Nonsurgical Care of Low Back Pain

[Control of neuropathic pain in lumbosacral dorsalgia]

The literature sources devoted to the problem of the formation of neuropathic pain in lumbosacral dorsalgia and the effective treatment regimens used are analyzed. The clinical and pathogenetic justification of the appointment of complex drug treatment is presented, taking into account the most significant causes of acute and chronic nonspecific back pain - radicular, facet, musculotonic syndromes. It has been shown that the most effective drugs are antiepileptic drugs, nonsteroidal anti-inflammatory drugs, muscle relaxants of central prologued action. It has been shown that the intensity of neuropathic pain decreases with the administration of pregabalin. In acute nonspecific back pain, the use of aceclofenac is effective. The severity of musculotonic pain syndrome is significantly reduced when using tolperizone (Midocalm-long). The results of the analyzed studies confirm the effectiveness and safety of the combination.

Chronic low back pain and back muscle activity during functional tasks

There is evidence that patients with low back pain favor their trunk muscles when moving. However, it is unknown whether this maladaptive behavior is generalized across different functional tasks. This study analyzed the back muscle activity of patients with chronic low back pain compared to asymptomatic controls during five functional tasks. The secondary aim of this study was to test whether the electromyographic activity of patients' back muscles was correlated with either the TAMPA scale score or the Örebro Questionnaire. Forty patients with chronic, non-specific low back pain and 40 asymptomatic participants were assessed on the electromyographic activity of the lumbar longissimus, ilio-costal and multifidus while picking up and placing an object on the ground, sitting down and standing up, and climbing stairs. There was statistical evidence of two-way interactions involving group by task (F_4,308 = 7.921, p < 0.001, η² = 0.049) and task by muscle (F_18,1386 = 2.912, p < 0.001, η² = 0.004), but not group by muscle (F_7,539 = 1.104, p = 0.359, η² = 0.004). Patients with chronic low back pain showed an increase in back muscle activity regardless of the type of functional task, except the left side of multifidus muscle during the picking up of a ball on the ground task. There was no correlation between the measure of kinesiophobia or the Örebro questionnaire score and the level of electromyographic activity.

[Results of a randomized double blind parallel study on the efficacy and safety of tolpersione in patients with acute nonspecific low back pain]

AIM

To evaluate the efficacy and safety of tolpersione injection and oral formulations combined with NSAID over NSAID monotherapy in acute non-specific low back pain.

MATERIAL AND METHODS

In this randomized double blind study 239 patients were included in the per protocol analysis. The first 5 days of treatment, patients received tolpersione or placebo injection which was followed by per os administration of tolpersione/placebo tablet up to 14 days. NSAID diclofenac tablet was used in both groups through the study. Functionality assessed by the Roland Morris Disability Questionnaire (RMDQ) at day 5 was the primary endpoint. Secondary endpoints were RMDQ at other time points, pain level change at rest and on movement assessed by the Visual Analogue Scale (VAS), the Clinical Global Impression of Improvement/Patient Global Impression of Improvement (CGI-I and PGI-I), change in the range of motion assessed by the distance from the fingertips to the floor, period of disability days, relative (%) changes in the daily dose of diclofenac from the 7th to the 14th day of therapy.

RESULTS AND CONCLUSION

The primary and secondary endpoints clearly demonstrated the significant superiority of tolpersione added to NSAID monotherapy over NSAID monotherapy. The safety assessment revealed no statistically significant differences between the two groups. Based on the results, tolpersione injection and per os formulations can be considered an effective and safe drugs in the combined therapy for patients with acute nonspecific back pain.

The influence of adjacent level disc disease on discectomy outcomes

PURPOSE

The state of adjacent level discs and its impact on surgical outcomes following single-level lumbar discectomy have not been previously investigated. The purpose of the present study was to determine if a significant relationship exists between the degree of preoperative adjacent level disc degeneration and post-operative clinical outcomes following lumbar discectomy.

METHODS

This study retrospectively used preoperative magnetic resonance imaging (MRI) and prospectively collected data from a randomized clinical trial at two tertiary-care academic hospitals. Patients who underwent a primary, single-level lumbar discectomy were included. Exclusion criteria included prior lumbar surgery. Outcome measures were the Modified Oswestry Disability Index (ODI) score and Visual Analog Scale (VAS) scores for back and leg pain. These were recorded at baseline and at 3 months, 1, and 2 years postoperatively. An independent reviewer graded adjacent level disc degeneration on all preoperative MRIs using the Pfirrmann grading scale. These data were then analyzed for correlation with each outcome measure.

RESULTS

Forty-seven patients were included in the study. No statistically significant correlations were found when comparing preoperative 3-month or 1-year postoperative scores or change from baseline of any outcome measure between Pfirrmann grades. Only about half the patients had 2-year follow-up, but at that time point a statistically significant difference in back VAS scores was observed between Pfirrmann groups. No other significant differences were observed at that point.

CONCLUSIONS

The degree of preoperative adjacent level degeneration does not significantly affect functional or pain relief outcomes following lumbar discectomy up to 1 year after surgery.

Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice

Part II of this two-part introduction to this Special Issue on physical therapy practice in the 21st century outlines a health-focused strategy for physical therapists to lead in the assault on lifestyle conditions, global health care priorities, described in Part I. Consistent with contemporary definitions of physical therapy, its practice, professional education, and research, physical therapy needs to reflect 21st-century health priorities and be aligned with global and regional public health strategies. A proposed focus on health emphasizes clinical competencies, including assessments of health, lifestyle health behaviors, and lifestyle risk factors; and the prescription of interventions to promote health and well-being in every client or patient. Such an approach is aimed to increase the threshold for chronic conditions over the life cycle and reduce their rate of progression, thereby preventing, delaying, or minimizing the severity of illness and disability. The 21st-century physical therapist needs to be able to practice such competencies within the context of a culturally diverse society to effect positive health behavior change. The physical therapist is uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of their causes, as well as manage these conditions. Physical therapists need to impact health globally through public and social health policy as well as one-on-one care. This role is consistent with contemporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes compared with invasive interventions, namely, drugs and surgery. A concerted commitment by physical therapists to health and well-being and reduced health risk is consistent with minimizing the substantial social and economic burdens of lifestyle conditions globally.

Prevalence, incidence, and recurrence of low back pain in scaffolders during a 3-year follow-up study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To describe the natural history of low back pain by its prevalence, incidence, and recurrence during a 3-year period and identify risk factors for cumulative incidence and recurrence of low back pain in scaffolders.

SUMMARY OF BACKGROUND DATA

Although some studies have described prevalence, incidence, or recurrence of low back pain, few studies have assessed two or more of these outcome measures simultaneously. Furthermore, little is known about the association between individual, physical, psychosocial, and health-related risk factors and cumulative incidence and recurrence of low back pain in scaffolders.

METHODS

Between 1998 and 2001, a cohort of 288 scaffolders (response 85%) completed a questionnaire at baseline and at three yearly follow-ups during 3 years.

RESULTS

At baseline 60% of the study population had had an episode of low back pain in the past 12 months of which 22% was of chronic nature. During follow-up, the yearly incidence of low back pain varied between 20% and 28%, while yearly recurrence rates were 64% to 77%. Only few workers consistently reported the presence (20%) or absence (26%) of low back pain each year. Weak significant associations were present for the following: age 35 to 44 years, moderate general health, high strenuous arm movements, and body mass index with the cumulative incidence of low back pain. Significant associations were found between high manual handling of material and high job demand and low job control and the cumulative recurrence of low back pain, while moderate general health only showed a weak significant association with this outcome measure.

CONCLUSIONS

Low back pain was a dynamic process with high rates for incidence, recurrence, and recovery. General health and work-related physical and psychosocial factors influenced both the incidence and recurrence of low back pain. The incidence and recurrence of low back pain depend strongly on the recall period of low back pain and the time-window of investigation.

Work-related low back pain

Low back pain is a common problem among working adults in the United States. Occupational risk factors for low back pain include forceful lifting, bending and twisting of the trunk, whole body vibration and heavy manual labor. The initial assessment of the patient with low back pain requires obtaining an occupational history to identify risk factors in the workplace in addition to the usual inquiries and physical assessment. For those with uncomplicated low back pain, minimal use of medical tests and rapid return to limited activity are indicated. Long-term prevention of low back pain requires modification of occupational or other risk factors.

Classification, diagnostic imaging, and imaging characterization of a lumbar herniated disk

The absence of universal nomenclature standardization with respect to the definition of a disk herniation and its different categories, especially regarding type and location, is still a major problem that will only be overcome when major national or international scientific societies join efforts to support a particular scheme. Meanwhile, it is important to realize that the two models that are currently most used are based on a different [figure: see text] perspective. Trying to straddle the two by opposing, for instance, bulging disk and herniation is doomed to failure because this exercise defies formal logic. MR imaging is currently the most accurate noninvasive imaging modality to diagnose a disk herniation and to determine its exact location. The determination of some pathoanatomic characteristics of herniated disks (type and composition) may require the use of CT, diskography, or CT diskography.

Effect of acupuncture on pain management in patients before and after lumbar disc protrusion surgery--a randomized control study

Management of acute and chronic low back and leg pain often includes the use of acupuncture. The effectiveness of this form of therapy is dependent upon compliance, which in turn is dependent on availability, response, treatment of proper acupoints, and the placebo effect. We hypothesized that classical acupuncture would be more effective than placebo acupuncture. One hundred and thirty-two patients with acute and chronic low back and leg pain were examined before and after surgery for lumbar disc protrusion. Diagnosis was based on CT and MRT findings. Patients received acupuncture drug-free throughout the study period. The visual analogue scale was used to assess pain intensity before and after (i.e. 30 min. 60 min. 2 h and 6 h) acupuncture. Classical acupuncture resulted in a significant reduction in pain that become increasingly stronger during the 6h study period. Placebo acupuncture lead to same early pain relief that did not reach statistic significant and then declined thereafter.

Differentiating lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity. Magnetic resonance imaging with discographic correlations

STUDY DESIGN

Independent evaluation by two observers of 132 lumbar discs in 45 patients with chronic low back pain investigated by both magnetic resonance imaging and discography.

OBJECTIVES

To assess some of the fundamental differences between lumbar disc protrusions, disc bulges, and discs with normal contour but abnormal signal intensity on T2-weighted magnetic resonance images.

SUMMARY OF BACKGROUND DATA

Moderate interobserver agreement has been reported when the morphologic terms normal, bulge, protrusion, and extrusion are used. The validity of this nomenclature remains unknown.

METHODS

Discs were evaluated on magnetic resonance images for central and peripheral signal characteristics, height, contour, and nerve root compression. Discograms were classified according to degrees of disc degeneration, disruption, and pain reproduction.

RESULTS

Loss of intervertebral height or abnormal signal intensity on magnetic resonance imagery was significantly associated with disc disruptions extending into or beyond the outer anulus on discograms. All 23 protrusions (100%) and 12 of 15 disc bulges (80%) were associated with Stage 2 or 3 anular disruptions and, in most instances, similar or exact reproduction of pain during disc injection. There was no significant difference between disc protrusions, disc bulges, and discs with normal contour but abnormal signal, with respect to degree of disc degeneration, extent of disruptions, or presence of discogenic pain.

CONCLUSIONS

In patients with chronic low back pain, loss of disc height or abnormal signal intensity is highly predictive of symptomatic tears extending into or beyond the outer anulus. Disc bulges and disc protrusions do not represent discs with significantly different internal architecture, based on the findings of discography, and are no more suggestive of symptomatic tears than discs showing normal contour but decreased height or abnormal signal intensity.

Outcomes research: a review

PURPOSE

The purpose of this article is to review the history of the medical outcomes movement as well as the methodologies used in outcomes research.

CONCEPT

Outcomes research refers to a genre of clinical investigation that emphasizes the measurement of patient health outcomes, including the patient's symptoms, functional status, quality of life, satisfaction with treatment, and health care costs.

RATIONALE

Outcomes research evolved from studies that demonstrated the presence of wide geographic variations in the practice of medicine and surgery. Such differences in utilization were unaccompanied by any discernible difference in patient outcomes. With escalating health care costs, there has been a growing interest in measuring the outcomes of medical intervention to determine the quality and appropriateness of medical care.

DISCUSSION

Outcomes may be measured both directly and indirectly, over differing periods of time, and with varying degrees of objectivity, reliability, and validity. Current research has focused on quality of life issues, which include the extent to which a patient's usual or expected physical, emotional, and social well-being have been affected by a medical condition or treatment. The true value of health care can be determined only by a systematic examination of patient outcomes. To accomplish this goal, methods are required that are relatively unfamiliar to many clinical researchers. Future clinical research should include patient-oriented outcome measures that would otherwise focus solely on physiological or anatomic outcomes. Such information will be essential in determining which medical and surgical treatment strategies should be abandoned and which will gain acceptance in the future.

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.

Transdermal fentanyl as treatment for chronic low back pain

Management of chronic low back pain often includes oral opioid use. The effectiveness of therapy is dependent upon compliance, which in turn is dependent upon response, side effects, access, and convenience. Our hypothesis was that a transdermal fentanyl system would provide more effective pain management than oral opioids. Fifty patients with chronic low back pain were examined. After litration to levels corresponding to current oral opioid use, each patient was maintained on transdermal fentanyl for one month. Oral opioid therapy was then resumed. Their experience was assessed with the a visual analogue scale for pain intensity, a numerical pain score, the Oswestry disability questionnaire, the pain disability index, and the Verran Snyder-Halpern sleep scale. Significant improvement in pain relief and disability was found with transdermal fentanyl compared with oral opioids. Mild opioid side effects were common, but easily controlled. Use of transdermal fentanyl is an effective alternative to oral opioids for managing chronic low back pain.

Biobehavioral pain research: a multi-institute assessment of cross-cutting issues and research needs

In 1994 ten NIH institutes sponsored an interagency workshop focusing on biobehavioral pain research. The workshop had three major goals: (1) to review the current status of biobehavioral pain research (2) to identify critical research needs, and (3) to enhance interdisciplinary and interagency cooperation in pain research. The purpose of this article is to summarize the presentations at this meeting and to highlight some of the key research recommendations. Research topics addressed include (a) understanding critical interfaces between biology and behavior; (b) pain, suffering, and emotion; (c) pain and behavior; (d) behavior-related interventions; (e) commonalities and differences in pain expression, experience, and treatment; and (f) pain in special populations. The article concludes with a summary of NIH pain research activities that have taken place since the workshop.

Low back pain

Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral.