Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Effectiveness of coordinated care to reduce the risk of prolonged disability among patients suffering from subacute or recurrent acute low back pain in primary care: protocol of the CO.LOMB cluster-randomized, controlled study

Background

Low back pain (LBP) is a common musculoskeletal condition and, globally, a leading cause of years lived with disability. It leads to reduced social participation, impaired quality of life, and direct and indirect costs due to work incapacity. A coordinated approach focusing on psychosocial risk factors, active reeducation, and the early use of tools to maintain employment, may be effective for improving prognosis of patients with LBP. Primary care professionals and multidisciplinary teams, who see patients in the early stages of LBP may be in the best position to implement such a coordinated approach. We designed this study to assess a coordinated multi-faceted strategy in primary care for patients with subacute or recurrent acute LBP.

Methods

The CO.LOMB study was designed as a multicentric, cluster-randomized, controlled study. Patients aged 18-60 years, with subacute or recurrent acute LBP are eligible. Patients also need to be employed (but can be on sick leave) with access to occupational health services. The clusters of GPs will be randomized (1:1) to either the Coordinated-care group or the Usual-care group. Patients will be assigned the group allocated to their GP. The healthcare professionals (GPs and associated physiotherapists) allocated to the Coordinated-care group will perform a 2-session study training. The following interventions are planned in the Coordinated-care group: exploration and management of psychosocial factors, active reeducation with a physiotherapist, the implementing of tools to maintain employment, and a reinforced cooperation between primary healthcare professionals. The primary objective is to assess the benefit of coordinated primary care to reduce disability in LBP patients at 12 months after enrollment: measure using the validated French version of the Roland Morris Disability Questionnaire. Secondary objectives include the evaluation of pain, work status, and quality of life at various time points. The study plans to enroll 500 patients in 20 GP clusters. Patients will be followed up for 12months.

Discussion

This study will evaluate the benefit of a coordinated multi-faceted strategy in primary care for patients with LBP. Notably whether this approach will alleviate the associated disability, attenuate pain, and promote the maintenance or return to work.

Clinical Trial Registration

NCT04826757.

Spinal Pain, Chronic Health Conditions and Health Behaviors: Data from the 2016-2018 National Health Interview Survey

Spinal pain and chronic health conditions are highly prevalent, burdensome, and costly conditions, both in the United States and globally. Using cross-sectional data from the 2016 through 2018 National Health Interview Survey (n = 26,926), we explored associations between spinal pain and chronic health conditions and investigated the influence that a set of confounders may have on the associations between spinal pain and chronic health conditions. Variance estimation method was used to compute weighted descriptive statistics and measures of associations with multinomial logistic regression models. All four chronic health conditions significantly increased the prevalence odds of spinal pain; cardiovascular conditions by 58%, hypertension by 40%, diabetes by 25% and obesity by 34%, controlling for all the confounders. For all chronic health conditions, tobacco use (45-50%), being insufficiently active (17-20%), sleep problems (180-184%), cognitive impairment (90-100%), and mental health conditions (68-80%) significantly increased the prevalence odds of spinal pain compared to cases without spinal pain. These findings provide evidence to support research on the prevention and treatment of non-musculoskeletal conditions with approaches of spinal pain management.

Sensorimotor, cognitive and affective behavior according to perceived level of disability in patients with chronic low back pain: an observational cross-sectional study

OBJECTIVES

The aim was to evaluate the influence of the level of disability on sensorimotor and psychological variables in nonspecific chronic low back pain (NCLBP).

METHODS

A cross-sectional observational study was performed with 90 participants, divided into one group with NCLBP (60 participants) and one asymptomatic group (30 participants). Symptomatic participants were divided into a "major" or "minor" disability group using the Roland Morris Disability Questionnaire score, resulting in two groups of 30 participants. All participants completed a series of self-administered questionnaires and performed sensorimotor tests.

RESULTS

There were no statistically significant differences in the sensorimotor variables except in pain intensity, which was greater in the NCLBP group with high lumbar disability. There were statistically significant differences between the symptomatic groups in the degree of self-efficacy, pain catastrophism and kinesiophobia.

CONCLUSIONS

Patients with NCLBP and high levels of disability present greater pain intensity and significantly poorer results in psychological variables compared with those with NCLBP and low levels of disability. In contrast, there were no differences for sensorimotor variables between the patients with NCLBP and high levels of disability and those with low levels of disability.

Risk factors for low back pain outcome: Does it matter when they are measured?

BACKGROUND

The early identification of factors that increase risk of poor recovery from acute low back pain (LBP) is critical to prevent the transition to chronicity. Although most studies of risk factors for poor outcome in LBP tend to investigate the condition once it is already persistent, there is evidence to suggest that this differs from risk factors measured during the early-acute stage. This study aimed to identify early risk factors for poor outcome in the short- and long-term in individuals with acute LBP, and to compare this with factors identified at 3 months in the same cohort.

METHODS

One hundred and thirty-three individuals were recruited within 2 weeks of an acute LBP episode and completed questionnaires related to their sociodemographic, psychological, clinical and history/treatment status at baseline and 3 months later, and their pain-level fortnightly for 12 months.

RESULTS

Of the 133 participants recruited, follow-up data was provided by 120 at 3 months, 97 at 6 months, 85 at 9 months and 94 at 12 months. Linear regression identified various factors at baseline (acute phase) and 3 months later that predicted short- and long-term outcome (pain level, change in pain). Key findings were that: (1) depressive symptoms at baseline most consistently predicted worse outcome; (2) psychological factors in general at 3 months were more predictive of outcome than when measured at baseline; (3) early health care utilisation predicted better outcome, whereas use of pain medication later (3 months) predicted worse outcome; and (4) sex and BMI predicted outcome inconsistently over 12-months.

CONCLUSIONS

The results highlight the multidimensional nature of risk factors for poor outcome in LBP and the need to consider time variation in these factors.

The Hausa Back Beliefs Questionnaire: Translation, cross-cultural adaptation and psychometric assessment in mixed urban and rural Nigerian populations with chronic low back pain

INTRODUCTION

Negative attitudes and beliefs about low back pain (LBP) can lead to reduced function and activity and consequently disability. One self-report measure that can be used to assess these negative attitudes and beliefs and to determine their predictive nature is the Back Beliefs Questionnaire (BBQ). This study aimed to translate and cross-culturally adapt the BBQ into Hausa and assess its psychometric properties in mixed urban and rural Nigerian populations with chronic LBP.

METHODS

The BBQ was translated and cross-culturally adapted into Hausa (Hausa-BBQ) according to established guidelines. To assess psychometric properties, a consecutive sample of 200 patients with chronic LBP recruited from urban and rural clinics of Nigeria completed the questionnaire along with measures of fear-avoidance beliefs, pain catastrophizing, functional disability, physical and mental health, and pain. One hundred of the 200 patients completed the questionnaire twice at an interval of 7-14 days to assess test-retest reliability. Internal construct validity was assessed using exploratory factor analysis, and external construct validity was assessed by examining convergent, divergent, and known-groups validity. Reliability was assessed by calculating internal consistency (Cronbach's α), intraclass correlation coefficients (ICC), standard error of measurement (SEM), minimal detectable change at 95% confidence interval (MDC95), and limits of agreement using Bland-Altman plots. Reliability (ICC, SEM and MDC95) was also assessed separately for rural and urban subgroups.

RESULTS

The factor analysis revealed a four-factor solution explaining 58.9% of the total variance with the first factor explaining 27.1%. The nine scoring items loaded on the first factor hence supporting a unidimensional scale. The convergent and divergent validity were supported as 85% (6:7) of the predefined hypotheses were confirmed. Known-groups comparison showed that the questionnaire discriminated well for those who differed in education (p < 0.05), but not in age (p > 0.05). The internal consistency and ICC (α = 0.79; ICC = 0.91) were adequate, with minimal SEM and MDC95 (1.9 and 5.2, respectively). The limits of agreements were -5.11 to 5.71. The ICC, SEM and MDC95 for the urban and rural subgroups were comparable to those obtained for the overall population.

CONCLUSIONS

The Hausa-BBQ was successfully adapted and psychometrically sound in terms of internal and external construct validity, internal consistency, and test-retest reliability in mixed urban and rural Hausa-speaking populations with chronic LBP. The questionnaire can be used to detect and categorize specific attitudes and beliefs about back pain in Hausa culture to prevent or reduce potential disability due to LBP.

Development of the Hausa version of the Pain Catastrophizing Scale: translation, cross-cultural adaptation and psychometric evaluation in mixed urban and rural patients with chronic low back pain

Background

Catastrophizing has been recognized as an important contributor to chronicity in individuals with chronic pain syndromes including low back pain (LBP). The Pain Catastrophizing Scale (PCS) is perhaps the most widely used tool to evaluate the degree of pain catastrophizing. However, its use is limited in Hausa-speaking countries due to the lack of a validated translated version.

Objective

To translate and cross-culturally adapt the PCS into Hausa (Hausa-PCS), and evaluate its psychometric properties in mixed urban and rural patients with chronic LBP.

Methods

The PCS was translated and cross-culturally adapted into Hausa in accordance with established guidelines. To evaluate its psychometric properties, a consecutive sample of 200 patients with chronic LBP was recruited from urban and rural Nigerian hospitals. Validity was evaluated by exploring content validity, factorial structure (confirmatory factor analysis [CFA]), construct validity (Spearman’s rho for a priori hypotheses) and known-groups validity. Reliability was evaluated by calculating internal consistency (Cronbach’s α), intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC) and limits of agreement with 95% confidence interval (LOA_95%).

Results

The Hausa-PCS was comprehensible with good content validity. The CFA confirmed a 3-factor structure similar to the original English version. The concurrent validity was supported as 83% (5/6) of the a priori hypotheses were confirmed. Known-groups comparison showed that the questionnaire was unable to differentiate between male and female or urban and rural patients (p > 0.05). Internal consistency and ICC were adequate for the Hausa-PCS total score (α = 0.84; ICC = 0.90) and the subscale helplessness (α = 0.78; ICC = 0.89) but for the subscales rumination (α = 0.69; ICC = 0.68) and magnification (α = 0.41; ICC = 0.43). The LOA_95% for the Hausa-PCS total score was between − 8.10 and + 9.75, with SEM and MDC of 3.47 and 9.62 respectively.

Conclusion

The Hausa-PCS was successfully developed and psychometrically adequate in terms of factorial structure, construct validity, internal consistency and test–retest reliability when applied in mixed urban and rural patients with chronic LBP. However, the internal consistency and reliability coefficients (ICC) for the individual subscales are inadequate. Thus, we support the use of the total score when evaluating pain catastrophizing for clinical or research purposes.

Yellow flag on prognostic factors for non-specific chronic low back pain patients subjected to mini-invasive treatment: a cohort study

OBJECTIVES

Research was conducted to study the efficacy of analgesic infiltration treatment in a well-selected population of patients with non-specific drug-resistant chronic low back pain. It studied the pain on a numeric rating scale and the physical and mental condition of patients using a short-form health survey-36, before and six months after invasive pain treatment.

DESIGN

This is a prospective observational single center cohort study.

SETTING

The study took place in the Multimodal Pain Therapy Unit of the IRCCS Institute of Neurological Sciences in Bologna, Italy.

SUBJECTS

Four hundred and thirteen out of a total 538 patients admitted to the unit with non-specific drug-resistant chronic low back pain were enrolled in the study.

METHOD

Patients were enrolled with written consent between April 2017 and November 2018. The study assessed NRS, BDI and SF-36 scores before and six months after mini-invasive treatment.

RESULTS

There is an inverse correlation between Mental Component Scale (MCS) and Physical component scale as measured by SF-36. Older patients in a worse physical condition but with a more positive outlook on their quality of life were more likely to improve after invasive treatment (p < 0.001). The BDI scale is more effective in the diagnosis of depression than MCS.

CONCLUSIONS

The prognostic value of MCS given to the patient before mini-invasive treatment could lead physicians to adopt a multimodal approach that includes consideration of the psychological features of pain and possibly antidepressant therapy.

Psychosocial areas of worklife and chronic low back pain: a systematic review and meta-analysis

BACKGROUND

The aim of this review was to synthesize the evidence on the potential relationship between psychosocial work factors from the Areas of Worklife (AW) model (workload, job control, social support, reward, fairness, and values) and chronic low back pain (CLBP; unspecific pain in the lumbar region lasting 3 months or longer).

METHODS

We conducted a systematic literature search of studies in Medline, PsycINFO, Web of Science, and CINAHL (1987 to 2018). Three authors independently assessed eligibility and quality of studies. In this meta-analysis, we pooled studies' effect sizes using a random-effects model approach and report sample size weighted mean Odds Ratios (ORs).

RESULTS

Data from 18 studies (N = 19,572) was included in the analyses. We found no studies investigating associations between fairness or values and CLBP. CLBP was significantly positively related to workload (OR = 1.32) and significantly negatively related to overall job control (OR = 0.81), decision authority (OR = 0.72), and two measures of social support (ORs = 0.75 to 0.78), even in prospective studies. Skill discretion and reward did not significantly relate to CLBP. Moderation analyses revealed several variables (e.g., exposure time, mean age and sex) affecting these relationships.

CONCLUSIONS

Our results support employees' workload, job control, and social support as predictors of CLBP. In this line, these work factors should be considered when developing programs to prevent chronic low back pain. Future studies should apply measures of CLBP that are more precise, and investigate the full areas of work life (AW) factors in combination.

Five-year development of lumbar disc degeneration-a prospective study

OBJECTIVE

To examine the impact of demographic, clinical, and genetic factors as well as herniated discs on 5-year development of disc degeneration in the lumbar spine, and to investigate associations between changes in lumbar degenerative findings and pain.

MATERIALS AND METHODS

In 144 patients with lumbar radicular pain or low back pain, we scored disc degeneration, herniated discs, and high-intensity zones in the posterior annulus fibrosus on lumbar magnetic resonance imaging (MRI) at baseline and 5-year follow-up. Genotyping (TaqMan assay) was performed for genes encoding vitamin D receptor (VDR), collagen XIα (COL11A), matrix metalloproteinase 1/9 (MMP1/MMP9), and interleukin 1α/1RN (IL-1α/IL-1RN). Associations were analyzed using multivariate linear regression adjusted for age, sex, smoking, body mass index, and baseline scores for degenerated discs and herniated discs (when analyzing impact of baseline factors) or for pain (when analyzing associations with pain).

RESULTS

Progression of disc degeneration over 5 years was significantly (p < 0.001) related to higher age and less disc degeneration at baseline, but not to sex, smoking, body mass index, herniated discs, or variants in the studied genes. No associations were identified between changes in disc degeneration or high-intensity zones and pain at 5-year follow-up. However, increased number of herniated discs over 5 years was associated with pain at rest (p = 0.019).

CONCLUSIONS

Age and disc degeneration at baseline, rather than genetic factors, influenced the 5-year development of disc degeneration in patients with lumbar radicular pain or low back pain. Development of herniated discs was related to pain at rest.

Analysis of Motor Control in Patients With Low Back Pain: A Key to Personalized Care?

Motor control exercise has been shown to be effective in the management of low back pain (LBP). However, the effect sizes for motor control exercise are modest, possibly because studies have used a one-size-fits-all approach, while the literature suggests that patients may differ in presence or type of motor control issues. In this commentary, we address the question of whether consideration of such variation in motor control issues might contribute to more personalized motor control exercise for patients with LBP. Such an approach is plausible, because motor control changes may play a role in persistence of pain through effects on tissue loading that may cause nociceptive afference, particularly in the case of peripheral sensitization. Subgrouping systems used in clinical practice, which comprise motor control aspects, allow reliable classification that is, in part, aligned with findings in studies on motor control in patients with LBP. Motor control issues may have heuristic value for treatment allocation, as the different presentations observed suggest different targets for motor control exercise, but this remains to be proven. Finally, clinical assessment of patients with LBP should take into account more aspects than motor control alone, including pain mechanisms, musculoskeletal health, and psychosocial factors, and may need to be embedded in a stratification approach based on prognosis to avoid undue diagnostic procedures. J Orthop Sports Phys Ther 2019;49(6):380-388. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7916.

Development of a standard set of outcome measures for non-specific low back pain in Dutch primary care physiotherapy practices: a Delphi study

PURPOSE

To develop a clinical standard set of outcome measures that are accepted for relevance and feasibility by stakeholders and useful for (a) interaction between patient and the professional, e.g. shared decision-making in goal-setting, monitoring and feedback based on outcomes, (b) internal quality improvement, and (c) external transparency in patients with non-specific low back pain (NSLBP) in primary care physical therapy.

METHODS

We used a consensus-driven modified RAND-UCLA Delphi method in seven steps with panellists (patients, representatives of patient and physiotherapy associations, researchers, policy makers, health insurers): (1) literature search, (2) first online survey, (3) patient interviews, (4) an experts meeting, (5) a consensus meeting, (6) second online survey, and (7) final approval of an advisory board. Steps 1-4 resulted in potential outcome measures. In the consensus meeting after discussion panellists voted for inclusion per measure. In the second online survey the final standard set was rated on relevance and feasibility on a 9-point Likert scale; when the median score was ≥ 7, the standard set was accepted and finally approved.

RESULTS

Thirteen draft outcome measures were rated and discussed, and finally, six outcome measures were accepted. The standard set includes the Quebec Back Pain Disability Scale, Oswestry Disability Index, Patient-Specific Functional Scale, Numeric Pain Rating Scale, Global Perceived Effect (GPE-DV), and the STarT Back Screening Tool (SBT).

CONCLUSION

This study presents a standard set of outcome measures for patients with NSLBP in primary care physiotherapy accepted for relevance and feasibility by stakeholders. The standard set is currently used in daily practice and tested on validity and reliability in a pilot study. These slides can be retrieved under Electronic Supplementary Material.

Low back pain among primary school teachers in Rural Kenya: Prevalence and contributing factors

Background

Low back pain (LBP) has been recognised as a common occupational problem with a high prevalence among work-related musculoskeletal disorders. Although there appears to be a high prevalence of LBP among school teachers, there is inadequate information on the prevalence and predisposing factors of LBP among primary school teachers in rural Western Kenya.

Aim

To determine the prevalence, factors associated with LBP and physical disability caused by LBP.

Setting

The setting was public schools in rural Western Kenya selected by simple random sampling method.

Methods

A cross-sectional study was conducted among primary teachers from public schools using a self-administered questionnaire. The questionnaire included information on LBP, demographic data, occupational and psychosocial factors and disability score. The 12-month prevalence, associated factors and LBP disability were analysed.

Results

The 12-month self-reported prevalence of LBP among primary teachers was 64.98%, with close to 70% of them reporting minimal disability. The logistic regression analysis showed that female gender (odds ratio [OR]: 1.692, p < 0.02) was associated with LBP and high supervisor support (OR: 0.46, p < 0.003) was negatively associated with LBP.

Conclusion

The prevalence of LBP among primary school teachers in rural Western Kenya is 64.98%, with the majority of them reporting minimal disability. The identified risk factors were female gender and low supervisor support. The presence of work-related psychosocial risk factors in this study suggests a comprehensive approach in evaluation and management of LBP. Preventive measures should be in place to prevent and reduce the progression of LBP disability.

Keywords

low back pain; rural; Kenya; teachers, primary school; public schools; risk factors; disability.

The influence of an educational internet-based intervention in the beliefs and attitudes of primary care professionals on non-specific chronic low back pain: study protocol of a mixed methods approach

BACKGROUND

Personal convictions in referral to pain cause misbeliefs in health professionals, which can influence patients who suffer from non-specific chronic low back pain. Likewise, health professionals' beliefs affect their advice and attitudes towards patients' treatment, becoming a possible cause of greater disability. The development of educational interventions based on the best scientific evidence in neurophysiology of pain could be a way to provide information and advice to primary care health professionals to change their cognition towards chronic non-specific low back pain. The use of Information and Communication Technologies allows the development of web sites, which might be one of the effective resources to modify misbeliefs and attitudes, in relation to the origin and meaning of non-specific chronic low back pain, of primary care professionals and that may modify their attitudes in patients' treatment.

METHODS

The aim of this project is to identify misbeliefs and attitudes of primary care physicians and nurses about chronic non-specific low back pain to develop a web-based educational tool using different educational formats and gamification techniques. This study has a mixed-method sequential exploratory design. The participants are medical and nursing staff working in primary care centers in the city of Lleida, Spain. For the qualitative phase of this study, the authors will use personal semi-structured interviews. For the quantitative phase the authors will use an experimental study design. Subjects will be randomly allocated using a simple random sample technique. The intervention group will have access to the web site where they will find information related to non-specific chronic low back pain, based on the information obtained in the qualitative phase. The control group will have access to a video explaining the clinical practice guidelines on low back pain.

DISCUSSION

This study has been designed to explore and modify the beliefs and attitudes about chronic low back pain of physicians and nurses working in primary care settings, using a web-based educational tool with different educational formats and gamification techniques. The aim of the educational intervention is to change their knowledge about the origin and meaning of pain, with the result of reducing their misbeliefs and attitudes of fear avoidance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02962817 . Date of registration: 11/09/2016.

Monte Carlo Simulations Demonstrate Algorithmic Interventions Over Time Reduce Hospitalisation in Patients With Schizophrenia and Bipolar Disorder

Non-adherence with pharmacologic treatment is associated with increased rates of relapse and rehospitalisation among patients with schizophrenia and bipolar disorder. To improve treatment response, remission, and recovery, research efforts are still needed to elucidate how to effectively map patient’s response to medication treatment including both therapeutic and adverse effects, compliance, and satisfaction in the prodromal phase of illness (ie, the time period in between direct clinical consultation and relapse). The Actionable Intime Insights (AI²) application draws information from Australian Medicare administrative claims records in real time when compliance with treatment does not meet best practice guidelines for managing chronic severe mental illness. Subsequently, the AI² application alerts clinicians and patients when patients do not adhere to guidelines for treatment. The aim of this study was to evaluate the impact of the AI² application on the risk of hospitalisation among simulated patients with schizophrenia and bipolar disorder. Monte Carlo simulation methodology was used to estimate the impact of the AI² intervention on the probability of hospitalisation over a 2-year period. Results indicated that when the AI² algorithmic intervention had an efficacy level of (>0.6), over 80% of actioned alerts were contributing to reduced hospitalisation risk among the simulated patients. Such findings indicate the potential utility of the AI² application should replication studies validate its methodologic and ecological rigour in real-world settings.

Characterizing the demographics of chronic pain patients in the state of Maine using the Maine all payer claims database

BACKGROUND

Chronic pain is currently a significant health problem in the United States. A comprehensive strategy is needed to increase prevention of chronic pain and to improve care for chronic pain patients. However, development of a successful strategy relies, in part, on a better understanding of the demographics and socioeconomics of patients living with chronic pain conditions. The current study was designed to understand the burden of chronic pain in the state of Maine by identifying the prevalence of chronic pain and its relationship with selected demographic and socioeconomic factors in Maine.

METHODS

The Maine All Payer Claims Database (MEAPCD) (2006-2011) was used in the secondary data analysis to assess the demographic characteristics (such as age, sex, insurance type, and county of residence) of chronic pain patients in Maine. Chronic pain patients were identified based on the presence of pre-identified chronic pain-associated ICD-9 code(s) and opioid prescription information. Potential associations between the prevalence of chronic pain and a number of socioeconomic factors were determined by comparisons to Maine Census data.

RESULTS

More women in the state were identified as having chronic pain across all counties and all age groups (> 10 years old). Surprisingly, the majority of chronic pain patients were identified based on the diagnostic code criteria and not the opioid prescription criteria. A greater utilization of public health insurance was seen within the chronic pain patients. At the county level, although neither education level nor income were associated with the prevalence of chronic pain, these factors significantly correlated with the usage of public health insurance.

CONCLUSIONS

Further detailed characterization of the chronic pain patient population in the state of Maine, using multiple data sources, can help design population-targeted strategies to prevent and manage chronic pain.

Effectiveness of classic physical therapy proposals for chronic non-specific low back pain: a literature review

INTRODUCTION

Chronic low back pain is a pathological process that compromises the functionality and quality of life worldwide. The objective of the study was to evaluate the effectiveness of classical physiotherapy in the management of non-specific chronic low back pain.

METHODS

A literature search in English electronic databases was performed from November to December of 2015. Only those studies addressing chronic non-specific low back pain by manual therapy and different types of exercises methods were included, and those, which combined acute or subacute pain with systematic reviews and clinical practice guidelines, were excluded. Studies involving cognitive-behavioral approaches were also excluded.

RESULTS

487 studies were identified, 16 were analyzed and 10 were excluded. Of the 6 studies reviewed, 5 of them achieved a moderate quality and 1 of them was of a low quality. Back School exercises and McKenzie's method were all ineffective. Osteopathic spinal manipulation proved effective when performed on the lower back and the thoracic area but only immediately after it was received, and not in the medium or long term. Massages proved effective in the short term too, as well as the global postural reeducation although ultimately this study can be considered of a low methodological quality.

CONCLUSIONS

Based on the data obtained, classical physiotherapy proposals show ineffectiveness in the treatment of chronic non-specific low back pain. More multidimensional studies are needed in order to achieve a better treatment of this condition, including the biopsychosocial paradigm.

[Clinical-demographic factors associated with fear-avoidance in subjects with non-specific chronic low back pain in Primary Care: secondary analysis of intervention study]

Objetivo

Describir algunas características sociodemográficas y clínicas de los sujetos con lumbalgia crónica inespecífica (LCI) atendidos habitualmente en atención primaria (AP), así como investigar su asociación con el miedo-evitación (ME).

Diseño

Descriptivo transversal. Análisis secundario de estudio de intervención.

Emplazamiento

Zonas Básicas de Salud del Distrito Sanitario de AP Costa del Sol (Málaga).

Participantes

Un total de 147 sujetos con LCI extraídos de la base de datos de un estudio de intervención previo en fisioterapia de AP. Características: edad, 18-65 años; comprensión del idioma español; ausencia de deterioro cognitivo, ausencia de fibromialgia, ausencia de cirugía dorsolumbar, y tolerancia al ejercicio físico.

Mediciones principales

La variable principal fue el ME (FABQ y subescalas FABQ-PA y FABQ-W); las variables clínicas incluyeron: dolor (NRPS-11), discapacidad (RMQ), tiempo de evolución, tratamientos previos y diagnósticos de imagen; las variables sociodemográficas incluyeron: sexo, edad, nivel educativo y situación laboral.

Resultados

El 51,7% de los sujetos presentaron elevado ME con la escala FABQ-PA. Incapacidad temporal (IT) [β = 24,45 (p = 0,009^*); β = 13,03 (p = 0,016^*); β = 14,04 (p = 0,011^*) para FABQ, FABQ-PA y FABQ-W, respectivamente]; estudios primarios [β = 15,09 (p = 0,01^*); β = 9,73 (p = 0,01^*) para FABQ y FABQ-PA], y discapacidad [β = 1,45 (p < 0,001); β = 0,61 (p < 0,001); β = 0,68 (p < 0,001) para FABQ, FABQ-PA y FABQ-W, respectivamente] aparecieron asociados al ME cuando fueron modelados por regresión multivariante.

Conclusiones

Algunos rasgos sociodemográficos y clínicos de la población con LCI son presentados. Las pruebas de imagen (81,63%) y los tratamientos previos pasivos (55,78%) podrían reflejar problemas de adherencia a las recomendaciones de las GPC. IT, estudios primarios y discapacidad se asociaron al ME. Los hallazgos deben ser interpretados a la luz de las posibles limitaciones. Algunas sugerencias para la práctica clínica son aportadas.

Risk and protective factors in the clinical rehabilitation of chronic back pain

OBJECTIVES

Chronic back pain (CBP) can lead to disability and burden. In addition to its medical causes, its development is influenced by psychosocial risk factors, the so-called flag factors, which are categorized and integrated into many treatment guidelines. Currently, most studies investigate single flag factors, which limit the estimation of individual factor significance in the development of chronic pain. Furthermore, factors concerning patients' lifestyle, biography and treatment history are often neglected. Therefore, the objectives of the present study are to identify commonly neglected factors of CBP and integrate them into an analysis model comparing their significance with established flag factors.

METHODS

A total of 24 patients and therapists were cross-sectionally interviewed to identify commonly neglected factors of CBP. Subsequently, the impact of these factors was surveyed in a longitudinal study. In two rehabilitation clinics, CBP patients (n = 145) were examined before and 6 months after a 3-week inpatient rehabilitation. Outcome variables, chronification factor pain experience (CF-PE) and chronification factor disability (CF-D), were ascertained with confirmatory factor analysis (CFA) of standardized questionnaires. Predictors were evaluated using stepwise calculations of simple and multiple regression models.

RESULTS

Through interviews, medical history, iatrogenic factors, poor compliance, critical life events (LEs), social support (SS) type and effort-reward were identified as commonly neglected factors. However, only the final three held significance in comparison to established factors such as depression and pain-related cognitions. Longitudinally, lifestyle factors found to influence future pain were initial pain, physically demanding work, nicotine consumption, gender and rehabilitation clinic. LEs were unexpectedly found to be a strong predictor of future pain, as were the protective factors, reward at work and perceived SS.

DISCUSSION

These findings shed insight regarding often overlooked factors in the development of CBP, suggesting that more detailed operationalization and superordinate frameworks would be beneficial to further research.

CONCLUSION

In particular, LEs should be taken into account in future research. Protective factors should be integrated in therapeutic settings.

Low back pain in healthy postmenopausal women and the effect of physical activity: A secondary analysis in a randomized trial

Epidemiological studies on the prevalence of musculoskeletal pain have consistently shown that this is a relevant health problem, with non-specific low back pain (LBP) being the most commonly reported in adult females. Conflicting data on the association between LBP symptoms and physical activity (PA) have been reported. Here, we investigated the prevalence of LBP and the effect of a 24-month non-specific PA intervention on changes in LBP prevalence in a series of Italian healthy postmenopausal women. We performed a secondary analysis in the frame of the DAMA trial, a factorial randomized intervention trial aimed to evaluate the ability of a 24-month intervention, based on moderate-intensity PA, and/or dietary modification, in reducing mammographic breast density in healthy postmenopausal women. The PA intervention included at least 1 hour/day of moderate PA and a more strenuous weekly activity, collective walks and theoretical group sessions. A self-administered pain questionnaire was administered at baseline and at the end of the intervention. The questionnaire was specifically structured to investigate the occurrence of musculoskeletal pain, the body localization, intensity and duration of the pain. Two hundred and ten women (102 randomized to PA intervention, 108 not receiving the PA intervention) filled out the questionnaires. At baseline LBP was present in 32.9% of the participants. Among women randomized to the PA intervention, LBP prevalence at follow up (21.6%) was lower than at baseline (33.3%) (p = 0.02), while in women who did not receive the PA intervention the LBP prevalence at baseline and follow up were 32.4% and 25.9%, respectively (p = 0.30). Overall, there was no significant between-group effect of PA intervention on LBP. Further studies are needed to understand the role of non-specific PA intervention, aimed to improve overall fitness, on LBP prevalence.

Lifetime Modulation of the Pain System via Neuroimmune and Neuroendocrine Interactions

Chronic pain is a debilitating condition that still is challenging both clinicians and researchers. Despite intense research, it is still not clear why some individuals develop chronic pain while others do not or how to heal this disease. In this review, we argue for a multisystem approach to understand chronic pain. Pain is not only to be viewed simply as a result of aberrant neuronal activity but also as a result of adverse early-life experiences that impact an individual's endocrine, immune, and nervous systems and changes which in turn program the pain system. First, we give an overview of the ontogeny of the central nervous system, endocrine, and immune systems and their windows of vulnerability. Thereafter, we summarize human and animal findings from our laboratories and others that point to an important role of the endocrine and immune systems in modulating pain sensitivity. Taking "early-life history" into account, together with the past and current immunological and endocrine status of chronic pain patients, is a necessary step to understand chronic pain pathophysiology and assist clinicians in tailoring the best therapeutic approach.

Comparison of the short-term effects of the conventional motorized traction with non-surgical spinal decompression performed with a DRX9000 device on pain, functionality, depression, and quality of life in patients with low back pain associated with lumbar disc herniation: A single-blind randomized-controlled trial

Objectives

This study aims to compare the efficiency of conventional motorized traction (CMT) with non-surgical spinal decompression (NSD) using the DRX9000™ device in patients with low back pain associated with lumbar disc herniation (LDH).

Patients and methods

Between March 2009 and September 2009, a total of 48 patients (29 females, 19 males; mean age 43.1±9.8 years; range, 18 to 65 years) were randomized into two groups. The first group (n=24) underwent CMT and the second group (n=24) underwent NSD for a total of 20 sessions over six weeks. The patients were evaluated before and after the treatment. Pain was assessed using the Visual Analog Scale (VAS), functional status using the Oswestry Disability Index (ODI), quality of life using the Short Form-36 (SF-36), state of depression mood using the Beck Depression Inventory (BDI), and the global assessment of the illness using the Patient's Global Assessment of Response to Therapy (PGART) and Investigator's Global Assessment of Response to Therapy (IGART) scales.

Results

There was no significant difference in the evaluation outcomes before the treatment between the groups. However, a statistically significant decline was found in the VAS, ODI, and BDI scores after the treatment in both groups (all p<0.001). Except for two subgroups, no significant changes were observed in the SF-36 form. Assessment of "marked improvement" was globally most frequently reported one in both groups. No significant difference was observed in the evaluation outcomes after treatment between the groups.

Conclusion

Our study results show that both CMT and NSD are effective methods in pain management and functional status and depressive mood improvement in patients with LDH, and NSD is not superior to CMT in terms of pain, functionality, depression and quality of life.

Current and future perspectives on lumbar degenerative disc disease: a UK survey exploring specialist multidisciplinary clinical opinion

OBJECTIVES

Despite lumbar degenerative disc disease (LDDD) being significantly associated with non-specific low back pain and effective treatment remaining elusive, specialist multidisciplinary clinical stakeholder opinion remains unexplored. The present study examines the views of such experts.

DESIGN

A reliable and valid electronic survey was designed to establish trends using theoretical constructs relating to current assessment and management practices. Clinicians from the Society of Back Pain Research (SBPR) UK were invited to take part. Quantitative data were collated and coded using Bristol Online Surveys (BOS) software, and content analysis was used to systematically code and categorise qualitative data.

SETTING

Specialist multidisciplinary spinal interest group in the UK.

PARTICIPANTS

38/141 clinically active, multidisciplinary SBPR members with specialist spinal interest participated. Among them, 84% had >9 years postgraduate clinical experience.

INTERVENTIONS

None.

OUTCOME MEASURES

Frequency distributions were used to establish general trends in quantitative data. Qualitative responses were coded and categorised in relation to each theme and percentage responses were calculated.

RESULTS

LDDD symptom recurrence, in the absence of psychosocial influence, was associated with physical signs of joint stiffness (26%), weakness (17%) and joint hypermobility (6%), while physical factors (21%) and the ability to adapt (11%) were postulated as reasons why some experience pain and others do not. No one management strategy was supported exclusively or with consensus. Regarding effective modalities, there was no significant difference between allied health professional and medic responses (p=0.1-0.8). The future of LDDD care was expressed in terms of improvements in patient communication (35%), patient education (38%) and treatment stratification (24%).

CONCLUSIONS

Results suggest that multidisciplinary expert spinal clinicians appear to follow UK-based assessment guidelines with regard to recurrent LDDD; there are, however, inconsistencies in the management approaches supported. This reflects the current literature and the lack of specific, formalised guidance. LDDD treatment stratification and further research are explicitly supported.

The Emotional Brain as a Predictor and Amplifier of Chronic Pain

Human neuroimaging studies and complementary animal experiments now identify the gross elements of the brain involved in the chronification of pain. We briefly review these advances in relation to somatic and orofacial persistent pain conditions. First, we emphasize the importance of reverse translational research for understanding chronic pain-that is, the power of deriving hypotheses directly from human brain imaging of clinical conditions that can be invasively and mechanistically studied in animal models. We then review recent findings demonstrating the importance of the emotional brain (i.e., the corticolimbic system) in the modulation of acute pain and in the prediction and amplification of chronic pain, contrasting this evidence with recent findings regarding the role of central sensitization in pain chronification, especially for orofacial pain. We next elaborate on the corticolimbic circuitry and underlying mechanisms that determine the transition to chronic pain. Given this knowledge, we advance a new mechanistic definition of chronic pain and discuss the clinical implications of this new definition as well as novel therapeutic potentials suggested by these advances.