Management of low back pain in computer users: A multidisciplinary approach

The impact of increased computer screen time during the COVID-19 pandemic on the occurrence of upper part of musculoskeletal diseases among health personnel

Health personnel who played a key role in the fight against the pandemic stayed during it burdened with increased working time using a computer. We analyzed the impact of increased computer working time during the COVID-19 pandemic on the occurrence of the upper part of musculoskeletal diseases among health personnel. The study group consisted of 418 health personnel, divided according to the time they worked at the computer during the pandemic: up to 2 h a day, from 3 to 5 h a day, and more than 6 h a day. The ICF profile analyzed symptoms of dysfunction of structures of the upper part of the musculoskeletal system (head and cervical spine, shoulder girdle, elbow joint, wrist joint). Employees working more than 6 h daily had a higher risk of developing restrictions in tone of isolated muscles and muscle groups p < 0.001), range of motion of the shoulder girdle (p < 0.001), increased tension of paraspinal muscles (p < 0.001), weakened shoulder girdle muscle strength (p < 0.001), elbow joint pain (p = 0.016), wrist joint pain (p < 0.001), coordination disorders (p = 0.004), difficulties in arm and hand use (p < 0.001), lifting and carrying objects (p = 0.008) and paraesthesia (p < 0.001) compared to those working less than 2 h daily. Additionally, working for 3-5 h and above 6 h compared to health personnel working up to 2 h was associated with a greater risk of headaches and cervical spine pain (p < 0.001), shoulder girdle pain (p < 0.001), limited mobility in the wrist joint (p = 0.003), and tremors (p < 0.001), that working below 2 h. Prolonged computer working time among health personnel during the COVID-19 pandemic is significantly associated with an increased risk of dysfunction and pain in structures of the upper part of the musculoskeletal system. Effective preventive measures are necessary to improve the functioning of the musculoskeletal system during extended periods of computer use.

Integrative medicine for musculoskeletal pains - A proposed model based on clinical experience

With an increasing number of chronic diseases and related disabilities, modern medicine is falling short of offering definitive, cost-effective, long-term solutions. As we realize contemporary medicine's limitations and side effects, we are gravitating towards whole-person care. Taking learnings from integrative medicine treatment of musculoskeletal pains, I comprehended that a paradigm shift is needed in thinking about etiopathogenesis and diagnosing disease. Different healing possibilities can be identified in humans if we shift our focus from reductionist science to whole-person care. Each health condition is an outcome of disturbed homeostasis involving multiple body systems. Based on homeostatic balancing principles and clinical experience, five interrelated and interdependent pathways are discussed. Based on these pathways, a working model of integrative medicine is presented. It can act as a template for medical practitioners to start integrative medicine practice for the benefit of patients. To make integrative medicine mainstream, there is a need to standardize care, frame regulations, train and educate the practitioners. At the same, it shall be put to rigorous scientific experimentation, research, and scrutiny.

Low Back Pain: A Comprehensive Review on the Diagnosis, Treatment Options, and the Role of Other Contributing Factors

BACKGROUND: In recent years, low back pain (LBP) is a growing major health issue around the world and mostly addressed in primary healthcare settings. This may be due to changing work environment including the nature of long sitting work hours, especially in the booming information and technology (IT) and Business Process Outsourcing (BPO) industry. LBP is normally considered as a combination of various types of pain and its related conditions, which eventually lead to disabilities. AIM: In this article, the aim is to discuss the current and future perspectives of LBP mainly on diagnosis and therapeutic front of LBP. METHODS: A search was performed using electronic databases, which include PubMed Central and Google Scholar, using the related key words “back pain and low back pain.” All related peer reviewed published articles were included regardless of the language, region, or the publication date. RESULTS: Although the management of LBP both in terms of diagnosis as well as in the therapeutic options has witnessed considerable progress but challenges are still exist not only within countries but also in the regions and continents among various medical professionals. However, in the past few years, a huge array of coordinated but randomized multi-center clinical studies were performed and various detailed insight investigations have been done, and substantial clinical guidelines have become available. Hence, a new view on evidence-based management approach for LBP has significantly improved recently and discussed here. CONCLUSION: Based on the available evidence and literature, this comprehensive review discusses the present and future perspectives of LBP mainly on diagnosis and therapeutic front for LBP. In addition, current intervention and prevention plans have failed to lessen the considerable burden of LBP and hence several areas which require more details, which deserves additional discussion to augment us through an understanding of this very important topic on improvements of multi tasked outcomes to benefit the affected patients.

Prevalence and predictors of low back pain in a Southern Nigerian hospital

Background

Low back pain (LBP) is the most common musculoskeletal disease in adults. The data on LBP from Sub-Saharan Africa are inadequate. The aim of this study was to assess the prevalence and analyze the predictors of LBP among hospital staff in a Nigerian tertiary hospital.

Materials and Methods

The study participants were recruited using an opt-in approach, with the aim of including representative numbers from each professional cadre. Each participant gave formal consent. Ethical clearance was obtained.

Results

Five hundred and sixty-three participants with the mean age of 36.0 ± 8.3 years and 62% female were interviewed. The point prevalence of LBP was 234 (42% [95% confidence interval [CI]: 37%-45%]). Profession was a significant predictor of LBP (P = 0.001) - nurses (53% [95% CI 43%-63%]), administrative officers (49% [95% CI 40%-59%]), engineers (50% [95% CI 24%-76%]), and health information staff (50% [95% CI 26%-75%]) had the highest prevalence. In univariate regression, female gender, increasing age, body mass index ≥25 kg/m2, and frequently adopting a bending posture, were significantly associated with LBP, while in multivariate regression, only the female gender was a significant predictor.

Conclusion

The pattern of both the professions at risk, due to the well-known mechanisms of poor ergonomics, and the marked risk for the female gender, in the hospital setting, suggest underresourced work and societal environments as the underlying factors-more research is needed.

Risk factors of non-specific neck pain and low back pain in computer-using office workers in China: a cross-sectional study

OBJECTIVES

Several studies have found that inappropriate workstations are associated with musculoskeletal disorders. The present cross-sectional study aimed to identify the risk factors of non-specific neck pain (NP) and low back pain (LBP) among computer-using workers.

DESIGN

Observational study with a cross-sectional sample.

SETTING

This study surveyed 15 companies in Zhejiang province, China.

PARTICIPANTS

After excluding participants with missing variables, 417 office workers, including 163 men and 254 women, were analyzed.

OUTCOME MEASURES

Demographic information was collected by self-report. The standard Northwick Park Neck Pain Questionnaire and Oswestry Low Back Pain Disability Index, along with other relevant questions, were used to assess the presence of potential occupational risk factors and the perceived levels of pain. Multinomial logistic regression analysis, adjusted for age, sex, body mass index, education, marital status and neck/low back injury, was performed to identify significant risk factors.

RESULTS

Compared with low-level NP, the computer location (monitor not in front of the operator, but on the right or left side) was associated with ORs of 2.6 and 2.9 for medium- and high-level NP, respectively. For LBP, the computer location (monitor not in front) was associated with an OR of 3.2 for high-level pain, as compared with low-level pain, in females. Significant associations were also observed between the office temperature and LBP (OR 5.4 for high vs low), and between office work duration ≥5 years and NP in female office workers (OR 2.7 for medium vs low).

CONCLUSIONS

Not having the computer monitor located in front of the operator was found to be an important risk factor for NP and LBP in computer-using female workers. This information may not only enable the development of potential preventive strategies but may also provide new insights for designing appropriate workstations.

Return-to-work coordination programmes for improving return to work in workers on sick leave

BACKGROUND

To limit long-term sick leave and associated consequences, insurers, healthcare providers and employers provide programmes to facilitate disabled people's return to work. These programmes include a variety of coordinated and individualised interventions. Despite the increasing popularity of such programmes, their benefits remain uncertain. We conducted a systematic review to determine the long-term effectiveness of return-to-work coordination programmes compared to usual practice in workers at risk for long-term disability.

OBJECTIVES

To assess the effects of return-to-work coordination programmes versus usual practice for workers on sick leave or disability.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), MEDLINE, Embase, CINAHL and PsycINFO up to 1 November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled workers absent from work for at least four weeks and randomly assigned them to return-to-work coordination programmes or usual practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full-text articles for study eligibility; extracted data; and assessed risk of bias from eligible trials. We contacted authors for additional data where required. We conducted random-effects meta-analyses and used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

We identified 14 studies from nine countries that enrolled 12,568 workers. Eleven studies focused on musculoskeletal problems, two on mental health and one on both. Most studies (11 of 14) followed workers 12 months or longer. Risk of bias was low in 10 and high in 4 studies, but findings were not sensitive to their exclusion.We found no benefits for return-to-work coordination programmes on return-to-work outcomes.For short-term follow-up of six months, we found no effect on time to return to work (hazard ratio (HR) 1.32, 95% confidence interval (CI) 0.93 to 1.88, low-quality evidence), cumulative sickness absence (mean difference (MD) -16.18 work days per year, 95% CI -32.42 to 0.06, moderate-quality evidence), the proportion of participants at work at end of the follow-up (risk ratio (RR) 1.06, 95% CI 0.86 to 1.30, low-quality evidence) or on the proportion of participants who had ever returned to work, that is, regardless of whether they had remained at work until last follow-up (RR 0.87, 95% CI 0.63 to 1.19, very low-quality evidence).For long-term follow-up of 12 months, we found no effect on time to return to work (HR 1.25, 95% CI 0.95 to 1.66, low-quality evidence), cumulative sickness absence (MD -14.84 work days per year, 95% CI -38.56 to 8.88, low-quality evidence), the proportion of participants at work at end of the follow-up (RR 1.06, 95% CI 0.99 to 1.15, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 1.03, 95% CI 0.97 to 1.09, moderate-quality evidence).For very long-term follow-up of longer than 12 months, we found no effect on time to return to work (HR 0.93, 95% CI 0.74 to 1.17, low-quality evidence), cumulative sickness absence (MD 7.00 work days per year, 95% CI -15.17 to 29.17, moderate-quality evidence), the proportion of participants at work at end of the follow-up (RR 0.94, 95% CI 0.82 to 1.07, low-quality evidence) or on the proportion of participants who had ever returned to work (RR 0.95, 95% CI 0.88 to 1.02, low-quality evidence).We found only small benefits for return-to-work coordination programmes on patient-reported outcomes. All differences were below the minimal clinically important difference (MID).

AUTHORS' CONCLUSIONS

Offering return-to-work coordination programmes for workers on sick leave for at least four weeks results in no benefits when compared to usual practice. We found no significant differences for the outcomes time to return to work, cumulative sickness absence, the proportion of participants at work at end of the follow-up or the proportion of participants who had ever returned to work at short-term, long-term or very long-term follow-up. For patient-reported outcomes, we found only marginal effects below the MID. The quality of the evidence ranged from very low to moderate across all outcomes.

First report of perforation of ligamentum flavum by sequestrated lumbar intervertebral disc

Disc fragments are well known to migrate to superior, inferior, or lateral sites in the anterior epidural space, posterior epidural migrated lumbar disc fragments is an extremely rare disorder, 61 cases have been reported to date. However, there were no cases with perforated ligamentum flavum (LF). We report a different case with perforation of ligamentum ligamentum by disc fragment. To the best of our knowledge, this is the first report of perforation LF by a posterior epidural migrated sequester disc.

Inequality in leg length is important for the understanding of the pathophysiology of lumbar disc herniation

Objective:

Inequality in leg length may lead to to abnormal transmission of load across the endplates and degeneration lumbar spine and the disc space. There has been no study focusing on lumbar disc herniation (LDH) and leg length discrepancy. This subject was investigated in this study.

Materials and Methods:

Consecutive adult patients with leg length discrepancy and low back pain (LBP) admitted to our department were respectivelly studied.

Results:

A total number of 39 subjects (31 women and eight men) with leg length discrepancy and LBP and 43 (25 females and 18 males) patients with LBP as a control group were tested. Occurrence of disc herniation is statistically different between patients with hip dysplasia and control groups (P < 0.05).

Conclusion:

The results of this study showed a statistically significant association between leg length discrepancy and occurrence of LDH. The changes of spine anatomy with leg length discrepancy in hip dysplastic patients are of importance in understanding the nature of LDH.

Ligamentum flavum hematomas: Why does it mostly occur in old Asian males? Interesting point of reported cases: Review and case report

Hematoma of the ligamentum flavum (LF) is a rare cause of neural compression and sciatica. Currently, the etiology and epidemiological characteristics of ligamentum flavum hematoma (LFH) are unknown and epidemiological investigations using rewieving of reported cases have not been performed. We report the case of a 63-year-old man with a LFH compressing the spinal canal at the left L2-L3 level, rewieved relevant literature. In Medline research, wefound a total of 50 reported cases with LFHs, and the interesting point of these cases were analyzed. Many of cases were old males. Interestingly, 39 of the 50 cases were reported from Asian countries. The ages of 42 patients could be verified. The youngest age was 45 years, oldest age was 81 years, and mean age was 66.07 years. Thirty-three out of these 42 patients (78.53%) were older than 60 years. An important aspect of the present review is to bring attention for occurrence in older Asian males. With an increasing number of elderly people in the general population, there is a need to investigate risk factors such as sexual gender, age, and geographic location for LFH.

Describing a new syndrome in L5-S1 disc herniation: Sexual and sphincter dysfunction without pain and muscle weakness

Context:

Little seems to be known about the sexual dysfunction (SD) in lumbar intervertebral disc herniation.

Aims:

Investigation of sexual and sphincter dysfunction in patient with lumbar disc hernitions.

Settings and Design:

A retrospective analysis.

Materials and Methods:

Sexual and sphincter dysfunction in patients admitted with lumbar disc herniations between September 2012-March 2014.

Statistical Analysis Used:

Statistical analysis was performed using the Predictive Analytics SoftWare (PASW) Statistics 18.0 for Windows (Statistical Package for the Social Sciences, SPSS Inc., Chicago, Illinois). The statistical significance was set at P < 0.05. The Wilcoxon signed ranks test was used to evaluate the difference between patients.

Results:

Four patients with sexual and sphincter dysfunction were found, including two women and two men, aged between 20 and 52 years. All of them admitted without low back pain. In addition, on neurological examination, reflex and motor deficit were not found. However, almost all patients had perianal sensory deficit and sexual and sphincter dysfunction. Magnetic resonance imaging (MRI) of three patients displayed a large extruded disc fragment at L5-S1 level on the left side. In fourth patient, there were not prominent disc herniations. There was not statistically significant difference between pre-operative and post-operative sexual function, anal-urethral sphincter function, and perianal sensation score. A syndrome in L5-S1 disc herniation with sexual and sphincter dysfunction without pain and muscle weakness was noted. We think that it is crucial for neurosurgeons to early realise that paralysis of the sphincter and sexual dysfunction are possible in patients with lumbar L5-S1 disc disease.

Conclusion:

A syndrome with perianal sensory deficit, paralysis of the sphincter, and sexual dysfunction may occur in patients with lumbar L5-S1 disc disease. The improvement of perianal sensory deficit after surgery was counteracted by a trend toward disturbed sexual function. Further researches are needed to explore the extent of this problem.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

BACKGROUND

Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction of physical, psychological and social influences, the 'biopsychosocial model', has received increasing acceptance. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.

OBJECTIVES

To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and screening of studies excluded in the previous version of this review.

SELECTION CRITERIA

All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors; and the index intervention was delivered by clinicians from at least two different professional backgrounds.

DATA COLLECTION AND ANALYSIS

Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses. We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression, anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence of baseline symptom severity and intervention intensity.

MAIN RESULTS

From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95% CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87, 95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events than usual care or physical interventions.Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity.

AUTHORS' CONCLUSIONS

Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant psychosocial impact are referred to MBR.