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PubMed1999

[Recommendations on care of back pain problems].

Back problems are a common cause of disability. There are important variations in the care provided, suggesting that some patients receive suboptimal treatment. Several Western countries have developed practice guidelines to improve this state of affairs. If guidelines are to improve the outcome for patients seeking care, they must give valid recommendations. In this article I compare ten practice guidelines for back problems. The guidelines are from nine Western countries and were published in the ten-year period 1987-97. There are significant variations in the recommendations given. The guidelines were developed according to different methods. A systematic, evidence-based approach is less prone to bias than an informal expert-based consensus. I conclude that the systematically developed US guideline (AHCPR 1994) and the British guideline (RCGP 1996) are the ones giving valid recommendations and are therefore the best options for practitioners.

Australia↗
PubMed2004

Back pain rehabilitation.

BACKGROUND: Back pain is a universal problem that becomes persistent in 5-10% of patients following an acute episode. This makes it one of the most costly areas of health care in Australia. OBJECTIVE: This article outlines the paradigm that general practitioners should adopt to assist the patient to live with their pain experience. DISCUSSION: The development of persistent back pain is not a static process but one that is heavily influenced by the context in which it occurs. Patient characteristics, health care providers and the health system environment contribute and interact to promote the development of persistent pain. Health care providers involved in managing persistent pain should remain confidant, positive and reassuring. They should encourage activity, discourage fear avoidance behaviour, and consider rehabilitation early before illness beliefs become entrenched. Multidisciplinary rehabilitation, when used early, aims to improve function and assist in the return to work process; when used late, it aims to prevent worsening disability and increased coping for patients.

Back Pain↗
PubMed2004

Pharmacotherapy in lower back pain.

In the US, back pain is the second most common cause of disability and the leading cause among men, with approximately 45% of the adult population experiencing lower back pain annually and a direct cost for diagnosis and treatment reported to be higher than 23 billion US dollars in 1990. However, despite the high prevalence of this condition, lower back pain diagnoses are commonly imprecise, and specific causes for lower back pain can only be determined in approximately 15% of patients. So, although for most patients with acute lower back pain, a simple cause-and-effect model can be described, often the result of a lumbar sprain or strain, clinicians must be alert to a variety of other conditions which may present in a similar fashion and require more emergent care. Pharmacotherapy and nondrug-related modalities have been shown to reduce pain and other related symptoms. Medication classes with known benefit include the nonsteroidal antiinflammatory drugs (NSAIDs), skeletal muscle relaxants, opioids, acetaminophen and the newer cyclooxygenase-2 (COX-2) inhibitors. This review analyzes the different drugs available for treating lower back pain in light of the most recent evidence coming from clinical studies. More critical research is needed to further define the roles of these medications in treating pain associated with lower back injury.

Analgesics↗
PubMed2002

Relationship between pain and vertebral motion in chronic low-back pain subjects.

OBJECTIVES: To investigate the relationship between intervertebral motion, intravertebral deformation and pain in chronic low-back pain patients. DESIGN: This study measured vertebral motion of the lumbar spine and associated pain in a select group of chronic low-back pain patients as they performed a standard battery of motions in all planes. BACKGROUND: Numerous studies have demonstrated that individuals with low-back pain have impaired spinal motion, yet few studies have examined the specific relationship between pain and motion parameters. Although it is accepted that the pain in mechanical low-back patients is due to specific spinal motions, no studies have related specific motions to pain measures. METHODS: Percutaneous intra-pedicle screws were placed into the right and left L4 (or L5) and S1 segments of nine chronic low-back pain patients. The external fixator frame was removed following the clinical external fixation test. The 3D locations of the pedicle screws and the level of pain were recorded as the subjects performed a battery of motions. The relationship between the pain and motion parameters was assessed using linear discriminant analysis and neural network models. RESULTS: The neural network model showed a strong relationship between observed and predicted pain (R(2)=0.997). The discriminant analysis showed a weak relationship (R(2)=0.5). CONCLUSIONS: Vertebral motion parameters are strongly predictive of pain in this select group of chronic low-back pain patients. The nature of the relationship is nonlinear and involves interactions; neural networks are able to effectively describe these relationships. RELEVANCE: Specific patterns of intervertebral motion and intravertebral deformation result in pain in chronic low-back pain patients. This substantiates the mechanical back pain aetiology.

Adult↗
PubMed1983

Invalid use of pain drawings in psychological screening of back pain patients.

Drawings by low back pain patients depicting the severity, type, and location of their pain have been suggested as a brief screening technique for psychological involvement in the pain complaints. A study of 212 back pain patients showed that pain drawings cannot validly be used in this way, since over half of the patients meeting MMPI criteria for psychological involvement in their pain were incorrectly identified as normal on the Pain Drawing test.

Back Pain↗
PubMed1999

Emergency department evaluation and treatment of back pain.

Patients with back pain commonly present in the emergency department for evaluation and treatment. Because it is a common syndrome with a generally benign origin, the examiner may overlook markers of serious disease. This article reviews the important historical and physical factors to consider, with an emphasis on the red flags of serious disease. This article also reviews the management of acute lumbosacral strain, sciatica, and disc herniation, cauda equina syndrome and spinal cord compression, and back pain in the patient with a history of cancer.

Back Pain↗
PubMed1988

Psychometric analysis of the audiovisual taxonomy for assessing pain behavior in chronic back-pain patients.

Sixty chronic back-pain patients were administered the audiovisual taxonomy of pain behavior during their first and last weeks in an inpatient multidisciplinary pain clinic. Audiovisual total score provided a useful index of pain behavior with a suitable frequency and reliability, while offering unique variance as a measure of treatment outcome. Patients' pain behaviors upon admission to the pain program were positively correlated with the following background variables: receiving worker's compensation, pounds overweight, and number of back surgeries. Patients' pain behaviors upon completion of the pain program were significantly correlated with their preferences for pain treatment modalities. High levels of pain behavior correlated with a preference for treatments of ice and heat. Low levels of pain behavior correlated with a preference for physical therapy, social work, lectures, and relaxation. It was suggested that treatment outcome in a multidisciplinary pain clinic is more immediately related to patients' coping styles and their choice of pain treatment modalities than to their demographics and personalities.

Adult↗
PubMed2004

Low back pain among endurance athletes with and without specific back loading--a cross-sectional survey of cross-country skiers, rowers, orienteerers, and nonathletic controls.

STUDY DESIGN: Cross-sectional survey among athletes competing at the national elite level in cross-country skiing, rowing, and orienteering, as well as a matched nonathletic control group. OBJECTIVE: To compare the prevalence of symptoms of low back pain between endurance sports with different loading characteristics on the lumbar region: cross-country skiing, rowing, and orienteering, as well as a nonathletic control group. SUMMARY OF BACKGROUND DATA: Although it is claimed that back pain is a frequent problem in endurance sports loading the lower spine such as rowing or cross-country skiing, the prevalence of low back problems in such sports has not been compared with relevant control groups. METHODS: Self-reported questionnaire on low back pain adapted for sports based on standardized Nordic questionnaires for musculoskeletal symptoms. Responders were 257 cross-country skiers (response rate: 100%), 199 rowers (99.5%), and 278 orienteerers (99.3%), and 197 control subjects (66%). RESULTS: Low back pain was reported to be somewhat more common among cross-country skiers and rowers than orienteerers and nonathletic controls. The prevalence among cross-country skiers of reported low back pain ever (65.4%) and low back pain during the previous 12 months (63.0%) was higher than nonathletic controls (OR [95% CI]: 1.94 [1.29-2.92]). Rowers (25.6%) reported missing training because of low back pain more frequently than orienteerers did (13.7%, OR: 2.16 [1.25-3.74]). The athletes reported more low back pain during periods when training and competition load was higher, and cross-country skiers more frequently reported having low back problems using classic than freestyle skiing techniques. CONCLUSIONS: Low back pain appears to be somewhat more common in endurance sports that specifically load the low back during training and competition. The relationship between seasonal training patterns and specific skiing techniques indicate that there is a relationship between low back pain and the specific loading patterns of skiing and rowing.

Adult↗
PubMed1992

Surface EMG topography and pain distribution in pre-chronic back pain patients.

The relationship between surface EMG recordings from paraspinalis recording sites and subjective pain ratings were examined in a group of pre-chronic back pain patients. thirty-eight back pain patients without major orthopedic diagnosis and a pain duration between 2 to 6 months participated in a three week long subjective pain rating. Following the completion of their pain diary, the paraspinal sites were assessed under the "static" postural conditions of sitting and standing using an EMG scanning procedure. Results of the correlational analysis revealed significant and positive relationships between pain and muscle activity in the upper back (Trapezius, T1 paraspinalis sites) and significant but negative relationships between erector spinae activity (L3 paraspinalis site) and pain. When considering etiological factors of pre-chronic back pain, the results support both the organicity model for upper back, as well as the biomechanical model for the lower back.

Adult↗
PubMed1994

Back pain distribution patterns: relationship to subjective measures of pain severity and disability.

OBJECTIVE: To investigate the relationship between subjective pain measures and clinical subgroupings as determined by pain distribution patterns in back pain patients. DESIGN: A prospective study using a computer-interview system. SETTING: The Anglo-European College of Chiropractic outpatient clinic. PATIENTS: Two hundred fourteen new patients with low back pain completed the computer back pain interview on their first or second visit to the clinic. No other inclusion criteria were applied. MAIN OUTCOME MEASURES: Computer versions of the VAS, Oswestry and St. Thomas' disability questionnaires and the pain drawing. RESULTS: Back pain patients with pain radiating below the knee (Group 3 patients) reported significantly higher levels of disability than patients with back pain alone (Group 1 patients) (p < .001) and back pain with pain referred to the buttock/thigh region (Group 2 patients) (p < .01). Similarly, Group 3 patients reported significantly higher levels of pain severity than both Group 1 (p < .01) and Group 2 (p < .05) patients. The increased level of disability reported by Group 3 patients almost exactly matched the increase in self-assessed pain severity. No differences were observed in the report of either pain severity or disability between Group 1 and Group 2 patients. CONCLUSION: Subjective pain measure scores were shown to be related to recognizable clinical subgroupings of back pain based on the distribution, but not the extent, of the patient's pain. Back pain patients with radicular pain below the knee were found to be a high disability/pain severity group compared with other groups of back pain patients. More work is needed to investigate the potential of subjective pain measures in the differential diagnosis of back pain syndromes.

Adolescent↗
PubMed2004

Compliance among general practitioners in France with recommendations not to prescribe bed rest for acute low back pain.

UNLABELLED: Acute low back pain is a very common reason for general practitioner visits. OBJECTIVE: To evaluate practices among French general practitioners regarding the prescription of bed rest in patients with low back pain. METHODS: 2000 general practitioners were to include the first three patients presenting within the first 3 d of onset of acute low back pain without nerve root pain. The characteristics of the pain, social and demographic characteristics of the patients, and treatments prescribed by the physicians were recorded. RESULTS: 5355 patients were included, of whom more than half had a history of one or more episodes of low back pain. The mean pain severity score on a 100-mm visual analog scale was 57.2 +/- 22.7 mm. Bed rest was recommended to 27.6% of the patients, for a mean duration of 4.4 d. Patients to whom bed rest was recommended were significantly more likely than the other patients to have chronic low back pain (32.1% vs. 26.5%) and received a greater number of medications. Bed rest was associated with significantly poorer outcomes in the multivariable analysis adjusting for confounding factors. CONCLUSION: Recommendations to avoid bed rest in patients with acute low back pain are widely followed in France. Furthermore, our results confirm that bed rest is associated with poorer outcomes.

Adult↗
PubMed2000

Acupuncture for low back pain.

BACKGROUND: Although low back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for the treatment of low back pain. OBJECTIVES: The objective of this review was to assess the effects of acupuncture for the treatment of non-specific low back pain. SEARCH STRATEGY: We searched the Cochrane Complementary Medicine Field trials register, the Cochrane Controlled Trials Register (1997, issue 1), Medline (1966 - 1996), Embase (1988 - 1996), Science Citation Index and reference lists of articles. SELECTION CRITERIA: Randomised trials of all types of acupuncture treatment that involves needling for subjects with non-specific low back pain. DATA COLLECTION AND ANALYSIS: Two reviewers blinded with respect to authors, institution and journal independently assessed trial quality and extracted data. MAIN RESULTS: Eleven trials were included. The methodological quality was low. Only two trials were of high quality. Three trials compared acupuncture to no treatment, which were of low methodological quality and provide conflicting evidence. There was moderate evidence from two trials that acupuncture is not more effective than trigger point injection or transcutaneous electrical nerve stimulation (TENS). There was limited evidence from eight trials that acupuncture is not more effective than placebo or sham acupuncture for the treatment of chronic low back pain. REVIEWER'S CONCLUSIONS: The evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.

Acupuncture Therapy↗
PubMed1998

The importance of radiating leg pain in assessing health outcomes among patients with low back pain. Results from the Veterans Health Study.

STUDY DESIGN: Cross-sectional data were analyzed from the Veterans Health Study, an observational study of patients receiving ambulatory care. OBJECTIVE: To develop a method of stratifying patients with low back pain by combining patient reports of radiating leg pain with the results of straight leg raising tests. SUMMARY AND BACKGROUND DATA: Four hundred thirty-four participants with low back pain were identified through patient reports of ever having had low back pain, of low back pain that began more than 3 months ago, and of a health-care visit for low back pain in the past year. Four hundred twenty-eight patients with low back pain were included in the current analysis. METHODS: Participants were mailed a health-related quality of life questionnaire and had an interview that included a low back pain questionnaire and a straight leg raising test. Patients' reports of radiating leg pain and results of the straight leg raising tests were combined into four hierarchical groups. This stratification was evaluated in relation to responses to the health-related quality of life questionnaire, localized low back pain, disability, and use of medical services. RESULTS: The intensity of localized low back pain and disability increased from Group 1 (low back pain alone) to Group 4 (pain below knee with positive straight leg raising test result), whereas health-related quality of life decreased. Group 4 patients were 5.1 times more likely than were Group 1 patients to use medications for low back pain (95% confidence interval 1.2, 22.9), 6.8 times more likely to have a spinal magnetic resonance study (95% confidence interval, 2.7, 17.2), and 3.9 times more likely to have surgery (95% confidence interval, 1.3, 11.4). CONCLUSIONS: The method of measuring correlation performs well in identifying patients with different levels of localized low back pain intensity, health-related quality of life, and use of services. It may be useful in studies of health outcomes, in clinical trials, and in predicting demands on health care resources.

Aged↗
PubMed2006

Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study (MIPORT).

OBJECTIVE: Chronic back pain is characterized by a combination of neuropathic and nociceptive mechanisms of pain generation. The prevalence of the neuropathic pain component is unknown. Thus, in the context of an explorative study, we aimed to determine the prevalence of signs and symptoms indicating neuropathic pain in adult patients treated by orthopaedists. We also aimed to assess the usefulness of handheld computers (PDAs) in data collection. METHODS: Prospective epidemiological study in 18 orthopaedic practices or centres throughout Germany. Physician and patient questionnaires (paper/pencil or on handheld computers, PDAs) for patients with back pain of at least 3 months in duration were applied, as well as the von Korff score to assess pain intensity (visual analogue scale, VAS; 0 = no pain, 10 = worst possible pain) and pain characteristics, the Hannover Functional Ability Questionnaire (FFbH-R), and if patients agreed to provide information, the short-form Patient Health Questionnaire (PHQ-D) for depression. RESULTS: For 717 patients, both patient and physician questionnaires were available. Mean patient age was 56 years; pain was predominantly located in the low back (87%). Median current pain intensity on the VAS was 5.0. Confirmed key signs and symptoms indicated neuropathic pain was frequent, e.g. radicular pain radiating beyond the knee towards the foot (40.0%), positive Lasegue sign (18.4%), or absent patellar reflex (17.3%). A third of all patients (33.5%) had >or=3 characteristic signs for neuropathic pain. Patient functionality was severely reduced (median 43.3%). There were no relevant differences in outcomes between patients using the paper/pencil method (47%) versus those preferring PDAs (53%). CONCLUSION: Screening for neuropathic pain in this setting is feasible with simple questionnaires and scales on PDAs. Neuropathic pain is a major contributor to chronic back pain and a frequent component in patients seen by orthopaedists. At least one third of all patients should undergo additional diagnostic measures to confirm the cause of neuropathic pain.

Back Pain↗
PubMed2002

Pain-related fear in acute low back pain: the first two weeks of a new episode.

The overall aim of this study was to explore the natural course of pain-related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain-related fear and sequential relationships between the occurrence of pain-related fear, pain and pain catastrophizing. Forty-four general practice patients who consulted their physician with a new episode of non-specific low back pain were recruited. They completed diaries on pain-related fear, pain and pain catastrophizing for 14 days following the consultation. Follow-up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain-related fear over the 2-week period. These groups differed on baseline characteristics and outcome at follow-up. A time-shift between the occurrence of pain-events and pain-related fear or pain catastrophizing could not be demonstrated.In summary, these results fit in with previous findings in chronic patients. A relevant subgroup of patients who might benefit from early intervention could be identified. These findings support the need for further research into fear mechanisms in acute low back pain.

Acute Disease↗
PubMed2006

Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain.

OBJECTIVES: The purposes of this study were to investigate the association among measures of fear-avoidance beliefs, pain intensity, and lumbar flexion and to determine if changes in these measures were predictive of treatment outcome following physical therapy for acute low back pain. It was hypothesized that items of the Fear-Avoidance Beliefs Questionnaire would be correlated with concurrent measures of pain intensity and lumbar flexion. In addition, it was hypothesized that changes in fear-avoidance beliefs would be predictive of changes in self-report of pain intensity and disability. STUDY DESIGN: Patients underwent a standard examination that included measures of fear-avoidance beliefs, pain intensity, lumbar flexion, and disability from low back pain. Patients were then re-examined after 4 weeks of physical therapy treatment. PATIENTS: Sixty-three patients with acute low back pain enrolled in a clinical trial of physical therapy treatment. RESULTS: Fear-Avoidance Beliefs Questionnaire items were consistently correlated with lumbar flexion, but not with measures of pain intensity. Pearson correlations indicated that changes in disability were significantly associated with changes in fear-avoidance beliefs and pain intensity, but not changes in lumbar flexion. Changes in fear-avoidance beliefs explained significant amounts of variance in changes in average pain intensity while controlling for changes in lumbar flexion. Changes in fear-avoidance beliefs explained significant amounts of variance in changes in disability while controlling for changes in average pain intensity. CONCLUSIONS: These results suggest that fear-avoidance beliefs have a similar association with pain intensity, physical impairment, and disability for patients with acute and chronic low back pain. This study provides preliminary support for the use of the Fear-Avoidance Beliefs Questionnaire as an outcome measure for patients with acute low back pain.

Acute Disease↗
PubMedDate not supplied

Back pain in children.

Back pain in children may be due to many causes, both orthopaedic and nonorthopaedic. As with adults, underlying pathophysiology is frequently multifactoral and includes both physiologic and psychologic components. Assessment should include a thorough age-appropriate history and physical examination, based on presenting symptoms. The nurse should be aware of the child's perception of pain and its meaning, as well as that of the family. Management of back pain in children should include not only referral to appropriate specialists as indicated, but also should include involvement of the family unit in the treatment plan.

Adolescent↗