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PubMed2005

[Chronic back pain and expert opinion].

Back pain, especially chronic back pain, is not only a medical and psychological burden but also an economic problem due to the extremely high associated costs. These are generated by treatment and rehabilitation measures, pensions and loss of working hours. The cause of pain is multifocal and frequently remains unclear. It is not the etiology of back pain that has changed in the last 20 years, but its rate of assessment and treatment options. According to the relevant literature, treatment of chronic back pain will most probably only succeed using multimodal concepts that have to consider medical/somatic and psychosocial aspects and be based on scientific training experience. Pain assessment is based on common legal and certification standards. However, typical decision and rating problems result from the difficulty of objective medical registration and grading of pain. Medical certification may often be complicated by co-morbidities such as somatic pain attacks, fibromyalgia, depression or anxiety. These cases necessitate close cooperation with other medical specialities.

Back Pain↗
PubMed1982

Controlled trial of imipramine for chronic low back pain.

Chronic low back pain is a common problem that has been noted in several studies to exist as a component of masked depression. To determine the usefulness of imipramine in the treatment of chronic low back pain, either by a direct action or indirectly via resolution of a depressive equivalent, 50 consecutive patients were entered into a controlled trail that employed serum imipramine and desipramine levels and Beck depression questionnaires. Forty-one patients completed the study, and 48 were used in the statistical analysis. Imipramine had a statistically significant effect over placebo in most, but not all, of the clinical parameters that were measured. A linear relationship between serum drug levels and reported symptoms was not noted. Only 10 of the 50 patients entered into the study were judged clinically depressed and, of these, 7 were depressed according to standard criteria. There was no statistically significant difference noted in either the initial or the change in Beck depression scores between those on imipramine and those on placebo. However, among those on the active drug, the patients with a greater symptomatic response had a simultaneous change in the total Beck depression scores (toward less depression) that approached statistical significance when compared with those with a less symptomatic response. Although the results are not conclusive, imipramine may possibly be useful in the treatment of chronic low back pain, especially so when it exists as a component of masked depression.

Adult↗
PubMed2003

Patient characteristics associated with opioid versus nonsteroidal anti-inflammatory drug management of chronic low back pain.

Chronic low back pain is both prevalent and costly in many industrialized nations. Although many modalities exist for the treatment of this condition, few are as commonly used or as controversial as the use of opioids. Many sets of guidelines exist for the prescription of opioids for chronic nonmalignant pain, but little evidence addresses what factors actually contribute to the decision to initiate and maintain patients on these drugs. In these studies we first identified 2 groups of 100 patients each, all with chronic low back pain. Group N patients received long-term nonsteroidal anti-inflammatory drug therapy for the treatment of their pain, whereas Group O received opioids long-term. The identities of the specific analgesics were tabulated. A list of variables including patient characteristics, healthcare utilization factors, and psychologic characteristics were extracted from their medical records. Regression analysis was performed, which resulted in the identification of 4 variables of age, depression, personality disorder, and history of substance abuse as being closely linked to the use of opioids for the treatment of back pain in preference to nonsteroidal anti-inflammatory drugs alone. By using the derived regression equation, 79% of patients could be correctly classified into Group O or Group N. Pain intensity did not predict opioid use. We present alternative explanations for these observations.

Aged↗
PubMed1999

Chronic low back pain: early interventions.

Low back pain is a common and costly social problem. Many of the long term outcomes of chronic low back pain (CLBP), such as those related to occupational and social function or patient and family coping, are sensitive to nursing intervention. To identify potentially productive areas for nursing intervention research, studies from 1990 to 1998 were reviewed that investigated (a) potential early indicators that acute or subchronic low back pain would result in chronic pain and disability, (b) patient perspectives on adaptation to chronic pain, and (c) the value of interventions undertaken during the acute and subchronic phases of back pain to modify long-term outcomes. Sixteen quantitative studies were identified that prospectively investigated the natural history and outcomes of low back pain. Six qualitative studies that investigated the perspectives of patients with back pain were also identified. Ten randomized clinical trials were identified that investigated interventions undertaken during the acute or subchronic stages of back pain. Clinical interventions that included advice to re-engage in activity, support to develop personalized goals, reinforcement for healthy gains and appropriate functional activities, and physical conditioning exercises tended to be successful in returning patients to work or limiting their self-reported disability and pain. Interventions that promoted communication at the work-site or modified the patient's job were also successful in promoting a faster return to work. Nonetheless, this is a nascent area of research in need of improvements related to the selection of appropriate subjects and controls, the timing and duration of interventions, and the reliability with which interventions are implemented. Furthermore, patients with back pain are most likely to benefit when nursing theories about chronic pain are linked to clinical intervention research.

Humans↗
PubMed1995

Cost of care for ambulatory patients with low back pain.

BACKGROUND: Low back pain is a common presenting complaint in primary care, and the rate of utilization of resources among physicians treating this condition varies. Charges associated with the care of patients with low back pain were analyzed for a series of patients in a multispecialty group practice setting. METHODS: One hundred seventy managed care patients were selected for review. Use of laboratory, plain radiography, magnetic resonance imaging (MRI), subspecialty referrals, and physical therapy was examined based on patient characteristics and physician specialty. Appropriateness of MRI and lumbar spine radiography according to published criteria was also studied. RESULTS: Overall utilization was higher for patients who were referred to a subspecialist, and costs for visits to subspecialists were higher. Charges for physician services and MRI accounted for a majority of the total charges. Patients who were referred for subspecialty care or MRI but did not meet criteria for utilization of these resources comprised 6% of the study population but accounted for 27% of the total charges. Five of 14 patients undergoing MRI did not meet the published clinical criteria determining need for MRI, and 10 of 17 patients referred to subspecialists did not meet referral criteria. Other patients who met criteria for MRI or subspecialty consultation did not receive these services. Seventeen percent of the patients referred for physical therapy had a symptom duration of 2 weeks or less at the time of referral and accounted for 17% of all physical therapy charges. CONCLUSIONS: The majority of costs associated with care for low back pain in this study were attributable to physician charges and the use of MRI. Charges for subspecialty physician services, lumbar spine radiographs, and MRI in patients not meeting appropriate criteria accounted for 19% of all costs.

Adult↗
PubMed1993

Increased central drive during fatiguing contractions of the paraspinal muscles in patients with chronic low back pain.

In low back pain patients the paraspinal muscles demonstrate excess fatigability. Whether the cause is "central" as could result from impaired motor unit recruitment due to poor motivation or fear of pain, or "peripheral", and caused by defects in the contractile apparatus, is unknown. Using surface electromyography in conjunction with a standardized isometric fatigue test, this study investigates the mechanisms causing paraspinal muscle dysfunction in patients with both nonsurgical and postsurgical chronic low back pain. During the fatigue test normal subjects and both patient groups exhibited electromyographic increases. These were significantly greater in both patient groups, indicating increased central drive to their muscles. These findings may suggest that patients' excess fatigue is peripheral in origin, with increased central drive arising secondary to muscle wasting or denervation, although a central activation defect has not been excluded. Impaired physical performance in low back pain patients does not seem to be caused by lack of central drive.

Adult↗
PubMed2004

[Diagnostics and minimally invasive therapy for chronic low back pain].

Chronic low back pain is one of the most frequent causes for seeking medical help in Germany. Many factors play a causal role in its pathogenesis. This is where the dilemma resides in narrowing down the diagnosis and deciding on subsequent therapeutic intervention. There is overall agreement on the concept of when it is expedient to initiate further diagnostic measures. With the exception of clear pathomorphological findings and the presence of cardinal symptoms or warning signs, so-called "red flags", primary back pain should not be subjected to any specific diagnostic tests and therapy during the first 3 months. We present well-established techniques for blockade, discography, and minimally invasive treatment options such as cryotherapy, procedures for thermal ablation, and intradiscal electrotherapy. Vertebroplasty, currently a frequently applied method, is also included in the discussion of minimally invasive treatment for chronic low back pain.

Back Pain↗
PubMed2004

[Marked similarity between the Dutch Institute for Health Care Improvement guideline 'Aspecific low back pain complaints' and the Dutch College of General Practitioners guideline 'Low back pain'].

The Dutch Institute for Healthcare Improvement's (CBO) guideline on the diagnosis and treatment of aspecific, acute and chronic, low back complaints corresponds in general to the Dutch College of General Practitioners' guideline with regard to the following topics: time-contingent treatment, restricted use of X-ray examination, and the options for non-medical treatment. A noteworthy exception in the CBO-guideline is the suggestion of manipulation of the spine as a possible treatment although there is no mention of proof of effectiveness.

Acute Disease↗
PubMed2004

Electronic diary assessment of pain-related fear, attention to pain, and pain intensity in chronic low back pain patients.

The present study investigated the relationships between pain-related fear, attention to pain, and pain intensity in daily life in patients with chronic low back pain. An experience sampling methodology was used in which electronic diary data were collected by means of palmtop computers from 40 chronic low back pain patients who were followed for one week. Attention to pain was hypothesized to mediate the relation between pain-related fear and pain intensity. Further, pain-related fear as a trait characteristic was expected to moderate the relation between attention to pain and pain intensity. Multi-level analysis was used for all analyses. Although the tested mediation models yielded statistically significant mediation effects, the sizes of these effects were relatively small and clinically irrelevant. Instead, results suggested that pain-related fear and attention to pain independently predicted pain intensity. No evidence for moderation of the relation between attention to pain and pain intensity by pain-related fear as a trait characteristic was found. Implications of the results from this study are discussed and suggestions for future research are provided.

Adaptation, Psychological↗
PubMed2006

Pain-related fear in low back pain: a prospective study in the general population.

A cognitive behavioural account of chronic low back pain (CLBP) proposes that the relationship between pain catastrophizing and functional disability is mediated by fear of movement/(re)injury. Several clinical studies already demonstrated the contribution of pain catastrophizing and fear of movement/(re)injury in the development and maintenance of CLBP. This study included people with low back pain (LBP) in the general population, and aimed to investigate whether fear of movement/(re)injury mediated the relationship between pain catastrophizing and functional disability, by examining several prerequisites for mediation. Data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort (DMC(3)) study were used, including 152 people suffering from LBP who completed both a follow-up questionnaire and a baseline questionnaire 6 months previously. This study was unable to demonstrate that the relationship between pain catastrophizing and functional disability was mediated by fear of movement/(re)injury, since the prerequisite that pain catastrophizing and functional disability were related, was not fulfilled. However, pain catastrophizing was significantly related to fear of movement/(re)injury 6 months later, above and beyond other contributing variables such as fear of movement/(re)injury already present at baseline. On its turn, fear of movement/(re)injury was related to functional disability, in addition to pain intensity. Although this study leaves some indistinctness concerning the actual relationships between pain catastrophizing, fear of movement/(re)injury, and functional disability, it does provide some evidence for the contributing role of these factors in LBP in the general population.

Activities of Daily Living↗
PubMed2001

[Medical diagnosis of pain between myth and reality--chronic lower back pain, as an illness of upright walking].

Chronic therapy-resistant low back pain is a major problem in medical care. In Germany there are many millions concerned, and the treatment expenses range at the top. Many of these patients underwent non-successful operations at the vertebral column and suffered a long-lasting odyssey of therapies before they are treated psychosomatically for the first time. Chronic low back pain is a disease including social, psychological as well as physiological aspects, and not only a problem of bones, muscles, or intervertebral disks. The problem is similar to that of fibromyalgia. On the basis of 9,000 case reports obtained during psychosomatic orthopedic treatment, character structures, unsolved problems of life and repressed emotional disturbances such as anger, jealousy, fear, and mourning could be identified as major psychosomatic risk factors for chronic low back pain. There is a high coincidence with other psychosomatically influenced diseases such as gastric and duodenal ulcera, asthma bronchiale, migraine with depressions, anxiety disorders, character neuroses, and narcissistic and other structural disturbances of the self. Exclusively somatic treatments without considering the existential situation and psychological methods hold the danger of a symptom shifting. The inpatient treatment from 9 a.m. to 5 p.m. ('Tagesklinik') with a combination of medical, physiotherapeutic and psychotherapeutic methods promotes a social training that counteracts the increasing constrictions in the accustomed life surroundings caused by low back pain. Chronic low back pain is an 'illness of the upright walk' in an anthropological, ethical sense. Considering low back pain as a strictly somatic disease is a modern myth of a medical treatment without existential understanding of human illness. It provokes failure of treatment and an enhancement of treatment cost.

Chronic Disease↗
PubMed2000

Abnormal brain chemistry in chronic back pain: an in vivo proton magnetic resonance spectroscopy study.

The neurobiology of chronic pain, including chronic back pain, is unknown. Structural imaging studies of the spine cannot explain all cases of chronic back pain. Functional brain imaging studies indicate that the brain activation patterns are different between chronic pain patients and normal subjects, and the thalamus, and prefrontal and cingulate cortices are involved in some types of chronic pain. Animal models of chronic pain suggest abnormal spinal cord chemistry. Does chronic pain cause brain chemistry changes? We examined brain chemistry changes in patients with chronic back pain using in vivo single- voxel proton magnetic resonance spectroscopy ((1)H-MRS). In vivo (1)H-MRS was used to measure relative concentrations of N-acetyl aspartate, creatine, choline, glutamate, glutamine, gamma-aminobutyric acid, inositol, glucose and lactate in relation to the concentration of creatine. These measurements were performed in six brain regions of nine chronic low back pain patients and 11 normal volunteers. All chronic back pain subjects underwent clinical evaluation and perceptual measures of pain and anxiety. We show that chronic back pain alters the human brain chemistry. Reductions of N-acetyl aspartate and glucose were demonstrated in the dorsolateral prefrontal cortex. Cingulate, sensorimotor, and other brain regions showed no chemical concentration differences. In chronic back pain, the interrelationship between chemicals within and across brain regions was abnormal, and there was a specific relationship between regional chemicals and perceptual measures of pain and anxiety. These findings provide direct evidence of abnormal brain chemistry in chronic back pain, which may be useful in diagnosis and future development of more effective pharmacological treatments.

Adult↗
PubMed1996

Pain profile of patients with low back pain referred to physical therapy.

Detailed pain descriptions for patients with low back pain referred to physical therapy have not been adequately summarized in the literature. The purpose of this study was to present a detailed pain characteristic profile for patients who were referred to physical therapy for treatment of low back pain. One hundred patients (52 males and 48 females) completed portions of the McGill Pain Questionnaire and were interviewed to obtain additional descriptions of pain using a comprehensive pain questionnaire developed for this study. The scores on the McGill Pain Questionnaire demonstrated variability from those previously reported in other populations of patients with low back pain. The comprehensive pain questionnaire revealed that the most intense pain was distributed across the waking hours. Seventy-seven of the 98 subjects (79%) noted that lifting and forward flexed postures increased the pain intensity. In contrast, only 27 of 98 subjects (28%) reported an increase in symptoms with backward bending. Seventy-four of the 98 subjects reported that sitting made their pain worse, and 17 of 84 subjects (20%) reported that sitting resulted in their worst pain. Fifty-nine of 84 subjects stated a recumbent position was the most effective means of relieving the pain. Fifty-two subjects (53%) reported that they experienced pain severe enough to wake them from sleep (night pain). Only three of these patients (6%) stated they were unable to fall back asleep once they were awakened. It was concluded that the detailed pain profile was consistent with symptoms associated with activity-related spinal disorders.

Adolescent↗
PubMedDate not supplied

The Nordic back pain subpopulation program: can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in nonpersistent low back pain?

OBJECTIVE: To investigate whether 3 distinct patterns of reactions to chiropractic care can predict early favorable treatment outcome in patients with nonpersistent low back pain (LBP). DESIGN: Multicenter practice-based predictive validity study. STUDY SUBJECTS: Sixty private practice chiropractors in Sweden recruited a maximum of 20 consecutive patients with LBP each, with a duration of less than 2 weeks at the time of consultation and a maximum of 30 days totally over the past year. METHODS: Chiropractic management was decided on by the treating chiropractor. The outcome variable was self-reported "definite improvement" at the fourth visit. The predictor variables included 3 hypothesized prognostic groups (best, intermediate, and least favorable) on the basis of clinical information collected at baseline and at the second visit. The covariates included age, sex, pain intensity during the past 24 hours, description of disability, duration and pattern of pain during the present attack, and duration and pattern of pain during the past 12 months. The 3 predictor groups were cross-tabulated against the outcome variable and the other covariates. Backward stepwise logistic regression was performed to test for confounding or modification from relevant covariates. RESULTS: Information was provided on 708 patients, of which 674 questionnaires were valid. Of the 223 patients in the hypothesized best prognostic group, 91% (95% CI, 79-100) reported to be "definitely improved" by the fourth visit, vs 76% (72-80) of the 420 patients in the intermediate prognostic group, and 36% (19-53) of the 31 patients in the least favorable prognostic group. These results were not altered after controlling for the covariates. CONCLUSION: For chiropractic patients with nonpersistent LBP, these findings show that it is possible to predict already by the second visit which patients may or may not report improvement at the fourth visit.

Adult↗
PubMed2002

Pain catastrophizing and kinesiophobia: predictors of chronic low back pain.

By using a population-based cohort of the general Dutch population, the authors studied whether an excessively negative orientation toward pain (pain catastrophizing) and fear of movement/(re)injury (kinesiophobia) are important in the etiology of chronic low back pain and associated disability, as clinical studies have suggested. A total of 1,845 of the 2,338 inhabitants (without severe disease) aged 25-64 years who participated in a 1998 population-based questionnaire survey on musculoskeletal pain were sent a second questionnaire after 6 months; 1,571 (85 percent) participated. For subjects with low back pain at baseline, a high level of pain catastrophizing predicted low back pain at follow-up (odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.0, 2.8) and chronic low back pain (OR = 1.7, 95% CI: 1.0, 2.3), in particular severe low back pain (OR = 3.0, 95% CI: 1.7, 5.2) and low back pain with disability (OR = 3.0, 95% CI: 1.7, 5.4). A high level of kinesiophobia showed similar associations. The significant associations remained after adjustment for pain duration, pain severity, or disability at baseline. For those without low back pain at baseline, a high level of pain catastrophizing or kinesiophobia predicted low back pain with disability during follow-up. These cognitive and emotional factors should be considered when prevention programs are developed for chronic low back pain and related disability.

Adult↗
PubMed2001

Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomized controlled study. Willow bark extract for low back pain.

OBJECTIVES: To compare the effects of a proprietary extract of willow bark (Assalix) and a selective inhibitor (rofecoxib) of the enzyme cyclo-oxygenase-2 (COX-2). METHODS: An open, randomized, post-marketing study was carried out in an out-patients clinic on two groups of patients aged 18 to 80 yr presenting over a 6-month period with acute exacerbations of low back pain. Using computer-generated random list, 114 patients were allocated to receive a daily dose of herbal extract containing 240 mg of salicin [PAID (phyto-anti-inflammatory drug) group] and 114 were allocated to receive 12.5 mg of the synthetic COX-2 inhibitor rofecoxib [NSAID (non-steroidal anti-inflammatory drug) group]. The doses were chosen according to existing recommendations. All patients were free to use whatever additional conventional treatments were thought necessary. The outcome measures were a modified Arhus index, its pain component and the Total Pain Index. RESULTS: Groups were well matched. After 4 weeks of treatment, the Arhus index had improved by about 20%, its pain component by about 30% and the Total Pain Index by about 35%. The number of pain-free patients (visual analogue scale score <2) was about 20 in each group. About 60% of the patients in each group responded well to the treatment (as judged by an improvement of >/=30% in the Total Pain Index relative to its baseline). The improvement was also reflected reasonably well in the physicians' and patients' judgements of the effectiveness of treatment, which were largely concordant. Few patients of either group resorted to the additional conventional treatment options. The incidence of adverse events was similar in the two groups. Treatment with rofecoxib was about 40% more expensive than that with Assalix. CONCLUSION: There was no significant difference in effectiveness between the two treatments at the doses chosen. Treatment with Assalix was less expensive.

Adolescent↗
PubMed1996

Quantified pain drawing in subacute low back pain. Validation in a nonselected outpatient industrial sample.

STUDY DESIGN: The criterion and construct validities of pain drawing, quantified by a simple total body area score of pain extent (area raw extent assessment score), were analyzed prospectively on consecutive patients (n = 103), drawn from a predefined blue collar worker population, all sick listed for 6 weeks as a result of low back pain. OBJECTIVES: To evaluate the validity of pain drawing as a screening tool in the secondary prevention of subacute low back pain. SUMMARY OF BACKGROUND DATA: Pain drawings have been used clinically for more than 40 years as a complement to a patient's verbal pain descriptions. The main objectives have been to differentiate functional pain from organic pain and to identify meaningful features in spatial-anatomic pain distribution. The ability of the pain drawing to delineate concurrent psychopathology correctly has been questioned. There is no consensus on which scoring method should be used. METHODS: The area raw extent assessment score was analyzed concurrently against the penalty point system and predictively against return to work and absenteeism over a period of 2 years. Content and construct validity assessed the relative influence of medical, psychologic, and subjective disability as well as psychosocial factors. RESULTS: Criterion validation of the area raw extent assessment score showed significant correlations, both concurrently against the penalty point score (r = 0.86, P < 0.001, with explained variance R2 = 0.75, P < 0.001) and predictively against occupational handicap (r = 0.48, P < 0.001). In construct validation, the highest explained variance was shown for medical (R2 = 0.46, P < 0.001) and psychologic factors (R2 = 0.46, P < 0.001) and psychologic factors (R2 = 0.34, P < 0.001) and for subjective disability (R2 = 0.32, P < 0.001). Variance in the area raw extent assessment score also was explained by psychosocial factors (R2 = 0.19, P < 0.01). CONCLUSIONS: Pain drawing quantification of the extent of pain shows high criterion and construct validity for the area raw extent assessment score. Content validity could be shown for significant clinical aspects of the disability experience--assets preferred for a screening tool in secondary prevention.

Activities of Daily Living↗