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PubMedDate not supplied

Ketorolac versus acetaminophen-codeine in the emergency department treatment of acute low back pain.

Acute low back pain is a common problem in the emergency department (ED). Effective management of acute pain enhances early rehabilitation and recovery. Given the importance of inflammatory mediators in pain generation and the adverse effects associated with opioids, it is logical to expect that a non-opioid agent with antiinflammatory and analgesic properties would provide excellent analgesia with fewer adverse effects. This double-blind, randomized, multicenter clinical trial, performed in six university and community hospital EDs, compares the analgesic efficacy and adverse effects of ketorolac to those of acetaminophen-codeine in ED patients with acute musculoskeletal low back pain. Our hypothesis was that ketorolac would provide superior analgesia with fewer adverse effects. One hundred twenty-three patients with acute low back pain were randomized to receive ketorolac (KET, N = 63) or acetaminophen-codeine (ACOD, N = 60). Most (79%) were males, and the mean age was 34.5 years. After baseline clinical assessment, patients were treated with ketorolac (10 mg every 4 to 6 h as needed, up to four daily doses) or acetaminophen-codeine (600 mg-60 mg, respectively, every 4 to 6 h as needed, up to six daily doses) and followed for one week. Pain intensity was assessed on visual analogue and categorical scales. Functional capacity, overall pain relief, and overall medication rating were assessed on categorical scales. Adverse events were documented. Primary outcomes included: 1) Pain intensity differences, based on visual analogue scores, for the 0 to 6 h treatment phase. 2) Incidence of adverse events. Secondary outcomes included analgesic efficacy, functional capacity, and overall subjective drug evaluation at one week. Both drugs provided substantial pain relief, with maximal effect 2.2 h after oral dosing. There were no significant differences in analgesic efficacy, functional capacity, or overall pain relief between the two groups. Sixteen patients (10 KET vs. 6 ACOD, NS) withdrew prematurely because of drug inefficacy. Patients in the ACOD group reported significantly more adverse drug events and serious adverse drug events. Seven patients--all in the ACOD group--withdrew from the study because of adverse drug events. Based on comparable efficacy and a superior adverse event profile, ketorolac was preferable to acetaminophen with codeine for the treatment of acute low back pain in the ED.

Acetaminophen↗

PubMed2005

The pathogenesis of discogenic low back pain.

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain.

Adult↗

PubMed2002

[Cause-specific treatment for nonspecific low back pain].

Nonspecific low back pain has long been a troublesome clinical entity in that the diagnoses are usually hard to define, and the effect of treatment unsure. We have been conducting long-term basic and clinical research in Zhujiang Hospital in an effort to find the exact mechanism for this disease and to explore its causal treatment. On the basis of literature review and treatment result evaluation, we recommend the following approaches for origin-specific diagnosis and treatments: (1) For spinal nerve dorsal ramus syndrome caused by mechanical stimulation on the stem part of the dorsal ramus, freezing the dorsal ramus with liquid-nitrogen may constitute the primary treatment. (2) In cases of low back pain originated from the lumbar disc due to degeneration of discs, treatment may be implemented through disc resection with or without arthrodesis. (3) Facet syndrome, a condition with low back pain that is seldom caused by pathological changes in the facet itself, but mostly by the pulling of the dorsal ramus due to the dislocation of the facet, should be attributed to the dorsal ramus syndrome. (4) Lumbar vertebra instability arising from loosened intervertebral conjunction calls for arthrodesis as the primary choice. (5) Interspinal ligaments injury can be most effectively treated by the combination of blocking and needle knife loosing. (6) Low back pain with underlying causes in the internal organs is often caused by diseases in the pelvic organs, and only these diseases are cured can the back pain be relieved. These origin-specific diagnosis and treatments we proposed here await further investigation and comments from our peers interested in this problem.

Humans↗

PubMed1987

[Labor of freight-container tractor drivers and low-back pain. Characteristics of the low-back pain through clinical findings].

In order to clarify the characteristics of the low-back pain which is prevalent among freight-container tractor drivers, a medical examination, composed of orthopedic tests and questions about health conditions, was carried out on 231 tractor drivers. Prevailing complaints were: dullness or stiffness of the shoulder (71%); dullness of the neck (69%); dullness of the low back (62%); low-back pain (42%); dullness of the lower limbs (39%) and dullness of the back (36%). The rates of complaints of dullness or pain of the neck, shoulder, upper limbs, back or lower limbs, and disturbance of daily activity were associated with the grade of low-back pain evaluated from the subjective symptoms. Orthopedic examination revealed fatigue signs of muscles i.e. tenderness of the body trunk and limbs, tenderness or percussion pain on the spinous processes, and poor results in some tests on muscle strength. These findings were seen more frequently in the group with subjective symptoms, but even among the group without symptoms, they were evident to some degree. These findings were considered to originate from the fact that the freight-container tractors had many ergonomic problems and the daily driving hours of many drivers were estimated to exceed the allowable vibration exposure time of the ISO.

Activities of Daily Living↗

PubMed1992

Classification of nonspecific low back pain. I. Psychological involvement in low back pain. A clinical, descriptive approach.

An unselected sample of outpatient subjects (n = 330) with localized nonspecific low back pain (LBP) was studied. Investigation consisted of clinical assessment, physical examination, and psychiatric interview based on the DSM-III classification. A psychiatric disorder, according to the DSM-III criteria (axis I) was found in 41% of the subjects. Multiple correspondence analysis and cluster analysis were used to objectively identify clinical subtypes without preconceived theoretical models. Correspondence analyses suggested the existence of a 'psychological pain' syndrome consisting of several of the following symptoms: diffuse back pain, impossibility to assess intensity of pain on a pain scale, aggravation of pain by changing climate, by domestic activities or by psychological factors and dysesthesias in the back. Cluster analysis provided support for a four-group classification of low back pain, which may be interpreted through the relationships between psychological disturbances and the LBP clinical features. The results call for further investigation of the complex relationship between psychological disturbances and back pain. However, clinicians must be aware of the interest of a minimal psychiatric assessment in low back pain patients: psychiatric disorders frequently appear in these patients and an appropriate treatment of the psychiatric syndrome may reduce back pain.

Adolescent↗

PubMed2005

[Epidural steroid injections and low back pain].

Low-back pain nearly affects all the people in the population; male or female, at any period of their lives and continues with spontaneous regressive attacks. In 10% of the patients, the pain persists despite conservative treatments and causes significant decrements of life quality. For this reason, the patients with chronic low back-pain are applying to pain specialists and treated with different invasive pain therapies. Epidural steroid injections are the most common invasive procedures in the treatment of low-back pain. However, the effects and outcomes are contradictory. Epidural steroid injections should be performed absolutely under fluoroscopic guidance. Pain selection should be made carefully and algorithms should be performed fastidiously.

Anesthetics, Local↗

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↗

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↗

PubMed1984

Mechanism of facet load transmission as a hypothesis for low-back pain.

Low-back pain has a complex and multi-faceted etiology. The articular facets have been shown to be load-bearing structures and may be a site for low-back pain. The aim of this paper is to establish the mechanism for the transmission of axial load across a facet joint and to propose a facet-related hypothesis for low-back pain. The mechanism of load transmission was studied by two methods. Lumbar segments were instrumented with an intervertebral load cell (IVLC) to measure disc load so that facet load could be deduced. The applied load was moved 10 mm anteriorly and 12.5 mm posteriorly from the center of the vertebral body. The facets then were separated from the body and loaded axially to determine their stiffness in tension and compression and to observe the failure mode of the joint. It was shown optically that compressive loading of the isolated facet joints was equivalent to spinal extension and tensile loading to spinal flexion. Lastly, a finite element model of a lumbar motion segment was developed to simulate the transmission of facet load and to study the effects of disc degeneration on facet loads. Results of the study on six lumbar segments revealed that the normal facets carried 3-25%. If the facet joint was arthritic, the load could be as high as 47%. Experiments on isolated facet joints revealed that they behaved as a stiffening spring in compression and were weak in tension.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1996

[Guidelines for treating low back pain in primary care. The Israeli Low Back Pain Guideline Group].

Low back pain (LBP) is a common problem in primary care, the successful management of which poses special challenges for patients and practitioners alike. It has been estimated that all adults will suffer LBP sometime during their lifetimes. It is one of the most frequent reasons for visiting a primary care physician, yet practitioners often find it difficult and frustrating to treat. This medical protocol is concerned with the diagnosis, treatment, and follow-up of low back pain in adults. It was developed for community-based, primary care physicians (general practitioners, family physicians, and internists) to serve as a general outline, to be adjusted in accord with the individual's circumstances. The protocol provides a "Ten Commandments" for the care of LBP, outlines the background of the problem, presents an overall algorithm and deals with issues of diagnosis, imaging, and treatment. In general, LBP in primary care is conceived of as a benign ailment, and emphasis is placed on reducing pain, resuming functioning and returning to work. The main task of the physician is to distinguish the less than 10% of cases with serious, specific causes of LBP from the more than 90% with nonspecific etiologies. In the great majority of patients, imaging studies such as X-ray, CT, MRI, and bone scan, and also EEG are unnecessary.

Family Practice↗

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↗

PubMed1999

[A simple therapeutic regime for subacute back pain].

Low back pain seems to be an intrinsic factor in most people's lives. Its cause is still largely unknown. Several structures have been suggested as important pain generators, but proof is still largely lacking. The prognosis is generally regarded as good, but in some patients acute low back pain progresses into a chronic disorder. Some suggest that our way of handling the problem might be partly responsible for the increase in chronic low back pain during the last forty years. Rather than structural derangement, a functional disturbance in the complex reflex system that coordiantes the network of paraspinal muscles could be the background for the impairment. A guarded behaviour and fear can increase the muscular dysfunction and make the situation worse. A simple regime for an effective fear-avoidance and activation program is outlined. The approach includes a clinical examination combined with information for patients about the nature of the problem, provided in a manner designed to reduce fear and give them reason to resume light normal activity.

Back Pain↗

PubMed2000

Individual and occupational determinants of low back pain according to various definitions of low back pain.

OBJECTIVES: To test associations between non-specific low back pain and several risk factors when definitions of low back pain vary. DESIGN/SETTING/PARTICIPANTS: A cross sectional study was set up in 1991, 725 workers from four occupational sectors answered a self administrated questionnaire including the Nordic questionnaire and questions about intensity of pain and individual and occupational factors. MAIN RESULTS: Prevalence of low back pain varied from 8% to 45% according to the definition used. Psychosomatic problems, bending or carrying loads were often associated to low back pain, whereas other risk factors were related to some specific dimensions of the disorder. CONCLUSIONS: Risk factors of low back pain vary with the definition. This could explain inconsistencies found in literature reviews. To be able to compare data, it seems important to be precise what definition is used and to use comparable questionnaires.

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

A spatial configuration of the lumbo-sacral part of the vertebral column--an importance in the etiology of low back pain.

Chronic low back pain is a very important problem in our civilization. Does a spatial configuration of the vertebral column have an influence on the occurrence of chronic low back pain? Author has compared values of Whitman-Fergusson's angle and Cobb's angle for standing position in patients and controls. No significant differences between both groups have been founded. Beside of this, inclination od sacrum to a horizontal line has had an influence on a value lumbar lordosis in both groups.

Adult↗

PubMed1999

The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain.

UNLABELLED: Low back pain (LBP) is one of the most common medical problems in our society. Increasingly, patients are turning to nonpharmacologic analgesic therapies such as percutaneous electrical nerve stimulation (PENS). We designed this sham-controlled study to compare the effect of three different frequencies of electrical stimulation on the analgesic response to PENS therapy. Sixty-eight consenting patients with LBP secondary to degenerative lumbar disc disease were treated with PENS therapy at 4 Hz, alternating 15 Hz and 30 Hz (15/30 Hz), and 100 Hz, as well as sham-PENS (0 Hz), according to a randomized, cross-over study design. Each treatment was administered for a period of 30 min three times per week for 2 wk. The pre- and posttreatment assessments included the health status survey short form and visual analog scales for pain, physical activity, and quality of sleep. After receiving all four treatments, patients completed a global assessment questionnaire. The sham-PENS treatments failed to produce changes in the degree of pain, physical activity, sleep quality, or daily intake of oral analgesic medications. In contrast, 4-Hz, 15/30-Hz, and 100-Hz stimulation all produced significant decreases in the severity of pain, increases in physical activity, improvements in the quality of sleep, and decreases in oral analgesic requirements (P < 0.01). Of the three frequencies, 15/30 Hz was the most effective in decreasing pain, increasing physical activity, and improving the quality of sleep (P < 0.05). In the global assessment, 40% of the patients reported that 15/30 Hz was the most desirable therapy, and it was also more effective in improving the patient's sense of well-being. We conclude that the frequency of electrical stimulation is an important determinant of the analgesic response to PENS therapy. Alternating stimulation at 15-Hz and 30-Hz frequencies was more effective than either 4 Hz or 100 Hz in improving outcome measures in patients with LBP. IMPLICATIONS: The frequency of electrical stimulation seems to be an important determinant of the analgesic efficacy of percutaneous electrical nerve stimulation. Mixed low- and high-frequency stimulation was more effective than either low or high frequencies alone in the treatment of patients with low back pain.

Analgesia↗

PubMed1997

Sacroiliac dysfunction in dancers with low back pain.

SUMMARY. Low back pain is a common occurrence in dancers. Studies have shown its prevalence to be around 12% of all dance type of injuries. It is commonly thought by health professionals who specialize in dance medicine that sacroiliac (SI) dysfunction is one of the more common causes of low back pain in dancers. The aetiology of SI dysfunction in dancers is related to both the biomechanics of the SI joint and the physiological demands placed on the SI joint from the dynamics of dance. Injury to the SI joint can be due to a combination of a single traumatic incident, from overuse factors involving repetitive microtrauma or from emotional stress. Clinical manifestations could be pain in the back, buttock, hip and leg, and limitation of movement specific to dance. Diagnosis is based upon the deviation from normal of both the static and kinetic functions of the low back and pelvis in its relationship to the biomechanics of dance. Treatment is aimed at relieving pain, restoring the function of the SI joint and returning the dancer to full function. Copyright 1997 Harcourt Publishers Ltd.

Journal Article↗

PubMed2001

Psychosocial function, clinical status, and radiographic findings in a group of chronic low back pain patients.

Low back pain is considered a problem with multiple facets for which the underlying causative factors should be determined. The aim of this study was to evaluate the relationships between depression, clinical status, and radiographic findings in a group of fifty patients with low back pain for more than 6 months. The patients underwent clinical examination and they completed Beck depression inventory (BDI), Aberdeen back pain scale (ABPS) and research questionnaire. Radiographic evaluations were performed. Clinical score and duration of symptoms were found to be positively correlated. The BDI scores were not found to be correlated with the existing variables. The ABPS scores were positively correlated with clinical scores and number of medications used.

Adult↗