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PubMedDate not supplied

[Guidelines for back pain].

Chronic back pain is one of our society's most important health problems, causing long periods of sick leave and early retirements. Recently the German Society of General Practice and Family Medicine (DEGAM) published an evidence-based guideline for low back pain. It has been developed according to the 10-step concept of guideline development of the DEGAM, aiming for early detection of complicated clinical conditions, avoidance of unnecessary diagnostic tests and prevention of chronicity. Complicated, uncomplicated and radicular pain are defined by patient history and a short clinical examination. Imaging and further diagnostic tests are reserved for patients at risk. Basic therapy consists of structured advice. The aim of the guideline is to get patients back to their usual activity supported by effective pain relief. Psychosocial factors which are important for the prognosis should be evaluated already during the first consultation. Manual therapy might help in acute pain. Patients with persistent pain symptoms and long periods of sick leave should be transferred to multiprofessional management including pain treatment, behavioural therapy and physiotherapy. A randomised controlled trial has been set up to study the efficacy of guideline implementation.

Activities of Daily Living↗
PubMed1995

Low back pain in the young. A prospective three-year follow-up study of subjects with and without low back pain.

STUDY DESIGN: This was a prospective 3-year follow-up study of randomized matched subgroups of 15-year-old school children with or without low back pain initially. OBJECTIVE: In addition to low back pain and leisure time physical activity, spinal mobility, trunk muscle strength, and early degenerative findings of the lumbar spine were evaluated. SUMMARY OF BACKGROUND DATA: Reliable epidemiologic studies on the prevalence of low back pain and development of early degenerative changes of the lumbar spine in young persons have been sparse. Along with several other characteristics, the relationship of these changes to frequent low back pain in young persons is not known. METHODS: After a questionnaire-based survey was administered, subjects with or without low back pain were examined initially and at follow-up with special reference to leisure time physical activity, anthropometry, spinal mobility, trunk muscle strength, and magnetic resonance imaging findings of the lumbar spine. RESULTS: At baseline and at follow-up, those subjects with initial low back pain were characterized by a low frequency of physical activity and decreased spinal function. During follow-up, the occurrence of disc degeneration increased significantly more in the original group with low back pain than among asymptomatic subjects. Furthermore, disc degeneration at baseline significantly predicted future frequent low back pain. Initial disc protrusion also predicted future frequent low back pain. CONCLUSION: After the rapid physical growth period, there seemed to be a causal relationship between the early evolution of the degenerative processes of the lower lumbar discs and frequent low back pain in several subjects.

Adolescent↗
PubMed2006

A randomized, single blind placebo controlled clinical trial on the effect of continuous ultrasound on low back pain.

Low back pain (LBP) is a very common problem in primary care and a major cause of disability. There is no evidence for the efficacy of therapeutic modalities such as ultrasound in LBP In a randomized, single blind placebo controlled clinical trial, we aimed to evaluate the effect of continuous ultrasound (US) in patients with non specific LBP Of the fifty eight patients recruited, 10 patients (8 women and 2 men) randomly allocated to ultrasound (n=5) or placebo controlled (n=5) groups. The patients were treated by either US or sham-US for ten sessions, three days per week, every other day. The outcome measures were Functional Rating Index (FRI), Hmax/Mmax ratio and range of motion (ROM), which were measured at baseline, after 5 treatment sessions and at the end of treatment. To analyze the data, The Mann Whitney U test and Wilcoxon Signed Rank test were used. After treatment, both US and placebo groups showed statistically significant decrease in FRI scores indicating improvement in functional ability (p = 0.042 and p = 0.043, respectively). The mean changes of FRI during the second five treatment sessions and after the end of treatment was significantly better in the US group than in the placebo group (p = 0.016 and p = 0.032, respectively). Before and after treatment, the mean H reflex latency and Hmax/Mmax ratio, right and left side were similar in the groups (p > 0.05), and no significant changes were observed in the treatment groups (p > 0.05). After treatment, the extension and lateral flexion range of motion significantly increased in the US group (p = 0.04), but the back movements in the placebo group did not show significant changes (p > 0.05). The present study supports the significant effect of US on LBP, and suggests that US may improve the functional ability of patients with non specific low back pain.

Adult↗
PubMed2006

A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care. SUMMARY OF BACKGROUND DATA: Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking. METHODS: A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms. RESULTS: Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months. CONCLUSIONS: Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

Academic Medical Centers↗
PubMed1988

Office management of low back pain.

Low back pain, with or without sciatica, is a very common medical problem. Since a great majority of patients can be successfully treated with nonoperative methods, office management of these patients is a very important issue for all clinicians. Patients with low back pain can be divided into three major groups: 1) the first group with acute (initial onset or very occasional recurrent) symptoms, 2) the second group with chronic (frequent intermittent recurrent or persistent) symptoms and 3) the third group with resistant symptoms. For the first group with acute symptoms, establishment of a specific diagnosis is rarely necessary. An active nonoperative treatment program (brief rest, protection, physical therapy modalities, medication, exercises, and reconditioning) provides a high rate (nearly 90 to 95 per cent) of success (return to normal activities and work) within 8 to 12 weeks. For the second group, with chronic symptoms, establishment of a specific diagnosis and a comprehensive and specific history are essential. Diagnostic procedures for specific pathologic conditions are outlined. A clear and specific treatment goal should be established and communicated to all the parties involved. Nonoperative treatment for this group includes back school, postural exercises, bracing, exercises for strength and endurance, work-site modification, vocational counseling, and pain management. For the third group with resistant symptoms, the role of the orthopedic or neurosurgeon is as a consultant to a pain management team for evaluation and treatment of missed diagnosis or complications of previous treatments.

Acute Disease↗
PubMed1999

Fractures of the lumbar vertebral endplate in the etiology of low back pain: a hypothesis on the causative role of spinal compression in aspecific low back pain.

It is hypothesized that, in a large number of cases of aspecific low back pain, the primary cause of the pain is a fracture of the vertebral endplate caused by compression forces. Clinical studies have shown that, in many low back pain patients, damage of the vertebral bodies and or the intervertebral disc is present. In vitro studies reveal that the most likely type of failure of this anterior part of the spine is a fracture of the endplate as a result of compression. The high incidence of aspecific low back pain concurs with the likeliness of compression fractures of the endplate to occur in everyday life. Furthermore, epidemiological findings and the natural history of low back pain appear to be in line with the proposed hypothesis.

Disease Progression↗
PubMed2003

Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain.

INTRODUCTION: Research concerning the development of low back pain (LBP) has traditionally focused on risk factors in search of explanations. This review focuses on comorbidity as a first step in identifying a frail subpopulation with a higher risk of developing low back pain, in particular persistent low back pain. Research into comorbidity might yield a greater understanding of the underlying mechanism for low back pain. Data sources Medline was searched from the beginning of the data base to December 2000, followed by a search through the authors' personal collections of epidemiologic literature regarding low back pain. All articles written in English were included if they related LBP to at least one other physical disorder. Articles were excluded if the prevalence of such disorders could not be compared to that of a control group or to the expected prevalence in a normal population. Data extraction The retrieved articles were evaluated for quality based on predefined methodological criteria, whereupon information about associations between low back pain and other physical disorders was extracted. RESULTS: Twenty-three articles were included. They showed positive associations to all disorders investigated (headache/migraine, respiratory disorders, cardiovascular disease, general health, and others) with the exception of diabetes. There was very little information regarding temporality, therefore there are no clues as to causal mechanisms. CONCLUSION: The literature leaves no doubt that diseases cluster in some individuals and that low back pain is part of this pattern. However, the nature of the relationship between low back pain and other disorders is still unclear.

Adult↗
PubMed2005

Back and neck extensor loading and back pain provocation in urban bus drivers with and without low back pain.

This study assessed low back and trapezius muscle activity in bus drivers, with or without recurrent low back pain (LBP), during the long term driving. In addition, low back and neck-shoulder pain intensities and fatigue were measured and the effect of low back support was observed. Also the possible source of LBP was attempted to assess by vibration pain provocation test and lumbar MRI. Forty bus drivers (recurrent LBP n = 25) participated in this study. Low back and neck-shoulder pain and subjective fatigue intensity was assessed by visual analogue scales (VAS) before and after driving. Lumbar paraspinal and trapezius muscle activation during driving was measured by surface EMG. Vibration pain provocation test was applied for all subjects. Average paraspinal myoelectric activity during driving was approximately 1% of MVC in both groups. Average trapezius myoelectric activity during driving was from 2 to 4% of MVC. Trapezius muscle activity was higher in back healthy drivers than in those with LBP. The low back support had no effect either on paraspinal or trapezius EMG activity. Low back and neck-shoulder fatigue increased during driving in both groups especially in those subjects with positive vibration pain provocation. The neck-shoulder pain and fatigue were more severe in drivers suffering from LBP. Low back support had no effect on low back and neck-shoulder subjective fatigue and neck-shoulder pain but tended to limit the LBP increase during driving. Paraspinal muscle loading in urban bus drivers was very limited and either LBP or ergonomic low back support had no effect on it. Trapezius muscle seemed to be less active in drivers suffering from recurrent LBP. Internal disc disruptions may expose to pain and fatigability during driving.

Journal Article↗
PubMed2004

The nordic back pain subpopulation program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low back pain.

OBJECTIVE: To identify demographic and clinic-related predictors for successful outcome in patients with persistent low-back pain who received chiropractic treatment. DESIGN: Prospective uncontrolled multicenter study with internal control groups. SUBJECTS: Each of 115 Norwegian chiropractors, out of 205 invited, were asked to recruit 10 consecutive patients who had low-back pain for at least 2 weeks at the time of consultation and a minimum of 30 days altogether within the preceding year. In all, 875 patients were included at baseline. The response rates at the fourth visit and at 3 and 12 months were 799, 598, and 512, respectively. METHODS: Baseline data were obtained through questionnaires administered to chiropractic patients and to their treating chiropractors; clinical information was obtained through questionnaires at the fourth visit from patients and chiropractors. Outcome was obtained from patients at the fourth visit. Mail surveys of patients were conducted after 3 and 12 months, and additional information was obtained from chiropractors at 12 months in relation to treatment history. POTENTIAL PREDICTORS: Demography and information on past and present history, clinical findings, and prognosis. OUTCOME VARIABLE: Number of low-back pain"free patients (defined as those with a maximum pain score of 1/10 and a maximum Oswestry score of 15/100). DATA ANALYSIS: Positive predictive values and relative risks were calculated for each categorized predictor variable singly and in combination in relation to being low-back pain free at the 3 follow-up surveys. RESULTS: Treatment outcome at the fourth visit was best predicted by a model containing the following 5 variables: sex, social benefit, severity of pain, duration of continuous pain at first consultation, and additional neck pain (odds ratios between 2.2 and 4.3). A similar profile was found at 3 months, but 2 different variables (relating to disability) were the final variables in relation to the 12-month status. These final models were best at predicting absence of treatment success. Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months, with relative risks of 3.0 (2.2-4.8) and 3.1 (1.5-6.5), respectively. CONCLUSION: In patients with persistent low-back pain, it is possible to exclude from treatment those who are unlikely to become low-back pain free after chiropractic care and to do this before they have been examined clinically. Early recovery is a strong predictor for outcome up to 1 year later.

Adolescent↗
PubMed1994

Patterns in low back pain hospitalizations: implications for the treatment of low back pain in an era of health care reform.

OBJECTIVE: To examine patterns in both surgical and nonsurgical low back pain (LBP) hospitalizations through time and among geographic regions and to explore the practical implications of these patterns for health care reform. SETTING: For time trends, the U.S. (1979-1987); for geographic variations, major regions of the U.S. (1987). DATE SOURCE: The National Hospital Discharge Survey. RESULTS: Rates of both surgical and nonsurgical LBP hospitalization varied twofold among regions of the U.S., and average lengths of stay for these types of hospitalization varied considerably as well. The U.S. rate of LBP surgery increased sharply during the period covered by the study. Over the same time, the U.S. rate of nonsurgical LBP hospitalization declined, as did average lengths of stay for both types of LBP hospitalization. CONCLUSION: Wide variations in LBP hospitalization practices raise the issue of which practices are most appropriate. Outcomes research addresses this issue, as does research on patient preferences for certain types of treatment. As indicated by the increasing rate of LBP surgery, more research also needs to be done on changing physician practice style. If such research were to result in a reduction in LBP hospitalization, savings in health care costs would be considerable.

Back Pain↗
PubMed1976

Studies on the low back pain among electric construction workers. Report 2. Workers' attitude to the prevention and the treatment of their low back pain.

In the previous report, the author demonstrated that the electric construction workers were exposed to the high risk of low back pain, and discussed on the ways to prevent and to treat their occupational disorders. He concluded that the improvement of their working conditions, especially lessening of the working load, was necessary to prevent occupational low back pain, and that it was the most helpful effect on their low back pain to take a rest on an after the attack of the disorder, while most of the medical treatment without a rest were almost helpless. In this report, the author studied and discussed on the workers' opinions on the ways to prevent and to treat their low back pain, by means of questionnaire-method. The workers examined were classified by whether they had the disorder or not and also by the grades of their working load. The results are as follow: 1. As for preventive measures, it is the most popular opinion that they should take care not to hurt their low back; nevertheless, as a matter of fact, their low back pain has been mainly resulted from overwork. 2. As for necessary means on the attack of low back pain, many workers believe that medical treatment is the most helpful to the disorder. Fewer workers recognize the low back pain as an occupational disorder and have opinion that they should take a rest on the attack of the disorder. 3. There is much discrepancy between the workers' opinions mentioned above and the occupational health doctors' recommendations that it is most desirable to improve the working conditions and to let the workers take a rest. 4. The more seriously they suffer from the disorder, the more practical and reasonable are the contents of their opinions. 5. In order to let these workers take a rest from labour more easily, the employers should recognize their low back pain as an occupational disorder, including offjob-payment.

Adult↗
PubMed2001

Recall bias, pain, depression and cost in back pain patients.

OBJECTIVES: To investigate the relationship between recall bias for pain stimuli in chronic low back pain patients and the cost of managing their back pain in primary care. DESIGN: A retrospective cross-sectional investigation. METHOD: A sample of 63 low back pain patients were interviewed in a primary care setting. Information was gathered on their pain intensity, disability ratings, depression, anxiety, and duration of pain. They were also presented with a surprise recall test for pain descriptors. The cost of each patient's treatment specifically for back pain in the previous 12 months was calculated. The relationship between the cost of back pain treatment and the scores from the interview were calculated first for total cost, and then for the breakdown of individual cost items. RESULTS: Results indicated that recall bias for pain stimuli were significantly related to total cost (R2 = 8%). A detailed analysis revealed that pain intensity was related to the number of appointments with the general practitioners; depression scores related to the number of appointments with the in-house osteopaths; and recall bias for pain stimuli related to referrals to external experts (out-patients). A minority of patients high on recall bias was found to account for a disproportionate amount of the cost. CONCLUSION: Although no causal path can be deduced from the findings, the study provides a novel approach to measuring psychological factors in back pain in reference to health care utilization. It is limited by its retrospective design, and should be followed by prospective studies to understand fully the relationship between cognitive bias and utilization of health services.

Adolescent↗
PubMed1990

Low-back pain in pregnancy. Abdominal muscles, sit-up performance, and back pain.

An attempt was made to determine the effect of pregnancy on the abdominal muscles and to correlate changes in abdominal muscles strength with low-back pain during pregnancy. The study included 328 women. Group A consisted of 164 pregnant women; group B consisted of 164 non-pregnant women. The race, age, height, weight, parity, profession, time devoted to physical fitness per week, abdominal length, and relation between the abdominal length to height were recorded. A detailed history relating to backache prior to and during pregnancy was obtained. Each woman was asked to perform a single sit-up. The results of the study indicate that about 10% of pregnant women develop severe low-back pain that interferes with daily life activities. About 49% of the non-pregnant women complained of LBP. The pain did not interfere with activities of daily living. During pregnancy, due to overstretching of the abdominal muscles, the ability to perform a sit-up is significantly decreased. Whereas all non-pregnant women could perform a sit-up, 16.6% of pregnant women could not perform a single sit-up. There was no statistically significant correlation between the sit-up performance and backache. It may be concluded that during pregnancy the abdominal muscles become insufficient.

Abdomen↗
PubMed1999

Prevalence of lumbar facet joint pain in chronic low back pain.

This prospective study was designed to determine the prevalence of lumbar facet joint pain in a consecutive series of patients with chronic low back pain treated at an interventional, multidisciplinary private pain management practice utilizing double diagnostic blocks, to determine the prevalence of false positive rate of uncontrolled facet joint blocks, and to determine the relationship of clinical features of responders and non-responders to double diagnostic blocks. One hundred and twenty patients with low back pain with or without lower extremity pain were selected. The procedure consisted of diagnostic blocks using lidocaine and bupivacaine on separate occasions, usually two weeks apart. Each facet joint nerve was infiltrated with either 0.4 to 0.6 ml of 1% lidocaine (Xylocaine(R)) or 1% lidocaine (Xylocaine(R)) and 0.25% bupivacaine (Marcaine(R)). A definite response was defined as substantial with at least 75% relief of pain in the symptomatic area following local anesthetic block. Confirmatory blocks using bupivacaine 0.25% were performed at the same levels as the first injection if definite relief was obtained. The response to bupivacaine blocks which lasted longer than the lidocaine blocks was accepted as a positive response. All blocks were performed under fluoroscopic guidance. Eighty-one patients (67.5%) reported a definite response to lidocaine blocks. Confirmatory blocks with bupivacaine were performed in all 81 patients with 54 patients, i.e. 45% of total sample or 66.6% of lidocaine positive group reporting definite response with a false positive rate of 41%. Prevalence and relationship of pain referral pattern in patients with and without facet joint pain confirmed by double blocks showed no significant correlation. We found no relationship between the history, physical findings, age, gender, trauma, duration of pain, and diagnostic blocks. However, history of previous surgery showed a negative correlation as only 29% of the patients after previous surgery were positive in contrast to 51% of the nonsurgical population. The results of this study echo previous concerns of reliability of uncontrolled single blocks, history, and clinical features. This study demonstrated that the facet joint is a source of pain in 45% of the patients suffering with chronic low back pain in an interventional pain management setting in a private practice.

Journal Article↗
PubMed2006

Danish version of the Oswestry disability index for patients with low back pain. Part 2: Sensitivity, specificity and clinically significant improvement in two low back pain populations.

In studies evaluating the efficacy of clinical interventions, it is of paramount importance that the functional outcome measures are responsive to clinically relevant change. Knowledge thereof is in fact essential for the choice of instrument in clinical trials and for clinical decision-making. This article endeavours to investigate the sensitivity, specificity and clinically significant improvement (responsiveness) of the Danish version of the Oswestry disability index (ODI) in two back pain populations. Two hundred and thirty three patients with low back pain (LBP) and/or leg pain completed a questionnaire booklet at baseline and 8 weeks follow-up. Half of the patients were seen in the primary (PrS) and half in the secondary sectors (SeS) of the Danish Health Care System. The booklet contained the Danish version of the ODI, along with the Roland Morris Questionnaire, the LBP Rating Scale, the SF36 (physical function and bodily pain scales) and a global pain rating. At follow-up, a 7-point transition question (TQ) of patient perceived change and a numeric rating scale relating to the importance of the change were included. Responsiveness was operationalised using three strategies: change scores, standardised response means (SRM) and receiver operating characteristic (ROC) analyses. All methods revealed acceptable responsiveness of the ODI in the two patient populations which was comparable to the external instruments. SRM of the ODI change scores at 2 months follow-up was 1.0 for PrS patients and 0.3 for SeS (raw and percentage). A minimum clinically important change (MCID) from baseline score was established at 9 points (71%) for PrS patients and 8 points (27%) for SeS patients using ROC analyses. This was dependable on the baseline entry score with the MCID increasing with 5 points for every 10 points increase in the baseline score. We conclude that the Danish version of the ODI has comparable responsiveness to other commonly used functional status measures and is appropriate for use in low back pain patients receiving conservative care in both the primary and secondary sector.

Denmark↗
PubMed1994

The effectiveness of four interventions for the prevention of low back pain.

OBJECTIVE: Low back pain affects 60% to 80% of US adults at some time during their lives. This review evaluates the effectiveness of four strategies to prevent low back pain for asymptomatic individuals: back and aerobic exercises, education, mechanical supports (corsets), and risk factor modification. DATA SOURCES: The MEDLINE database was searched for all relevant articles published in English between 1966 and 1993. Bibliographies of identified articles were searched to ensure that all pertinent articles had been gathered and back pain specialists reviewed our final bibliography for completeness. STUDY SELECTION AND DATA EXTRACTION: A total of 190 articles were identified, and the 64 that contained original data about preventing low back pain were reviewed. Studies were graded according to strength of study design. DATA SYNTHESIS: There is limited evidence based on randomized trials and epidemiological studies that exercises to strengthen back or abdominal muscles and to improve overall fitness can decrease the incidence and duration of low back pain episodes. There is minimal evidence to support the use of educational strategies to prevent low back pain and insufficient evidence to recommend about the use of mechanical supports. Although there is no evidence supporting risk factor modification for preventing low back pain (smoking cessation and weight loss), there are other reasons to recommend the interventions. CONCLUSION: There is limited evidence to recommend exercise to prevent low back pain in asymptomatic individuals, but there is insufficient evidence to recommend other prevention strategies. These conclusions should be viewed cautiously since they are primarily based on studies conducted in the workplace rather than in clinical settings.

Behavior Therapy↗