terms of cost-effectiveness, reliability, and reproducibility. The model may help clinicians improve their understanding and evaluation of lumbar diseases and LBP from a quantitative perspective in practical work. (ChiCTR2100048250).

The Determination of the Efficacy of Neural Therapy in Conservative Treatment-resistant Patients with Chronic Low Back Pain

STUDY DESIGN

A randomized clinical trial.

OBJECTIVE

The aim of this article is to determine the effectiveness of neural therapy (NT) in patients with chronic low back pain (LBP) who are resistant to medical and physical therapies.

SUMMARY OF BACKGROUND DATA

Patients with LBP generally respond well to the treatment, whereas some cases do not improve via medical and physical therapies. Although trigger point injections (TPIs) may be an effective short-term treatment in selected patients with LBP, they are not recommended in patients with chronic LBP due to a long-lasting benefit not being demonstrated.

METHODS

Fifty patients, who had inadequate functional recovery and pain relief, with chronic LBP were randomly divided into two groups: Group 1, only single TPI; Group 2, NT. NT including local-segmental treatment (intradermal injections) on the lumbosacral region, 5 M injection (intradermal injections of the projection of the pelvic organs on the suprapubic region), pelvic plexus injection, i.v. injection (2 mL) for five sessions per a week. All patients in group 2 received the same kind of intervention every seance but interference field injections (injections into umbilicus for all patients and injections into scars resulting from vaccination and surgical operations such as cesarean section, if any) were also applied at the only first seance. The Visual Analog Scale (VAS) scores for current pain during activities and Roland Morris Disability Questionnaire (RMDQ) scores for disability were recorded at baseline and 1, 3, 6 months post-injection.

RESULTS

The VAS and RMDQ scores at 3 and 6 months were significantly lower in Group 2 versus Group 1 (P < 0.05).

CONCLUSION

NT may be an alternative treatment option in patients with chronic LBP for pain relief and functional recovery in the long run.Level of Evidence: 2.

Sensorimotor and body perception assessments of nonspecific chronic low back pain: a cross-sectional study

BACKGROUND

Low back pain (LBP) is one of the most common musculoskeletal disorders, causing significant personal and social burden. Current research is focused on the processes of the central nervous system (particularly the sensorimotor system) and body perception, with a view to developing new and more efficient ways to treat chronic low back pain (CLBP). Several clinical tests have been suggested that might have the ability to detect alterations in the sensorimotor system. These include back-photo assessment (BPA), two-point discrimination (TPD), and the movement control tests (MCT). The aim of this study was to determine whether the simple clinical tests of BPA, TPD or MCT are able to discriminate between nonspecific CLBP subjects with altered body perception and healthy controls.

METHODS

A cross-sectional study was conducted. At one point in time, 30 subjects with CLBP and 30 healthy controls were investigated through using BPA, TPD and MCT on the lower back. Correlations among the main covariates and odds ratios for group differences were calculated.

RESULTS

MCT showed an odds ratio for the presence of CLBP of 1.92, with a statistically significant p-value (0.049) and 95%CI. The TPD and BPA tests were unable to determine significant differences between the groups.

CONCLUSIONS

Of the three tests investigated, MCT was found to be the only suitable assessment to discriminate between nonspecific CLBP subjects and healthy controls. The MCT can be recommended as a simple clinical tool to detect alterations in the sensorimotor system of nonspecific CLBP subjects. This could facilitate the development of tailored management strategies for this challenging LBP subgroup. However, further research is necessary to elucidate the potential of all the tests to detect alterations in the sensorimotor system of CLBP subjects.

TRIAL REGISTRATION

No trial registration was needed as the study contains no intervention. The study was approved by the Swiss Ethics Commission of Northwest and Central Switzerland (EKNZ) reference number 2015-243.

Efficacy of Core Stability in Non-Specific Chronic Low Back Pain

(1) Background: Management of chronic low back pain (cLBP) is often multidisciplinary, involving a combination of treatments, including therapeutic exercises. Core stability exercises aim to improve pain and disability in cLBP increasing spinal stability, neuromuscular control, and preventing shear force that causes injury to the lumbar spine. The purpose of this study was to review the available evidence about the effectiveness in reducing pain and improving disability of core stability exercises for non-specific cLBP. (2) Methods: We perform a systematic research on common Medline databases: PubMed, Pedro, and Cochrane Library. Search results were limited to articles written in English and published between January 2005 and November 2020.The search provided a total of 420 articles. Forty-nine articles met the inclusion criteria and 371 articles were excluded. (3) Results: Core stability provides great therapeutic effects in patients with non-specific chronic low back pain reducing pain intensity, functional disability, and improving quality of life, core muscle activation, and thickness. Evidences suggest that core stability is more effective than rest or no/minimal intervention and combination with other types of exercise for cLBP have shown grater efficacy. (4) Conclusion: Core stability could be proposed in a comprehensive approach in cLBP, the combination with other modalities of therapeutic exercise should be promoted. Patient compliance is crucial to determine the efficacy of the intervention.

The Application of Mesenchymal Stromal Cells and Their Homing Capabilities to Regenerate the Intervertebral Disc

Chronic low back pain (LBP) remains a challenging condition to treat, and especially to cure. If conservative treatment approaches fail, the current “gold standard” for intervertebral disc degeneration (IDD)-provoked back pain is spinal fusion. However, due to its invasive and destructive nature, the focus of orthopedic research related to the intervertebral disc (IVD) has shifted more towards cell-based therapeutic approaches. They aim to reduce or even reverse the degenerative cascade by mimicking the human body’s physiological healing system. The implementation of progenitor and/or stem cells and, in particular, the delivery of mesenchymal stromal cells (MSCs) has revealed significant potential to cure the degenerated/injured IVD. Over the past decade, many research groups have invested efforts to find ways to utilize these cells as efficiently and sustainably as possible. This narrative literature review presents a summary of achievements made with the application of MSCs for the regeneration of the IVD in recent years, including their preclinical and clinical applications. Moreover, this review presents state-of-the-art strategies on how the homing capabilities of MSCs can be utilized to repair damaged or degenerated IVDs, as well as their current limitations and future perspectives.

Acute Effects of a Brief Physical Exercise Intervention on Somatosensory Perception, Lumbar Strength, and Flexibility in Patients with Nonspecific Chronic Low-Back Pain

BACKGROUND

Evidence-based clinical guidelines consider physical exercise one of the best nonpharmacological interventions for low-back pain (LBP), but it is necessary to clarify the exercise-induced hypoalgesia effect of different modalities of exercise in chronic pain populations.

PURPOSE

This study focused on exploring acute changes in tactile and pressure-pain perception and lumbar strength and flexibility in patients with nonspecific chronic LBP (NSCLBP) after performing one of three 20-minute physical exercise modalities.

METHODS

A total of 81 patients with NSCLBP were pseudorandomly distributed into three groups of 20-minute physical exercise - 1) aerobic (n=21, mean age 42±9.72 years, nine men), 2) stretching (n=21, mean age 40±11.37 years, ten men), and 3) strengthening (n=20, mean age 35.80±11.56 years, ten men) - and 4) a control group (n=19, mean age 38.64±10.24 years, eight men), and completed self-reported questionnaires during the same period. Tactile and pressure-pain thresholds and isometric lumbar muscle endurance and flexibility were assessed before and after this brief exercise-based intervention.

RESULTS

All groups were comparable in terms of sociodemographic and clinical data, cardiovascular capacity, and self-reported data onphysical disability, mood, motivation, psychological response to stimulus properties of physical exercise, and physical activity enjoyment. Our analyses revealed higher tactile sensitivity (p<0.001) and pressure-pain thresholds (p<0.001) at the forefinger than other body locations. We also found lower pain sensitivity (p=0.010) and pressure pain-intensity ratings (p=0.001) and higher lumbar flexibility (p<0.001) after intervention. After calculation of absolute pre-post differences, higher tactile sensitivity was observed at the gluteus medius muscle than the erector spinal muscle only after aerobic intervention (p=0.046).

CONCLUSION

These results add some evidence about different modalities of exercise-induced hypoalgesia in NSCLBP. However, the fact that we also found improvements in the control group limits our conclusions.

Long-Term Clinical Outcomes With the Activ-L Lumbar Arthroplasty System

BACKGROUND

Low back pain (LBP) due to degenerative disc disease (DDD) is the most common occupational disorder worldwide. Lumbar total disc replacement (LTDR) has provided an alternative to rigid fusion to relieve pain with less motion restriction. We present clinical results with long-term follow-up from a single-center, single-surgeon series of patients treated with the Activ-L artificial disc.

METHODS

Thirty-three patients with symptomatic single-level DDD who failed nonsurgical therapy for a minimum of 6 months underwent single-level arthroplasty with the Activ-L system between 2007 and 2012. Demographic, preoperative, and postoperative data were collected prospectively. Clinical factors reviewed included occupational status, sensory deficits, functional status determined by Oswestry Disability Index (ODI), back pain, leg pain, pain medication consumption, and radiographic imaging.

RESULTS

Average age at surgery was 38.0 ± 7.8 years, and the majority of patients were male (60.6%). Average follow-up was 2.7 ± 1.7 years. Average ODI at preoperative baseline was 54.6 ± 13.5, with scores significantly improved at 6 weeks (28.6 ± 17.4, P < .0001), 3 months (24.1 ± 16.8, P < .0001), 6 months (22.3 ± 16.3, P < .0001), 1 year (18.8 ± 15.3, P < .0001), and final follow-up (15.6 ± 16.4, P < .0001). Most patients (87.8%) reported pain medication usage within 14 days of baseline evaluation, with consumption decreasing significantly at 1-year (34.5%, P < .0001) and long-term follow-up (21.2%, P < .0001). One patient experienced mild unilateral graft subsidence at 1 year, which remained stable on radiographs at 5 years. None of the prostheses required revision surgery.

CONCLUSIONS

The Activ-L disc replacement system is safe and effective for treating single-level lumbar DDD. Patients reported significant improvement in functional outcomes and decreases in pain medication consumption. Further investigation of the Activ-L system in larger populations is warranted.

CLINICAL RELEVANCE

LBP is a common cause of disability worldwide, and better treatment options are needed to improve outcomes, including pain and mobility. Spine surgeons may choose the Activ-L disc replacement as a safe and effective treatment for LBP caused by single-level lumbar DDD.

Confluent abscesses in autochthonous back muscles after spinal injections : A case report and narrative review of the literature on low back pain and spinal injections

Injection therapy is a frequently used method for the treatment of subacute and chronic low back pain (LBP) despite scant evidence for its effectiveness. To date there are relatively few studies comparing this method with other treatments. Moreover, there are many possible side effects associated with injection therapies, some of which are potentially life threatening. We present the case of a 59-year-old woman admitted to the emergency department with confluent abscess formations of autochthonous back muscles and staphylococcal sepsis caused by injection therapy performed by a general practitioner for LBP. The findings of this case report emphasize a careful selection of patients for this type of treatment and a multidisciplinary approach to treatment of LBP.

Insights of stem cell-based endogenous repair of intervertebral disc degeneration

Low back pain has become more prevalent in recent years, causing enormous economic burden for society and government. Common therapies used in clinics including conservative treatment and surgery can only relieve pain. Subsequent cell-based treatment such as mesenchymal stem cell transplantation poses problems such as short duration of therapeutic effect and tumorigenesis. Recently, the discovery and identification of stem cell niche and stem/progenitor cells in intervertebral disc bring increased attention to endogenous repair strategy. Therefore, we review the studies involving endogenous repair strategy and present the characteristics and current status of this treatment. Meanwhile, we also discuss the strategy and perspective of endogenous repair strategy in future.

Manual handling of patients: role of kinesiophobia and catastrophizing in health workers with chronic low back pain

BACKGROUND

Biomechanical overload due to patients' manual handling represents a relevant contributor to chronic low back pain (LBP). Fear of movement (also known as kinesiophobia) and catastrophising may influence the development of chronic complaints and lower performances also in working environments, despite these issues are poorly investigated.

AIM

The aim of this study is twofold: 1) to evaluate the levels of kinesiophobia and catastrophizing in a sample of health personnel with chronic LBP and employed in activities specifically requiring patients' manual handling; 2) to appraise the influence of these factors on disability.

DESIGN

Cross-sectional observational study.

SETTING

Four Italian hospitals.

POPULATION

Sixty-four healthcare workers suffering from nonspecific low back pain, exposed to the spinal risk of biomechanical overload due to patients' manual handling.

METHODS

We assessed kinesiophobia, catastrophizing and disability by means of validated questionnaires (the Tampa Scale of Kinesiophobia [TSK], the Pain Catastrophizing Scale [PCS], and the Oswestry Disability Index [ODI], respectively). Values of central tendency and dispersion of the variable of interest were calculated, along with the association among variables through multiple linear regression analysis.

RESULTS

The results showed presence of kinesiophobia (TSK=34.0; IQR=28.2-42.09), catastrophizing (PCS=20.5; IQR=10.2-29.0) and disability (ODI=28.8; IQR=13.5-40.0) in the population enrolled. Disability was significantly predicted by kinesiophobia and catastrophizing (R2=0.529 P=0.00003).

CONCLUSIONS

Kinesiophobia and catastrophizing are present in health workers with chronic LBP involved in patients' manual handling and are linked to disability. Further investigations in this field are recommended to investigate a role for cognitive-behavioral strategies aimed at managing catastrophizing and kinesiophobia to increase working abilities.

CLINICAL REHABILITATION IMPACT

The assessment of catastrophizing and kinesiophobia is crucial in health workers engaged with patients' manual handling and suffering from chronic LBP.

State anxiety improves prediction of pain and pain-related disability after 12 weeks in patients with acute low back pain: a cohort study

QUESTION

Do measures of state anxiety and trait anxiety in people with acute low back pain (ALBP) improve prediction of chronic low back pain (CLBP), defined as pain or pain-related disability at 12 weeks?

DESIGN

Observational multi-centre prospective cohort study in primary physiotherapy care with measurements at baseline and at 12 weeks of state and trait anxiety, as well as other established prognostic factors for CLBP.

PARTICIPANTS

People with nonspecific ALBP, aged 18 to 60 years, who had been pain free for ≥ 3 months before their current ALBP, and who were being treated according the Dutch clinical guidelines.

OUTCOME MEASURES AND ANALYSIS

CLBP was defined as a pain score ≥ 3/10 on the Numerical Pain Rating Scale (primary outcome), and as a pain-related disability score ≥ 19/70 on the Pain Disability Inventory. Univariate and multivariate logistic regression analyses estimated how the risk of CLBP differed with state and trait anxiety and other established prognostic factors.

RESULTS

Most (204 of 225) participants completed both assessments. State anxiety was an independent predictor of CLBP, whether defined as pain or pain-related disability at 12 weeks, in contrast to trait anxiety. State anxiety improved the predictive performance of the model, with area under the curve (AUC) increasing from 0.64 (95% CI 0.56 to 0.71) to 0.75 (95% CI 0.68 to 0.82) and Nagelkerke's R² increasing from 0.08 to 0.24 for the primary outcome measure, pain. For the secondary outcome measure, pain-related disability: AUC 0.63 (95% CI 0.54 to 0.72) improved to 0.73 (95% CI 0.65 to 0.82) and Nagelkerke's R² increased from 0.05 to 0.16. Adding trait anxiety to the prognostic model for pain improved the AUC from 0.64 (95% CI 0.56 to 0.71) to 0.70 (95% CI 0.62 to 0.77) and Nagelkerke's R² from 0.08 to 0.15.

CONCLUSION

State anxiety in patients with ALBP improved prediction of CLBP, defined as pain and pain-related disability at 12 weeks.

Is age more than manual material handling associated with lumbar vertebral body and disc changes? A cross-sectional multicentre MRI study

OBJECTIVE

Conflicting evidence exists to what extent manual material handling (MMH) causes lumbar disc disease, lack of evidence exist that this effect takes place especially at L5-S1 level, where the greatest moment occurs. The aim was to assess if lumbar vertebral body and disc changes are more common in people whose job involves significant MMH and, if so, to evaluate if lumbar vertebral body and disc changes are more prevalent in the lower part of the lumbar spine (L4-L5 and L5-S1).

DESIGN

Observational, cross-sectional, with quasi-random recruitment.

SETTING

Outpatient radiology units of three large hospitals in northern (Bologna and Brescia) and southern (Bari) Italy.

PARTICIPANTS

183 consecutive adult subjects (89 males, 94 females) aged 20-70 years referred by the general practitioner or a specialist for MRI of the lumbar spine.

PRIMARY AND SECONDARY OUTCOME MEASURES

Neuroradiologists (blind to clinical assessment) evaluated the prevalence of intervertebral disc and vertebral body changes in standardised MRI examinations. History of personal and family musculoskeletal diseases and injuries, current and previous MMH at work and during leisure time were assessed by interview and self-administered questionnaire.

RESULTS

Participants were classified according their occupational exposure to MMH. No association was found between MMH and vertebral body and intervertebral disc changes, whereas age over 45 years was consistently associated with more disc extension beyond the interspace changes, Pfirrmann changes, osteophytes and Modic changes: the association was statistically significant at the conventional 5% level.

CONCLUSIONS

Age, and not MMH, seems to primarily affect the presence of intervertebral disc changes; prospective studies are needed to better explore the relationship between MMH and the possible presence (and level) of lumbar vertebral body and/or disc changes.

Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare

BACKGROUND

It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed.

OBJECTIVE

The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare.

DESIGN

This was an explorative study using qualitative content analysis.

METHOD

Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities).

CONCLUSION

This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.

Application of Pilates-based exercises in the treatment of chronic non-specific low back pain: state of the art

According to the current recommendations on the management of chronic non-specific low back pain (CNLBP), the intervention in this group of patients should include a programme of exercises. Pilates is a system of exercises widely used in patients with low back pain. The practices based on this method have promoted the restoration of the function of muscles involved in lumbopelvic stabilisation, that is, transversus abdominis, multifidus, diaphragm and pelvic floor muscles. During each exercise, specific principles of this method should be followed to restore or sustain the motor control of the lumbar spine and proper body posture. The aim of this study is to present the current state of knowledge concerning the application of Pilates method in the management of CNLBP as well as to define factors (eg, duration, frequency, exercises performed on a mat or specific equipment) influencing the effectiveness of Pilates in these individuals.

Mixed-methods development of a new patient-reported outcome instrument for chronic low back pain: part 2-The Patient Assessment for Low Back Pain-Impacts (PAL-I)

We describe qualitative and quantitative development and preliminary validation of the Patient Assessment for Low Back Pain-Impacts (PAL-I), a patient-reported outcome measure for use in chronic low back pain (cLBP) clinical trials. Concept elicitation and cognitive interviews (qualitative methods) were used to identify and refine symptom concepts. Classical test theory and Rasch measurement theory (quantitative methods) were used to evaluate item-level and scale-level performance of the PAL-I using an iterative approach between qualitative and quantitative methods. Patients with cLBP participated in concept elicitation interviews (N = 43), cognitive interviews (N = 38), and assessment of paper-to-electronic format equivalence (N = 8). A web-based sample of self-reported patients with cLBP participated in quantitative studies to evaluate preliminary (N = 598) and revised (n = 401) drafts and patients with physician-diagnosed cLBP (N = 45) participated in preliminary validation of the PAL-I. The instrument contained 9 items describing cLBP impacts (walking, sitting, standing, lifting, sleep, social activities, travelling, climbing, and body movements). Item-level performance, scale structure, and scoring seemed to be appropriate. One-week test-retest reproducibility was acceptable (intraclass correlation coefficient 0.88 [95% confidence interval, 0.78-0.94]). Convergent validity was demonstrated with PAL-I total score and Roland-Morris Disability Questionnaire (Pearson correlation 0.82), MOS-36 Physical Functioning (-0.71), and MOS-36 Bodily Pain (-0.71). Individual item scores and total score discriminated between numeric rating scale tertile groups and painDETECT categories. Interpretation of paper and electronic administration modes was equivalent. The PAL-I demonstrated content validity and is potentially useful to assess treatment benefit in clinical trials of cLBP therapies.

Relationships Between Trunk Movement Patterns During Lifting Tasks Compared With Unloaded Extension From a Flexed Posture

OBJECTIVES

The purpose of this study was to investigate between movement patterns of trunk extension from full unloaded flexion and lifting techniques, which could provide valuable information to physical therapists, doctors of chiropractic, and other manual therapists.

METHODS

A within-participant study design was used. Whole-body kinematic and kinetic data during lifting and full trunk flexion were collected from 16 healthy male participants using a 3-dimensional motion analysis system (Vicon Motion Systems). To evaluate the relationships of joint movement between lifting and full trunk flexion, Pearson correlation coefficients were calculated.

RESULTS

There was no significant correlation between the amount of change in the lumbar extension angle during the first half of the lifting trials and lumbar movement during unloaded trunk flexion and extension. However, the amount of change in the lumbar extension angle during lifting was significantly negatively correlated with hip movement during unloaded trunk flexion and extension (P < .05).

CONCLUSIONS

The findings that the maximum hip flexion angle during full trunk flexion had a greater influence on kinematics of lumbar-hip complex during lifting provides new insight into human movement during lifting. All study participants were healthy men; thus, findings are limited to this group.

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

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

Quebec Serve and Protect Low Back Pain Study: A Web-based Cross-sectional Investigation of Prevalence and Functional Impact Among Police Officers

STUDY DESIGN

Web-based cross-sectional study.

OBJECTIVE

The aim of this study was to describe the prevalence and the burden of low back pain (LBP) and chronic low back pain (CLBP) among Quebec police officers.

SUMMARY OF BACKGROUND DATA

Police officers have work-related factors associated with LBP, but chronicity and impacts of this condition have been little explored among this population.

METHODS

Between May and October 2014, a web-based cross-sectional study was conducted among police officers working in the province of Quebec (Canada). Nine police organizations accepted to disseminate the email invitation to their members. The survey included the French-Canadian version of the Nordic Musculoskeletal Questionnaire and other items regarding functional impact of LBP and associated treatments.

RESULTS

A total of 3589 police officers completed the questionnaire. Mean age was 38.5 ± 8.7 years, 32.0% were women, and 67.4% reported being car-patrol officers. A majority reported LBP symptoms in the past 12 months (67.7%) and 96.5% of them perceived that presence of LBP was totally/partially linked to their work in the police force. Prevalence of CLBP among all responders was 28.7%. Police officers reporting CLBP, as compared to those reporting acute or subacute LBP symptoms in the past 12 months, were more likely to report LBP-related reduction of work activities (64.4% vs. 45.7%; P < 0.001) and more working days lost in the past 12 months (average of 11.9 ± 43.5 vs. 1.5 ± 9.8; P < 0.001). A greater proportion also reported LBP-related health care visits in the past 12 months (86.2% vs. 64.2%; P < 0.001) and current use of pain medications/complementary alternative medicines (90.1% vs. 69.7%; P < 0.001).

CONCLUSION

CLBP is a frequent and burdensome condition among Quebec police officers. Our results underline the importance for police organizations to promote CLBP prevention and to implement workplace management programs.

LEVEL OF EVIDENCE

3.

Health utilities for chronic low back pain

BACKGROUND

Chronic low back pain (LBP) is a common health problem, with a large potential for primary prevention. Health utilities (HU) reflect which proportion of their expected remaining life time individuals would hypothetically trade to be alleviated of a health condition of interest. A value of 0 means "prefer to die immediately", a value of 1 means "not willing to trade any life time". The aim of this cross-sectional study was to assess HU for LBP patients and for healthy participants and to examine whether HU for LBP are useful indicators to substantiate preventive and therapeutic decision making.

METHODS

Healthy participants (n = 126) and LBP patients (n = 32) were recruited mainly among the employees of a tertiary care hospital in Germany. Standardized LBP scenarios were presented to all participants and HU values were assessed using the time-trade-off method.

RESULTS

Median HU for LBP were 0.90 (IQR 0.31) for participants and 0.93 (IQR 0.10) for LBP patients. Measurements were consistent across illness severity ratings with HU and with a visual analogue scale (VAS); in the healthy sample the intraclass correlation coefficient (ICC) was 0.61 (95% CI 0.23-1.00, F(1125) = 190, p < .001), in the patient sample the ICC was 0.66 (95% CI = 0.24-1.00, F(1,31) = 62, p < .001). 8% of participants reported HU of 1. There was no statistically significant relation between HU and age, income, or gender.

CONCLUSION

On average, participants chose a 7 to 10% shorter life expectancy to avoid LBP, but almost 1 in 10 participants were not willing to trade any life years. The results indicate a certain stability of HU due to the comparability of HU ratings across patients and healthy participants, the measurement consistency when comparing VAS and HU ratings, and the lack of association between demographic variables and HU. This underlines the usefulness of HU for measuring illness severity in comparative health economics evaluations of preventive and therapeutic measures that address chronic LBP or other pain-characterized diseases. Future studies should focus on different LBP intensities and derive stratified HU that reflect the distribution of pain intensity in the population.

Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Expandable Technology: A Clinical and Radiographic Analysis of 50 Patients

OBJECTIVE

Interbody cage implantation during minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF) presents challenges. Expandable cages when collapsed facilitate insertion; subsequent expansion in situ optimizes endplate contact. This report describes clinical and radiographic outcomes of MIS TLIF with an expandable cage.

METHODS

Researchers retrospectively analyzed prospective data from 50 patients (62 operative levels) when an expandable interbody spacer was combined with transpedicular posterior stabilization. Clinical outcomes, fusion rates, incidence of reoperation, and device-related complications were obtained from clinical and radiographic records.

RESULTS

Mean patient age was 58.1 years (56.2% female). In all, 76% (38/50) underwent 1-level fusion, and 24% (12/50) 2-level fusion. Average operative time was 239.9 ± 86.9 minutes for 1-level and 350.3 ± 74.9 minutes for 2-level procedures; average hospital stay overall was 2.5 ± 1.7 days, with no intraoperative complications reported. Mean visual analogue scale and Oswestry Disability Index scores decreased significantly from preoperative to all postoperative assessment times (6, 12, and 24 months) (P < 0.05). Intervertebral disc height (8.3 ± 2.7 vs. 11.3 ± 1.9 mm) increased significantly, with increases sustained over 24 months (P < 0.05). Postoperative radiographs showed no evidence of cage migration, subsidence, or collapse and suggested fusion at all operative levels by 12 months and 24 months (93%, 54/58; 97%, 28/29), respectively.

CONCLUSIONS

An expandable interbody cage led to significant improvement in clinical and radiographic outcomes after MIS TLIF, including intervertebral disc height restoration and high fusion rates, with no evidence of device-related complications.