Regional back pain

Musculoskeletal myths

This paper discusses a number of common myths in the musculoskeletal pain management and rehabilitation/athletic development fields. The origins or rationale for these beliefs are reviewed. New scientific evidence disputing or refuting the myth is then presented followed by and explanation and evidence for an updated perspective.

Sex differences in consequences of musculoskeletal pain

STUDY DESIGN

Cross-sectional population-based study.

OBJECTIVE

To study sex differences in consequences of musculoskeletal pain (MP): limited functioning, work leave or disability, and healthcare use.

SUMMARY OF BACKGROUND DATA

MP is a major public health problem in developed countries due to high prevalence rates and considerable consequences. There are indications that consequences of MP differ for men and women.

METHODS

Data of a Dutch population-based study were used, limited to persons 25 to 64 years of age (n = 2517). Data were collected by a postal questionnaire.

RESULTS

Women with any MP report more healthcare use for MP, i.e., contact with a medical caregiver and use of medicines than men, while men report more work disability (ever in life) due to low back pain only, irrespective of work status. None of the sex differences can be explained by age, household composition, educational level, smoking status, overweight, physical activity, and pain catastrophizing. Older age was related to more limited functioning due to MP (women), work disability due to MP (men), and healthcare use due to MP (men and women). A one-person household was associated with work disability (women) and use of medicines (men). Low educational level was associated with limited functioning (men), work leave (men), contact with a medical caregiver (men), and work disability (men and women). Smoking was associated with limited functioning (men), work leave (women), and healthcare use (women). Physical inactivity was associated with limited functioning due to MP in women. Pain catastrophizing was associated with limited functioning, work leave, and healthcare use (men and women) and work disability (men).

CONCLUSIONS

Consequences of MP show a slightly different pattern for men and women. Women with any MPreport more healthcare use for MP, while men report more work disability due to low back pain only. These sex differences can not be explained by general risk factors, but associations between these factors and consequences of MP show some sex differences.

The influence of diabetes mellitus on lumbar intervertebral disk herniation

BACKGROUND

It has recently been proven that smoking has a negative influence on lumbar disk herniation. This is probably due to microangiopathy. Our purpose was to find out if patients operated on for lumbar disk disease also have an increased incidence of diabetes mellitus. We have also examined if this increased incidence could be the result of diagnostic uncertainties (diabetic neuropathy operated as lumbar disk disease).

METHODS

This is a prospective study. One hundred two patients operated on in our department for lumbar disk herniation were compared with 98 patients of the same age who were admitted for elective surgery and did not take cortisone. History for diabetes mellitus, blood glucose, and glycated hemoglobin were examined. chi(2) test was used for statistical analysis. We have also compared the results of the diabetics and nondiabetic patients operated on for lumbar disk disease.

RESULTS

There was a statistically significant increased incidence of diabetes mellitus in patients operated on for lumbar disk disease. There was no difference in the results at 3 months of the 2 groups of patients operated on for lumbar disk disease.

CONCLUSIONS

Patients operated on for lumbar disk disease have a statistically significant increased incidence of diabetes mellitus compared with similar patients operated on for other reasons. This difference cannot be explained by diagnostic uncertainties because if patients with diabetic polyneuropathy were wrongly operated on for lumbar disk disease, their results would not be as good as those of the other patients operated on for lumbar disk disease. Diabetes mellitus must be a predisposing factor in patients operated on for lumbar disk disease.

Risk factors for musculoskeletal symptoms and ensuing health care use and sick leave

STUDY DESIGN

Longitudinal study with a 6-month follow-up.

OBJECTIVE

To investigate whether demographic, work-related physical and psychosocial risk factors involved in the occurrence of musculoskeletal symptoms also determine subsequent health care use and sick leave.

SUMMARY OF BACKGROUND DATA

Preventing the socioeconomic consequences of disability from musculoskeletal symptoms may be a goal separate from that of eliminating the symptoms themselves; thus, other factors may need to be addressed in intervention.

METHODS

A questionnaire provided data on demographics and work-related factors, musculoskeletal symptoms, and ensuing health care use and sick leave among 407 industrial workers.

RESULTS

The 12-month prevalence of low back pain (LBP) and neck/upper extremity symptoms was 52% and 56%, respectively. Of those individuals with symptoms at baseline, 68% had a recurrence of LBP, and 62% a recurrence of neck/upper extremity symptoms during a 6-month follow-up. The recurrence of sick leave for a particular musculoskeletal complaint was approximately 30%, while recurrence of health care use was more than 40%. Recurrence of symptoms, health care use, and sick leave were strongly associated with a history of severe symptoms. Physical load, high job strain, and low social support at work determined the occurrence of LBP, related health care use, and sick leave. Older age and living alone were also important risk factors, especially for sick leave. High job strain determined the occurrence of neck/upper extremity symptoms, related health care use, and sick leave. Being female and living alone increased the probability of the occurrence of all 3 endpoints, especially the occurrence of sick leave.

CONCLUSIONS

Work-related factors that were associated with the occurrence of musculoskeletal symptoms were quite similar to those associated with health care use and sick leave. However, for LBP, older age and living alone, and, for neck/upper extremity symptoms, living alone and being female more strongly determined whether subjects with these complaints took sick leave. These results imply that prevention strategies aimed at minimizing the risks of the occurrence of work-related musculoskeletal symptoms and prevention programs aimed at reducing sick leave may need to emphasize different sets of risk factors.

Ergonomic Pain--Part 2: Differential Diagnosis and Management Considerations

Work-related musculoskeletal disorders (MSDs) can produce ergonomic pain in several different regions of the body, including the shoulder, elbow, wrist and hand, lumbar spine, knee, and ankle/foot. Each family of disorders is distinctive in presentation and requires diagnosis-specific interventions. Because of the complex nature of these disorders, management approaches may not always eliminate symptoms and or completely restore patient function to a level found prior to symptom onset. As a consequence, ergonomic measures should be implemented to reduce the overload on tissue and contribute to patient recovery. However, functional limits may persist and the clinician must make further decisions regarding a person's functional status in the chronic stages of the patient's care.

Risk factors for sickness absence because of low back pain among scaffolders: a 3-year follow-up study

STUDY DESIGN

A prospective cohort study was conducted.

OBJECTIVE

To find risk factors for short-term (<or=14 days) and long-term (>14 days) sickness absence because of low back pain among scaffolders.

SUMMARY OF BACKGROUND DATA

Although some studies have described the relation between work-related risk factors for musculoskeletal disease and sickness absence, little is known about the role of individual, physical, and psychosocial factors and different end points of low back pain as risk factors for sickness absence among scaffolders.

METHODS

Between 1998 and 2001, 222 scaffolders and 66 supervisors (response rate, 86%) completed a questionnaire at baseline. In addition, data on sickness absence were collected from absence records.

RESULTS

At baseline, 60% of the study population had experienced an episode of low back pain in the 12 months preceding the investigation, 37% of which were of chronic nature. During the follow-up period, 34% of the population had been on sick leave for at least one episode of low back pain. The risk factors for sickness absence less than 2 weeks were a high physical load from strenuous arm movements and severe low back pain. Workers with severe low back pain were at higher risk for sickness absence longer than 2 weeks. Psychosocial workload and individual characteristics did not predict the occurrence of sickness absence because of low back pain.

CONCLUSIONS

Because work-related physical load was a risk factor for sickness absence less than 2 weeks and severe low back pain was a risk factor for sickness absence both shorter than and longer than 2 weeks, a focus on secondary prevention for scaffolders with severe low back pain is advised.

Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain

STUDY DESIGN

A controlled clinical trial.

OBJECTIVES

To examine the long-term effect of an informative approach to low back pain.

SUMMARY OF BACKGROUND DATA

In management and prevention of low back pain, back school based on an ergonomic approach have played in important role. The effect of such informative interventions is not clear.

METHODS

A 5-year follow-up study was done on patients included in a previous study. The outcome was measured by return to work or still on sick leave. The patients were allocated to an intervention group (n = 245) and a control group (n = 244). Only the intervention group was called in for examination and intervention and answered a battery of tests for psychological and health factors. The intervention apart from the clinical examination consisted of education in an "mini back school." The program was based on a new medical model for low back pain.

RESULTS

Forty-seven (19%) of the patients in the intervention group, compared with 84 patients (34%) in the control group, were still on sick leave after 5 years (P < 0.001). There were fewer recurrences of sick leave (P < 0.03) in the intervention group than in the control group. Based on Internal Health Locus of Control, number of children, and income, 75% were correctly classified as nonreturners in the intervention group.

CONCLUSIONS

This study indicates that subchronic low back pain may be managed successfully with an approach that includes clinical examination combined with information for patients about the nature of the problem, provided in a manner designed to reduce fear and give them reason to resume light activity.

Prognostic factors for musculoskeletal sickness absence and return to work among welders and metal workers

OBJECTIVES

To analyse factors that determine the occurrence of sickness absence due to musculoskeletal problems and the time it takes to return to work.

METHODS

A longitudinal study with two year follow up was conducted among 283 male welders and metal workers. The survey started with a standardised interview on the occurrence of musculoskeletal complaints. 61 (22%) workers were lost to follow up. Data on sickness absence among 222 workers during the follow up were collected from absence records and self reports. Regression analysis based on proportional hazards models was applied to identify risk factors for the occurrence and duration of sickness absence due to various musculoskeletal complaints.

RESULTS

During the follow up 51% of the workers attributed at least one period of sickness absence to musculoskeletal complaints which accounted for 44% of all work days lost. A history of back pain was not associated with sickness absence for back pain, partly because subjects with back pain were more likely to be lost to follow up. Neck or shoulder pain and pain of the upper extremities contributed significantly to neck or shoulder absence (relative risk (RR) 3.35; 95% confidence interval (95% CI) 1.73 to 6.47) and to upper extremities absence (RR 2.29; 95% CI 1.17 to 4.46), respectively. Company and job title were also significant predictors for sickness absence due to these musculoskeletal complaints. Absence with musculoskeletal complaints was not associated with age, height, body mass index, smoking, and duration of employment. Return to work after neck or shoulder absence was worse among metal workers than welders (RR 2.12; 95% CI 1.08 to 4.17). Return to work after lower extremities absence was strongly influenced by visiting a physician (RR 11.31; 95% CI 2.94 to 43.46) and by musculoskeletal comorbidity (RR 2.81; 95% CI 1.18 to 6.73).

CONCLUSIONS

Complaints of the neck or shoulder and upper extremities in the 12 months before the study were associated with sickness absence for these complaints during the follow up. Workers with absence due to pain from back, neck or shoulder, upper extremities, or lower extremities were at higher risk of subsequent sickness absence in the next year.

Classics from the spine literature revisited: a randomized trial of 2 versus 7 days of recommended bed rest for acute low back pain

STUDY DESIGN

Review of a trial of bed rest for patients with acute low back pain.

OBJECTIVES

To assess the validity and results of the study, and their applicability to and influence on current clinical practice and recommendations.

SUMMARY OF BACKGROUND DATA

Although bed rest has been a cornerstone of treatment for acute low back pain, historically this recommendation was largely based on "expert opinion." In 1986, Deyo et al. published a randomized study of 2 versus 7 days of recommended bed rest for acute low back pain. Despite results from this and other studies, current clinical practice and treatment recommendations continue to overemphasize bed rest.

METHODS

The study was reviewed using structured criteria adopted from the medical literature that focus on the validity of the study design, the results of the treatment, and the relevance of the findings to clinical practice.

RESULTS

Two hundred and three patients were randomized to 2 versus 7 days of recommended bed rest. Groups were similar at baseline evaluation. Outcomes assessed at 3 and 12 weeks were similar between groups, except that patients receiving a recommendation for 2 days of bed rest had significantly fewer days of work absence than those recommended 7 days. Limitations of the study included poor compliance with recommended bed rest, especially in the 7-day group, a marginal sample size without information on relevant confidence intervals, and patient characteristics that may have affected the generalizability of these findings to others with acute low back pain.

CONCLUSIONS

Despite limitations, this study provided strong evidence that less bed rest was associated with similar outcomes for acute low back pain along with quicker return to work. Results from this and other studies support a shift away from bed rest as a primary recommendation in the initial management of low back pain. In spite of this, bed rest recommendations for episodes of low back pain remain common. Additional efforts are needed to change clinical practice.

Work incapacity from low back pain: the international quest for redress

Disabling back pain plagues industrialized societies. Generally redress adheres to a Prussian paradigm that those injured at work are more deserving than those who have worked but can no longer do so because of diseases not related to work. Those who never have worked are least entitled. A comparison of the way the Prussian paradigm behaves in different cultures is instructive and daunting; no generalizable solution has emerged. It is time to cast off the Prussian paradigm. It is clinically unsound and, judging from the experience of the past century, ethically flawed.

Disability resulting from occupational low back pain. Part I: What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins

This is the first of two papers that systematically review available scientific evidence on the causes of disability from occupational low back pain, and the effectiveness of interventions to prevent it-before disability begins (primary prevention-Part I) and after its onset (secondary prevention-Part II). This first paper reviews the risk factors for the onset of pain and associated disability followed by a critical summary of intervention studies attempting to achieve prevention and to evaluate the results.

Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins

This is the second of two papers that systematically review available scientific evidence on the causes of disability from occupational low back pain, and the effectiveness of interventions to prevent it after its onset (secondary prevention). This paper reviews the national history of how back pain and the risk factors for its extension into chronic disability, followed by a critical summary of intervention studies attempting to reduce the duration of this disability, and to evaluate the results.

Disorders characterised by pain: a methodological review of population surveys

OBJECTIVE--To review a series of conceptual and methodological problems encountered in surveys primarily devoted to pain disorders. CRITERIA FOR INCLUSION AND EXCLUSION OF ARTICLES--Published reports were systematically collected by electronic database searches (Medline), citations in existing publications, and through personal contacts. Relevant articles from clinical and epidemiological research on pain were included and special attention was given to epidemiological research on back pain. CONCLUSIONS--Surveys of pain disorders should be based on a multidimensional pain model that includes nociceptive input, pain perception, suffering, and pain behaviour as major components. Because of the limited applicability of diagnostic procedures or genuine "non-specificity" of pain states, or both, epidemiological surveys may result in a considerable proportion of cases without an identifiable pathophysiological basis. Staging and grading procedures for pain disorders (as distinguished from classification) may comprise various aspects of pain perception: regional distribution, pain intensity, temporal characteristics, sensory qualities, and dimensions of cognitive-emotional appraisal. Description of temporal development and chronification (staging) should refer to different components of the multidimensional pain model. Explicit a posteriori procedures for grading are preferable to implicit grading based on question wording. Evidence from several sources suggests that localistic concepts of pain may be misleading. Identification of complex pain syndromes should be one primary target for epidemiological pain surveys. Of the many factors that may impair the reliability and validity of data collected in pain surveys, recall biases seem to deserve special attention.

Supralevator anorectal abscess presenting as acute low back pain and sciatica

Anorectal abscess is a suppurative process that begins in the anal glands. Clinical presentation is variable and depends on the direction and tissue plane along which the infection tracks. All cases require urgent incision and drainage. We report an unusual case of a supralevator abscess in a man who presented to the emergency department on two occasions with acute low back pain and sciatica. The case demonstrates the importance and difficulty of identifying the exceptional case among the numerous routine cases of mechanical low back pain. Attentiveness to atypical features should direct the clinician to a more extensive evaluation for serious illness. The case also illustrates that sciatica is not a diagnostic end-point but rather a label for a pain syndrome that encompasses a long differential diagnosis.

Acute low back pain and economics of therapy: the iterative loop approach

We use the measurement iterative loop as a conceptual framework to examine the economics of common therapies for acute non-specific low back pain. The measurement iterative loop systematically assesses the interlocking facets of an illness from the community health perspective, including quantifying burden of illness, etiology, assessment of therapeutic effectiveness, and economic evaluation of therapies. The iterative loop reveals that: (1) burden of illness, although known to be substantial, is so far inaccurately measured, (2) little is known about such factors as provider and patient compliance; and (3) the economics of therapy can guide us in this time of clinical uncertainty when no therapy appears clearly superior. For therapies with at least some support from randomized controlled trials, bedrest appears to be economically superior. Besides burden of illness, compliance, and current therapies, future research should address such "therapeutic" options as early return to work and patient self-management.

Economic outcome under Medicare prospective payment at a tertiary-care institution: the effects of demographic, clinical, and logistic factors on duration of hospital stay and part A charges for medical back problems (DRG 243)

We investigated the effects of prospectively identified factors on the duration of hospital stay and part A charges in 240 hospitalizations (of 230 patients) for the diagnosis-related group "medical back problems" (DRG 243) at a tertiary-care institution in 1985 to determine whether heterogeneity existed within this reimbursement category. We confirmed our initial postulates that nonosteoporotic fractures and neck problems, as well as hospitalizations primarily for myelography after outpatient neurologic evaluation, had considerably different economic outcomes and thus excluded these categories from further analysis. Statistical analysis (forward stepwise regression) of the remaining 132 patients who had "general medical back problems" showed that increasing age, associated osteoporosis, and therapeutic injections best explained variation in the natural logarithm of duration of stay (R2 = 0.16). Total number of diagnoses, spondylosis, associated osteoporosis, age, therapeutic injections, and performance of special procedures best explained the variation in the logarithm of part A charges (R2 = 0.29). The ability to identify factors within a specified category that affect the duration of hospitalization and part A charges jeopardizes the fairness of prospective payment, and we believe that DRG 243 should be adjusted for age, comorbidity, and readily identifiable clinical syndromes that have disparate economic consequences. Because of poorly substantiated efficacy and a significant association with longer hospital stays and higher part A charges, clinicians should review the use of therapeutic injections for medical back problems. Analysis of case-mix such as ours should be helpful in promoting efficient practice and ensuring the fairness of any reimbursement system.

Occurrence of spinal pain syndromes in a group of apparently healthy and physically fit sportsmen (orienteers)

The prevalence of three spine-related pain syndromes was assessed in 739 apparently healthy leisure-time sportsmen (orienteers). The three syndromes were (i) low back pain or stiffness, (ii) thoracic inter-scapular back pain or stiffness, and (iii) frontal chest pain or discomfort. The mean age of the sportsmen was 32.7 years (range 10-65). For low back pain or stiffness the cumulative occurrence was 471 per 1,000, for thoracic back problems it was 146 per 1,000, and for chest pain or discomfort 85 per 1,000. The three pain syndromes were highly associated, i.e. they tended to occur in the same individual.