European Commission COST B13 Management Committee. European guidelines for the management of low back pain

Facet joint parameters which may act as risk factors for chronic low back pain

BACKGROUND

Facet orientation (FO) and facet tropism (FT) are two important structural parameters of lumbar facet joint. The purpose of this study was to evaluate the association between facet joint parameters and chronic low back pain (LBP).

METHODS

From June 2017 to January 2019, a total of 542 cases were enrolled in this study. There were 237 males and 305 females with a mean age of 35.8 years (range 18~59 years). All the cases were divided into a LBP group (LBP group) and a non-LBP group (N-LBP group) in this study. We compared their clinical parameters and facet joint parameters between two groups.

RESULTS

The LBP group was composed of 190 male and 252 female, whose ages ranged from 17 to 59 years (35.6 ±7.9 y). The N- LBP group was composed of 47 male and 53 female, whose ages ranged from 18 to 59 years (35.9 ± 7.5 y). Of these parameters, BMI (P = 0.008) and FT (P = 0.003) at all three levels were found to be significantly associated with incidence of chronic LBP (P < 0.05), but FO were only found to be significant at L3-L4 level and L5-S1 level (P < 0.05). Logistic regression analysis showed that high BMI and large FT were significant risk factors for chronic LBP (P < 0.05), and FT were found to might be independent risk factors for chronic LBP.

CONCLUSION

FT may play a more important role in the pathogenesis of chronic LBP.

Low back pain in emergency ambulance workers in tertiary hospitals in China and its risk factors among ambulance nurses: a cross-sectional study

OBJECTIVE

Low back pain (LBP) could cause serious consequences and has been shown to be prevalent among emergency ambulance workers. Studies on the prevalence of and risk factors for LBP among emergency ambulance workers are scarce in China. The study aimed to determine the prevalence of LBP among ambulance workers, including doctors, nurses and drivers, and to explore the risk factors for ambulance nurses' chronic LBP (lasting for at least 3 months).

DESIGN

Cross-sectional study.

SETTING

Emergency ambulance systems from 38 tertiary hospitals in Shandong, China were selected by random cluster sampling.

PARTICIPANTS

A total of 1560 ambulance workers completed the study.

OUTCOME MEASURES

A paper-based questionnaire that included the Nordic Musculoskeletal Questionnaire, which evaluated LBP, the Dutch Musculoskeletal Questionnaire, which assessed ergonomic factors, and the Job Content Questionnaire, which assessed stress, was used. Multivariate logistic regression analysis was conducted to quantify the association of potential risk factors with chronic LBP among ambulance nurses.

RESULTS

The 1 year prevalence of LBP lasting for at least 24 hours, 7 days and 3 months was 86.1%, 50.6% and 21.1%, respectively, among 498 ambulance nurses; 70.5%, 36.4% and 15.8% among 519 doctors; and 57.5%, 23.8% and 12.3% among 543 drivers. The factors contributing to chronic LBP among ambulance nurses were the frequent bending of the trunk, heavy or awkward lifting, shift work, low job satisfaction, high psychological fatigue, high psychological job demand, low job control, low supervisor support, older age, female sex and obesity.

CONCLUSIONS

LBP was more prevalent among ambulance nurses than among ambulance doctors and drivers. Many factors, especially psychosocial and ergonomic factors, contributed to ambulance nurses' chronic LBP. Comprehensive measures might be needed to control LBP.

Psychosocial Stress Reactivity as Predictor of Operative Outcome in Lumbar Disc Surgery

BACKGROUND

A large proportion of the population suffers from chronic back pain. For optimal treatment, the question arises which patients would benefit from conservative therapy and for whom lumbar disc surgery is most appropriate. It seems reasonable to analyze the impact of paraclinical parameters on the operation outcome to identify patients who would benefit less from surgery or need special pre-/postoperative medical care.

MATERIALS AND METHODS

From March 2012 to July 2014, 32 patients were treated via microscopically supported interlaminar fenestration and discectomy at the Department of Neurosurgery, University Hospital Carl Gustav Carus Dresden. One day before the operation, a cortisol survey was made during the stress response of the Trier Social Stress Test. At the same time, a survey of relevant questionnaires was conducted by which the postoperative symptom experience was made operational and comparable with the evaluation of the same information thirty days afterwards.

RESULTS

It could be shown that there is a connection between cortisol reactivity and the pain burden following operations. Patients with a greater cortisol reaction under stress exposition partially experienced more intense postoperative pain than the patients with a lower cortisol reaction. However, this relationship could only be explained by single significant results, whereas further calculations could not produce any significance.

CONCLUSIONS

Cortisol reactivity seems to be associated with pain development. The inconsistent findings in empiricism as well as in this investigation are indicative of a complex association of postoperative pain and cortisol reactivity, which needs to be examined further.

Association of pain and depression in those with chronic low back pain: the mediation effect of patient sexual functioning

OBJECTIVES

One theoretical model suggests that the pathway from pain to depression is through the disruption of social and relationship function. This study sought to test this hypothesis by considering the mediating effect of sexual functioning on the association between pain intensity and depressive symptoms in sexually active patients with chronic low back pain.

MATERIALS AND METHODS

This was a cross-sectional study on consecutive patients attending a chronic pain management clinic in Iran. All measures (pain intensity, depressive symptoms, sex-specific sexual function) were obtained by a self-report questionnaire, completed by patients while attending the clinic. Sobel testing, including bias-corrected bootstrapping, was used to produce 95% confidence intervals (95% CI) to test the mediating effect of sexual function.

RESULTS

A total of 742 patients (351 men, 391 women) took part in this study. Both the male and female mediation models showed a significant association between pain intensity and depressive symptoms, and both the models were significantly mediated by sexual functioning (P<0.001). Effect size calculations show a medium to large effect on male patients (κ 0.23; 95% CI, 0.15-0.39) and a medium effect for female patients (κ 0.16; 95% CI, 0.06-0.28). Both the models accounted for over 50% of the variance in depressive symptoms (model R).

DISCUSSION

This study has shown that sexual functioning significantly mediates the relationship between pain intensity and depressive symptoms in sexually active patients with chronic low back pain. Clinicians may wish to consider the assessment of sexual functioning within this patient group and align treatments that address sexual dysfunction and general pain management.

[Perioperative pain management: what is evidence based?]

BACKGROUND

Adequate post-operative acute pain therapy after spinal surgical procedures is essential for many patients. However, patients already receiving chronic opioid therapy pre-operatively present a special challenge for the treating physician during the post-operative period when managing their acute pain. The team must consider multiple approaches of acute pain management and it is important to proceed according to current evidence-based methods.

THERAPY

A wide spectrum of options for pain management after spinal surgery is currently available. This includes various therapeutic methods as well as regional anesthesia. Considering the various options, the method of choice for post-operative analgesia depends on the expected pain, therapy effectiveness, and the applicability with regard to potential side-effects.

METHOD

In addition to the basic analgesic therapy consisting of opioid and non-opioid drugs, chronic pain patients may require co-analgesics or combination analgesics from this class.

CONCLUSION

Regional anesthesia is currently the predominant method of choice for post-operative acute pain management. Neuraxial blockage is especially important when considering all spinal procedures.

The role of sleep problems in the development of depression in those with persistent pain: a prospective cohort study

STUDY OBJECTIVES

One theoretical model suggests a pathway between pain and the development of depression through sleep problems. Here, we prospectively test the hypothesis that incident sleep problems, in those with persistent pain, increase risk of new onset probable depression, and investigate the role of "pain that interferes with daily life" (pain interference) on this pathway.

DESIGN

Prospective cohort study.

SETTING

Community based population study within UK.

PARTICIPANTS

Participants with persistent pain nested within a larger longitudinal community study.

MEASUREMENTS

Participants were mailed health questionnaires at baseline (time 1) with follow-up at 3 years (time 2) and 6 years from baseline (time 3). Questionnaires at baseline and at follow up contained measures of sleep problems (Jenkins Sleep Questionnaire), depressive symptoms (Hospital Anxiety and Depressive Scale), and pain interference.

RESULTS

In total, 2,622 participants returned health questionnaires at all time points and indicated the presence of pain at each time point. After adjustment for age, gender, marital status, employment status, alcohol intake, smoking status, and body mass index, having a new period of sleep problems at year 3 more than trebled the risk of a new period of probable depression at year 6 (relative risk 3.47, 95% CI 1.97 to 6.03). Mediation analysis showed that pain interference played a significant but relatively minor role in the pathway.

CONCLUSION

Clinicians treating patients with persistent pain may wish to consider options that involve addressing the prevention or treatment of sleep problems, in addition to their primary focus of pain management.

Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281)

BACKGROUND

The IMPaCT Back study (IMplementation to improve Patient Care through Targeted treatment for Back pain) is a quality improvement study which aims to investigate the effects of introducing and supporting a subgrouping for targeted treatment system for patients with low back pain (LBP) in primary care. This paper details the subgrouping for targeted treatment system and the clinical training and mentoring programmes aimed at equipping clinicians to deliver it. THE SUBGROUPING AND TARGETED TREATMENT SYSTEM: This system differs from 'one-size fits all' usual practice as it suggests that first contact health care practitioners should systematically allocate LBP patients to one of the three subgroups according to key modifiable prognostic indicators for chronicity. Patients in each subgroup (those at low, medium or high risk of chronicity) are then managed according to a targeted treatment system of increasing complexity. THE SUBGROUPING TOOLS: Subgrouping tools help guide clinical decision-making about treatment and onward referral. Two subgrouping tools have been used in the IMPaCT Back study, a 9-item version used by participating physiotherapists and a 6-item version used by GPs. The targeted treatments. The targeted treatments include a minimal intervention delivered by GPs (for those patients at low risk of poor outcome) or referral to primary care physiotherapists who can apply physiotherapy approaches to addressing pain and disability (for those at medium risk) and additional cognitive-behavioural approaches to help address psychological and social obstacles to recovery (for those at high risk). THE TRAINING PACKAGES: Building on previous interventions for other pilot studies and randomized trials, we have developed and delivered clinical training and support programmes for GPs and physiotherapists.

DISCUSSION

This paper describes in detail the IMPaCT Back study's subgrouping for targeted treatment system and the training and mentoring packages aimed at equipping clinicians to deliver it, within the IMPaCT Back study.

STUDY REGISTRATION

ISRCTN55174281.

A process of subgroup identification in non-specific low back pain using a standard clinical examination and cluster analysis

BACKGROUND AND PURPOSE

Non-specific low back pain (NSLBP) accounts for over 85% of all low back pain. Homogenous subgroups may exist within this diagnosis. This study derived a clinical examination and evaluated the examination's ability to identify homogenous subgroups in NSLBP.

METHODS

Patients with NSLBP were examined using a standardized clinical examination. Each patient was examined by two physiotherapists. Data were analysed for item reliability and the presence of distinct subgroups using cluster analysis. Cross-validation of the clusters identified was conducted.

RESULTS

Three hundred and one patients were examined. The inter-tester reliability of the majority of items was moderate to substantial (52% of items with kappa > 0.40). A K-means cluster analysis of the two data sets revealed agreement on the presence of two subgroups. One group (n = 47, 16%) had higher fear avoidance beliefs, anxiety and disability. They were more likely to be provoked by pain provocative tests. They were also more likely to be judged as having central sensitization and a dominant psychosocial component to their presentation.

CONCLUSION

The identification of a group of hypervigilant NSLBP patients should allow the interventions to be targeted towards this group. A valid, standardized clinical examination does contribute to the diagnostic management of NSLBP.

[Comparative psychological aspects of itching and pain]

Itching is a major symptom of chronic skin diseases such as atopic dermatitis and leads to considerable psychological strain. Chronic itching lowers patient's quality of life similar to chronic pain and influences the medical treatment. The frequently resulting scratching behavior (short-term avoidance of itch) leads to continuation and exacerbation of the disease, just as with specific pain behavior. For the development of itching and pain psychosocial factors have been identified in addition to somatic ones. However, recent data suggest that there is a complex interaction between pain and itching and comparable mechanisms of neuronal sensitization. In contrast to traditional biomedical one-dimensional models which focus mainly on physical and not psychological factors of a disease, recent data support a biopsychosocial model of development and maintenance for itching and pain. Biopsychosocial understanding of a disease should consequently be taken as the basis for treatment and the importance of interdisciplinary treatment is emphasized. This article will focus on chronic itching and pain with particular consideration of psychological factors.

The Spanish version of the "STarT Back Screening Tool" (SBST) in different subgroups

OBJECTIVE

The aim of this study was to translate and culturally adapt the original version of the STarT Back Screening Tool (SBST) to Spanish for different population subgroups.

DESIGN

Translation and cultural adaptation of a questionnaire.

SETTING

Primary care settings.

METHOD

Thirty-eight people distributed by: gender; adults and elderly; and with or without pain. Phases: a) Forward translation (English-Spanish); b) Evaluation of the clarity, the acceptability and the familiarity of the content of the obtained Spanish version by means of cognitive interviews to participants, and c) Translation of the final Spanish version of the questionnaire back into the original language.

RESULTS

The participants interviewed indicated that most of the items of the questionnaire were clear and comprehensible, showing greater difficulty in understanding in the dimensions of disability and anxiety. Furthermore, the questionnaire was more difficult to understand by the elderly and patients with a previous non-specific low back pain episode.

CONCLUSION

The Spanish version of the SBST questionnaire was obtained, which was shown to be comprehensible and adapted to the general population in Spain. Due to being short and easy to use, it is a potentially useful tool for use in primary care.

The long-term effects of naprapathic manual therapy on back and neck pain - results from a pragmatic randomized controlled trial

BACKGROUND

Back and neck pain are very common, disabling and recurrent disorders in the general population and the knowledge of long-term effect of treatments are sparse. The aim of this study was to compare the long-term effects (up to one year) of naprapathic manual therapy and evidence-based advice on staying active regarding non-specific back and/or neck pain. Naprapathy, a health profession mainly practiced in Sweden, Finland, Norway and in the USA, is characterized by a combination of manual musculoskeletal manipulations, aiming to decrease pain and disability in the neuromusculoskeletal system.

METHODS

Subjects with non-specific pain/disability in the back and/or neck lasting for at least two weeks (n = 409), recruited at public companies in Sweden, were included in this pragmatic randomized controlled trial. The two interventions compared were naprapathic manual therapy such as spinal manipulation/mobilization, massage and stretching, (Index Group), and advice to stay active and on how to cope with pain, provided by a physician (Control Group). Pain intensity, disability and health status were measured by questionnaires.

RESULTS

89% completed the 26-week follow-up and 85% the 52-week follow-up. A higher proportion in the Index Group had a clinically important decrease in pain (risk difference (RD) = 21%, 95% CI: 10-30) and disability (RD = 11%, 95% CI: 4-22) at 26-week, as well as at 52-week follow-ups (pain: RD = 17%, 95% CI: 7-27 and disability: RD = 17%, 95% CI: 5-28). The differences between the groups in pain and disability considered over one year were statistically significant favoring naprapathy (p < or = 0.005). There were also significant differences in improvement in bodily pain and social function (subscales of SF-36 health status) favoring the Index Group.

CONCLUSIONS

Combined manual therapy, like naprapathy, is effective in the short and in the long term, and might be considered for patients with non-specific back and/or neck pain.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN56954776.

Effectiveness of an early cognitive-behavioral treatment in patients with work disability due to musculoskeletal disorders

OBJECTIVE

To evaluate whether an early cognitive-behavioral treatment complementary to a rheumatologic care program, for patients with recent-onset temporary work disability caused by musculoskeletal disorders (MSDs) is effective.

METHODS

Patients with an MSD-related temporary work disability episode from 3-8 weeks' duration who were in a rheumatologic care program were randomized into a control group (rheumatologic care program) or an intervention group (rheumatologic care program plus cognitive-behavioral treatment). Enrollment lasted 24 months and followup lasted 6-24 months. Efficacy variables included duration of temporary work disability episodes, total number of work days saved, relative efficacy, and relative rate to return to work. An economic evaluation was also performed.

RESULTS

One hundred eighty-one patients were included (66 control and 115 intervention patients), generating 222 episodes of MSD-related temporary work disability. Episodes tended to be shorter in the intervention group than in the control group (mean 98 versus 127 days; P = 0.053), with a relative efficacy of 22.9%. There were no differences in duration of the first episode between groups (mean 105 versus 110 days; P = 0.79), but relapse episodes were significantly shorter in the intervention group (mean 63 days versus 197 days; P = 0.0002). Costs were also lower in the intervention group. To save 1 day of temporary work disability, $13.50 had to be invested in the program. Each dollar invested generated a benefit of $4.08. The program had a net benefit of $172,607.

CONCLUSION

Early cognitive-behavioral treatment complementary to a rheumatologic care program is cost-effective, adds >20% efficacy to the rheumatologic care program, and reduces the duration of relapses.

Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone

Tizanidine and aceclofenac individually have shown efficacy in the treatment of low back pain. The efficacy and tolerability of the combination have not yet been established. The objective of the study was to evaluate the efficacy and safety of aceclofenac-tizanidine fixed dose combination against aceclofenac alone in patients with acute low back pain. This double-blind, double-dummy, randomized, comparative, multicentric, parallel group study enrolled 197 patients of either sex in the age range of 18-70 years with acute low back pain. The patients were randomized to receive either aceclofenac (100 mg)-tizanidine (2 mg) b.i.d or aceclofenac (100 mg) alone b.i.d for 7 days. The primary efficacy outcomes were pain intensity (on movement, at rest and at night; on VAS scale) and pain relief (on a 5-point verbal rating scale). The secondary efficacy outcomes measures included functional impairment (modified Schober's test and lateral body bending test) and patient's and investigator's global efficacy assessment. aceclofenac-tizanidine was significantly superior to aceclofenac for pain intensity (on movement, at rest and at night; P < 0.05) and pain relief (P = 0.00) on days 3 and 7. There was significant increase in spinal flexion in both the groups from baseline on days 3 and 7 with significant difference in favour of the combination group (P < 0.05). There were significantly more number of patients with excellent to good response for the aceclofenac-tizanidine treatment as compared to aceclofenac alone (P = 0.00). Both the treatments were well tolerated. In this study, aceclofenac-tizanidine combination was more effective than aceclofenac alone and had a favourable safety profile in the treatment of acute low back pain.

Effect sizes of non-surgical treatments of non-specific low-back pain

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

Naprapathic manual therapy or evidence-based care for back and neck pain: a randomized, controlled trial

OBJECTIVES

To compare naprapathic manual therapy with evidence-based care for back or neck pain regarding pain, disability, and perceived recovery. Naprapathy that is common in the Nordic countries and in some states in the United States is characterized by manual manipulations with a focus on soft and connective tissues, aiming to decrease pain and disability in the musculoskeletal system.

METHODS

Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks.

RESULTS

At 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results.

DISCUSSION

This trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.

The LBP patient perception scale: a new predictor of LBP episode outcomes among primary care patients

OBJECTIVE

To describe a new tool designed to capture patients' perception of their low back pain (LBP) episodes-the patient perception scale (PPS) and test its ability to predict episode outcomes.

METHODS

Thirty-two family physicians recruited 526 low back pain patients during an office visit. Physicians completed a short questionnaire at the index visit, which included both their assessments of patients' patient perception scale (PPS-doc) and contact information. Patients were then interviewed by telephone within 2 weeks after the index visit, with follow-up telephone contacts at 2, 4, 8 and 12 months. The patient perception scale as reported by the physician (PPS-doc) and patient (PPS-pt), each constituent question, and different combinations were analyzed for their ability to predict patient outcomes.

RESULTS

Patients' responses (PPS-pt) proved predictive for all outcome items. PPS-doc was much less predictive. Measures of patient centeredness did not perform well in this study.

CONCLUSION

By using a short scale based on the patient's perception of pain (PPS-pt), it is possible to predict adverse outcomes of a low back pain episode. The patient perception scale should be evaluated further and perhaps combined with other instruments for targeting care and chronicity prevention efforts in low back pain.

PRACTICE IMPLICATIONS

The PPS-pt could potentially be used as part of the standard initial patient evaluation of new LBP patients, as a proxy for "yellow flags" (markers of psychosocial risk) where a positive score might be the equivalent to high-risk identification. The apparent advantage of this scale is its brevity and simplicity of administration. The separation, through this scale of pain episodes into simple and complex LBP might be a useful tool for helping direct resources and avoiding chronicity.

Efficacy and tolerability of paracetamol/tramadol (325 mg/37.5 mg) combination treatment compared with tramadol (50 mg) monotherapy in patients with subacute low back pain: A multicenter, randomized, double-blind, parallel-group, 10-day treatment study

BACKGROUND

In various pain studies, the single-dose combination of paracetamol/tramadol (PIT) was found to be more effective than either agent alone. PIT could provide benefit in patients with subacute low back pain (LBP).

OBJECTIVE

This study compared the efficacy and tolerability of PIT with tramadol alone (T) in patients with subacute LBP and assessed whether, under comparable analgesic conditions, PIT would be better tolerated.

METHODS

This was a multicenter, randomized, double-blind, parallel-group study. Patients were enrolled if they suffered from nonspecific LBP lasting 10 to 42 days and experienced at least moderate pain (> or =40 mm on a 100-mm visual analog scale). Patients were randomized and treated for 10 days with PIT (325 mg/37.5 mg) or T (50 mg). The study outcomes were treatment efficacy (pain intensity, pain relief, patient satisfaction, physicians' assessment of pain control) and tolerability (adverse events [AEs], patients' tolerability judgment).

RESULTS

A total of 119 patients were enrolled (PIT, n = 59; T, n = 60). Demographic characteristics of patients were comparable between the PIT and T groups in regard to age (mean, 56.5 vs 54.1 years, respectively), sex (women/men, 38121 vs 31129), race (white, 96.1% vs 94.2%), and body mass index (24.9 vs 26.1 kg/m2). Pain intensity (mean [SD] percentage of worst imaginable pain) improved from nearly identical levels at baseline (P/T, 67.5 [13.0] vs T, 65.3 [14.6]; P = NS) to similarly low levels at the final visit (P/T, 27.9 [22.7] vs T, 24.8 [21.6]; P = NS). The reduction in pain intensity was significant in both treatment groups (P < 0.001). Adequate pain relief (ie, "moderate," "important," or "complete") was observed in 81.6% (40149) of PIT patients versus 82.9% (39147) of T patients (P = NS). Comparably high rates of overall patient satisfaction (72.5% [37151] vs 72.9% [35148], respectively; P = NS) were achieved. Both treatment groups took a comparable number of daily units of study medication, which resulted in significantly (P < 0.001) lower daily doses of tramadol in the P/T group (mean [SD], 172.5 [46.6] mg) than in the T group (227.3 [59.7] mg). More P/T patients (84.3%) than T patients (68.8%) judged treatment tolerability as good or very good (P = NS). Significantly fewer AEs (P < 0.001) were observed in PIT patients, and the overall incidence of AEs (mostly opioid-typical AEs [eg, nausea, dizziness/vertigo, sleepiness/drowsiness, constipation, vomiting]) was much lower after P/T compared with T (P = 0.019). The most common AEs in the P/T and T groups were nausea (8159 vs 21160 patients, respectively; P = 0.012) and dizziness (3/59 vs 15/60 patients; P= 0.006).

CONCLUSIONS

Tramadol, alone and in combination with paracetamol, provided highly effective analgesia for these patients with subacute LSP However, the combination of PIT, which resulted in 25% less tramadol than equianalgesic daily doses of T alone, considerably reduced the incidence of AEs and improved tolerability.

Back education in elementary schoolchildren: the effects of adding a physical activity promotion program to a back care program

Promoting a physically active lifestyle whilst optimizing the spinal load at a young age seems to be advocated within the scope of early back pain prevention efforts. The present study aimed at evaluating the effects of combining a back care program with a physical activity promotion program in elementary schoolchildren. In a pre-post design over two school years, back care knowledge, back care behavior, fear avoidance beliefs and back pain reports were evaluated in children classified into three categories--those who received a back care and a physical activity promotion program (n=190), those who received only a back care program (n=193) and those in a control group (n=172) (mean age at baseline: 9.7 years+/-0.7). Physical activity levels were evaluated in a sub-sample of 26 pupils in each group. The back care program and the physical activity promotion program were both comprehensive ones. In both intervention groups, the scores for back care related knowledge and back care behavior were significantly higher than the control group. The increase in the sum score for back care behavior was significantly higher in the back care group than in the back care plus physical activity promotion group. Significant interaction effects showed an increase in fear-avoidance beliefs between pre- and post-tests in the control group, significantly different from the better scores in both intervention groups. Interaction effects were not significant for pain reports. In the back care plus physical activity promotion group, the daily moderate to vigorous physical activity levels decreased by 8 min per day while a decrease by 31 min per day was found in the back care group and a decrease by 36 min per day in the control group. However, group differences were not significant. The present study findings favor the addition of a physical activity promotion program to a back care program in elementary schools within the scope of early back pain prevention efforts. However, the findings also emphasize the disadvantages of implementing both programs simultaneously in a school curriculum that is already full.

Low back pain prevention's effects in schoolchildren. What is the evidence?

Given the high prevalence rates of back pain, as early as in childhood, there has been a call for early preventive interventions. To determine which interventions are used to prevent back problems in schoolchildren, as well as what the evidence is for their utility, the literature was searched to locate all investigations that used subjects under the age of 18 and not seeking treatment. Included investigations were specifically designed as an intervention for low back pain (LBP) prevention. Additionally, a literature search was performed for modifiable risk factors for LBP in schoolchildren. The literature-update search was performed within the scope of the "COST Action B13" of the European Commission, approved for the development of European guidelines for the management of LBP. It was concluded that intervention studies in schoolchildren focusing on back-pain prevention are promising but too limited to formulate evidence-based guidelines. On the other hand, since the literature shows that back-pain reports about schoolchildren are mainly associated with psychosocial factors, the scope for LBP prevention in schoolchildren may be limited. However, schoolchildren are receptive to back-care-related knowledge and postural habits, which may play a preventive role for back pain in adulthood. Further studies with a follow-up into adulthood are needed to evaluate the long-term effect of early interventions and the possible detrimental effect of spinal loading at young age.