Chronic back pain: more than pain in the back. Findings of a regional survey among insurees of a workers pension insurance fund

BACKGROUND: Surveys with a main focus on back pain tend to isolate the complaint from possibly concomitant pains, other symptoms and disorders. Severe chronic back pain is assumed here to imply more than pain in the back. PARTICIPANTS AND METHODS: We report results from a two stage survey conducted in 1998 - 2000. The initial postal questionnaire addressed all 10,000 actively employed blue collar workers from a regional pension fund (Landesversicherungsanstalt Schleswig-Holstein) aged 40 - 54 and residing in or around Luebeck/Germany (68 % males). Subjects reporting severe and disabling back pain were invited to a socio-medical examination. The response and participation rates were 58 % and 65 % respectively. Non-response and non-participation seem to result in minor though opposite, effects. RESULTS: The prevalence of current back pain (back pain of any severity within the past 7 days) is high (68 %; including 16 % with severe, disabling back pain) despite the preponderance of males and a probable healthy worker effect. 82 % of subjects participating in the second round reported recurrent or persisting back pain on the day of examination, in the majority with a chronic fluctuating and overall deteriorating course pattern. 18 % reported no current back pain and hence gave prospective (and additionally retrospective) evidence of an episodic-intermittent course of the disorder. The former group showed significantly more pains, bodily complaints, dysfunctional cognitions, emotional distress and concomitant disorders. 35 % of them indicated back pain as their dominant health problem; 49 % identified back pain and another disorder as dominant, and 16 % reported other prominent health problems. More than 70 % of "other" disorders originated from the musculoskeletal system often involving the extremities. SUMMARY AND CONCLUSION: Back pain is very common among blue collar workers. Severe disabling back pain is usually associated with numerous other pains, bodily complaints, disorders, and indicators of psychological distress ("amplified back pain"). However, even amplified back pain is not always the sole or dominant health problem. Assessing the degree of "amplification" seems helpful in splitting a previously homogeneous group of severely affected back pain sufferers-with possible prognostic and therapeutic consequences.     

Exercise and smoking habits in patients with and without low back and leg pain

The exercise and smoking habits of low back or leg pain sufferers vs. persons not having low back or leg pain are compared. The type, frequency and length of exercise is determined from a study of 576 low back or leg pain sufferers compared to 50 persons who state they are symptomatic. The same was done for smoking habits. Thirty-three percent of low back or leg pain sufferers smoked as compared to 14% of those without pain. Forty-seven percent of low back or leg pain sufferers as compared to 86% of non-sufferers exercised regularly. The level of physical activity and general exercise have been found to improve strength, mobility and endurance; this might prevent future back injury. Our study is to determine differences in the exercise habits of persons with low back and/or leg pain vs. those who do not have pain, with the intention being to see if pain sufferers exercise less.     

Chronischer unspezifischer Rückenschmerz

Chronic low back pain represents an important issue not only for the patients but also for society. Apreventive diagnosis could open the possibility to predict the individual probability of developing chronic low back pain in pain-free persons or persons with sub-acute low back pain if no further preventive interventions would be started. Every year about 20% of adults will suffer from back pain and 70-80% of society will suffer from back pain during their lives. In most cases back pain is alleviated within the first 6 weeks without any medical intervention. Only a few cases are progredient and chronic with immense costs for society and health care systems. It is necessary to find out which individuals will probably suffer from chronic back pain in the future. The diagnostic outcome of the classification should help to answer the question which subgroups of patients with chronic low back pain will especially benefit from exercise therapy or cognitive behavior therapy?     

Heritability of low back pain and the role of disc degeneration

Twin studies suggest that both disc degeneration and back pain have a genetic component. We were interested in estimating the heritability of low back pain in men and examining whether genetic influences on back pain are mediated through genetic influences on disc degeneration. Thus, we conducted a classic twin study with multivariate quantitative genetic models to estimate the degree to which genetic (or environmental) effects on back pain were correlated with genetic (or environmental) effects on disc degeneration. Subjects included 147 monozygotic and 153 dizygotic male twin pairs (N=600 subjects) from the population-based Finnish Twin Cohort. All subjects underwent lumbar magnetic resonance imaging and completed an extensive interview, including back pain history and exposure to suspected risk factors. Disc height narrowing was the degenerative finding most associated with pain history, and was used to index disc degeneration in the models. Statistically significant genetic correlations were found for disc height narrowing and different definitions of back pain, such as duration of the worst back pain episode (r(g)=0.46) and hospitalization for back problems (r(g)=0.49), as well as disability in the previous year from back pain (r(g)=0.33). The heritability estimates for these back pain variables ranged from 30% to 46%. There also were statistically significant, but weaker, environmental correlations for disc height narrowing with back symptoms over the prior year. A substantial minority of the genetic influences on pain was due to the same genetic influences affecting disc degeneration. This suggests that disc degeneration is one pathway through which genes influence back pain.     

The treatment of neck and low back pain: who seeks care? who goes where?

BACKGROUND: Neck and low back pain are leading causes of morbidity and health care utilization. However, little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain. OBJECTIVES: The objectives of this study were to: 1) describe health care utilization for neck and back pain; 2) determine the characteristics of individuals seeking health care for neck and back pain; and 3) identify the characteristics of patients who consult medical doctors, chiropractors, or both. DESIGN: Population-based cross-sectional mailed survey. SUBJECTS: Subjects were randomly selected adults from the Saskatchewan Health Insurance and Registration File. MEASURES: Demographic, socio-economic, general health, comorbidity, health-related-quality-of-life, pain severity and health care utilization data were collected. The main outcome was whether subjects with prevalent neck or low back pain visited a health care provider in the previous month. RESULTS: Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. Compared with medical patients, fewer chiropractic patients lived in rural areas or reported arthritis, but they reported better social and physical functioning. More patients consulting both providers reported disabling neck or back pain. CONCLUSIONS: Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.     

Is occupational or leisure physical activity associated with low back pain? Insights from a cross-sectional study of 1059 participants

BackgroundLow back pain is a highly prevalent and disabling musculoskeletal disorder. Physical activity is widely used as a prevention strategy for numerous musculoskeletal disorders; however, there is still conflicting evidence as to whether physical activity is a protective or risk factor for low back pain or whether activity levels differ between people with and without low back pain.ObjectiveTo investigate the association between low back pain and different types (occupational and leisure) and intensities (moderate and vigorous) of physical activity.MethodsThis is cross-sectional observational study. We included in this study a total of 1059 individuals recruited from a Spanish twin registry with data available on low back pain. Outcome: Self-reported leisure and occupational physical activity were the explanatory variables. The low back pain outcome used in this study was recurrent low back pain.ResultsOur results indicate that leisure physical activity is associated with a lower prevalence of recurrent low back pain. In contrast, occupational physical activity, such as carrying, lifting heavy weight while inclined, awkward postures (e.g. bending, twisting, squatting, and kneeling) are associated with a higher prevalence of recurrent low back pain. There was no statistically significant association between other occupational physical activities, such as sitting or standing, and low back pain.ConclusionLeisure and occupational physical activity are likely to have an opposed impact on low back pain. While leisure physical activity appears to be protective, occupational physical activity appears to be harmful to low back pain. Future longitudinal studies should assist in formulating guidelines addressing specific types and intensity of physical activity aimed at effectively preventing low back pain.     

Chronic low back pain patients around the world: cross-cultural similarities and differences.

OBJECTIVE: The current study sought to determine whether there were any significant cross-cultural differences in medical-physical findings, or in psychosocial, behavioral, vocational, and avocational functioning, for chronic low back pain patients. DESIGN: Partially double-blind controlled comparison of six different culture groups. SETTING: Subjects were selected from primarily ambulatory care facilities specializing in treating chronic pain patients. PATIENTS-SUBJECTS: Subjects consisted of 63 chronic low back pain patients and 63 healthy controls. Low back pain patients were randomly selected from six different culture groups (American, Japanese, Mexican, Colombian, Italian, and New Zealander). Ten to 11 were gathered per culture from a pool of patients treated at various pain treatment programs. Likewise, 10 or 11 control group subjects were obtained from each culture from a pool of healthy support staff. MAIN OUTCOME MEASURES: The Sickness Impact Profile and the Medical Examination and Diagnostic Information Coding System were used as primary outcome measures. RESULTS: Findings showed that (a) low back pain subjects across all cultures had significantly more medical-physical findings and more impairment on psychosocial, behavioral, vocational, and avocational measures than controls did; (b) Mexican and New Zealander low back pain subjects had significantly fewer physical findings than other low back pain groups did; (c) the American, New Zealander, and Italian low back pain patients reported significantly more impairment in psychosocial, recreational, and/or work areas, with the Americans the most dysfunctional; and (d) findings were not a function of working class, age, sex, pain intensity, pain duration, previous surgeries, or differences in medical-physical findings. CONCLUSIONS: It was concluded that there were important cross-cultural differences in chronic low back pain patients' self-perceived level of dysfunction, with the American patients clearly the most dysfunctional. Possible explanations included cross-cultural differences in social expectation; attention; legal-administrative requirements; financial gains; attitudes-expectations about usage, type, and availability of health care; and self-perceived ability and willingness to cope.     

A prognostic approach to defining chronic pain

This paper develops a prognostic approach to defining chronic back pain. Possible and probable chronic back pain were defined, respectively, by a 50% and an 80% (or greater) probability of future clinically significant back pain. We assessed whether an empirically derived chronic pain classification satisfied these validating criteria among 1213 primary care back pain patients assessed at baseline and at 1, 2 and 5 year follow-ups. From multiple measures of back pain intensity and dysfunction, Latent Transition Regression Analysis empirically identified four pain severity latent classes: no pain; mild pain; moderate pain and limitation; and severe, limiting pain. From one observation point to the next, patients were most likely to remain in the same pain severity class, but chronic pain was better characterized as a dynamic state than a static trait. Among persons with severe, limiting pain, prognostic variables (depression, diffuse pain, pain persistence) improved prediction of future severe, limiting pain. A risk score developed from pain severity and prognostic measures identified risk levels corresponding to 50 and 80% probability thresholds for predicting future clinically significant back pain. At baseline and 1 year, 6.1 and 4.4% of study patients met or exceeded the 80% risk threshold for probable chronic back pain. An additional 20.3% at baseline and 12.5% at 1 year met or exceeded the 50% risk threshold for possible chronic back pain. Defining chronic pain prospectively, by risk thresholds for future clinically significant pain, provides an empirically grounded approach to chronic pain assessment.     

Medical-legal issues regarding patients with low back pain

Low back pain can present legal issues that require input from the patient's treating physicians. Because low back pain can lead to partial or complete disability, either on a short-term or long-term basis, patients may be unable to earn a living, which may make it necessary for patients to seek government aid, personal insurance benefits, or insurance benefits through workers compensation or even, when the low back pain was caused by an incident that was the fault of a third party, through a personal injury claim lawsuit. This article reviews the legal issues relevant to low back pain.     

Experts' opinions on complementary/alternative therapies for low back pain

BACKGROUND: Complementary/alternative therapies are used for low back pain more frequently than for any other indication, yet evidence for or against their efficacy is fragmentary. Notwithstanding this void, the high prevalence of such therapies drives their integration into our health care systems. Expert opinions on the use of complementary/alternative therapies for low back pain could therefore be helpful until more data from randomized, controlled trials become available. OBJECTIVE: A postal questionnaire survey was designed to generate opinion from a systematically identified expert panel on the clinical effectiveness of complementary/alternative therapies for low back pain. METHODS: Computerized searches were conducted to systematically identify by objective criteria 50 clinical experts on low back pain. Each panel member received a questionnaire to assess the perceived clinical effectiveness of complementary/alternative therapies for 4 defined categories of low back pain. RESULTS: For acute uncomplicated low back pain, osteopathy and chiropractic were rated as effective by most experts. For chronic uncomplicated low back pain, most experts considered acupuncture as effective. Experts perceived homeopathy generally as ineffective for any type of low back pain. Clinical experience with herbalism as a treatment for low back pain was insufficient to form an opinion. CONCLUSION: Experts' opinion is in favor of the effectiveness of osteopathy and chiropractic for acute uncomplicated low back pain. Acupuncture is judged to be of some value for chronic, uncomplicated low back pain. Homeopathy is perceived as ineffective for any type of low back pain. Insufficient experience with herbalism as a treatment for low back pain prevents firm conclusions.     

Migraine as a Sequela to Chronic Low Back Pain

SYNOPSIS
The occurrence of headache as a sequela of low back pain was examined in a sample of chronic pain patients. All patients had low back pain without history of head, neck, or upper back injury or headache onset simultaneous with the low back pain, Consistent with prior research, headache was found to be a common concomitant of back pain. In many patients, headache was found to have begun or exacerbated markedly after onset of low back pain. Prevalence of migraine in female patients was significantly higher than the population prevalence for females in the United States; this was not true for male patients. Potential mechanisms for explaining the high prevalence of migraine following low back pain are discussed, including increased muscle tension, psychosocial factors, and analgesic overuse.     

Chronic low back pain in traumatic lower limb amputees

OBJECTIVE: To ascertain the prevalence of back pain amongst traumatic lower limb amputees attending a regional rehabilitation centre and to determine the possible causes of back pain. DESIGN: All traumatic lower limb amputees given a semi-structured questionnaire to complete and a comparative subgroup of amputees with back pain and without back pain underwent physical examination, gait analysis, magnetic resonance scanning (MRI) and gait/standing stability analysis. SETTING: A subregional amputee rehabilitation centre. RESULTS: Transfemoral amputees were more likely to suffer from back pain (81 %) than transtibial amputees (62%) (p<0.05) and of those suffering from severe back pain, 89% and 81% also suffered from severe pain in the phantom limb and severe stump pain respectively. In two comparative subgroups of amputees there was no significant difference between back pain and pain-free groups except those with pain were more likely to have a body mass index (BMI) ratio above 50% of the recommended ratio. No difference in degeneration or disc disease between the groups on MR scans was found. Impact ground reaction forces during walking, irrespective of limb, were significantly greater (p < 0.05) in the pain-free group than in the pain group, as was walking speed. Gait asymmetry measures were similar in both groups. Centre of pressure displacement measures during standing were greater in the pain group than in the pain-free group. CONCLUSIONS: Low back pain in amputees is a significant problem equal to that of pain in the phantom limb and a biomechanical (myofascial) rather than a degenerative aetiology is suggested.     

Gluteus medius muscle activation patterns as a predictor of low back pain during standing

BACKGROUND: Low back pain is a primary source of disability and economic costs. Altered trunk muscle activation in people with low back pain, specifically agonist/antagonist co-activation, has been previously demonstrated. Prevailing theory considers this muscle activation pattern to be adaptive to low back pain. Muscle activation patterns prior to, and during, the development of low back pain in asymptomatic individuals, have not been well studied. METHODS: Participants, without a history of low back pain, stood in a constrained area for 2 h. Continuous surface electromyography was collected from trunk and hip muscles. Participants rated their discomfort level on visual analog scale every 15 min. Cross-correlation analyses were used to determine co-activation patterns. Blind predictions were made to categorize participants into low back pain and non-low back pain groups, and comparisons made to visual analog scale scores. FINDINGS: 65% of previously asymptomatic participants developed low back pain during the protocol. Co-activation of the bilateral gluteus medius muscles was found to be prevalent in the low back pain group (P= .002). 76% of the participants were correctly classified into low back pain and non-low back pain groups based on presence or absence of gluteus medius co-activation, with sensitivity= .87 and specificity= .50. INTERPRETATION: Agonist-antagonist co-activation may not be entirely adaptive, and may in fact predispose some individuals to develop low back pain. Muscle activation patterns at the hip may be a useful addition for screening individuals to identify those at risk of developing low back pain during standing.     

Relation between low back pain and X-ray changes. 4. Lysis and olisthesis

In a comparative study of 1024 low back pain and healthy subjects, prelysis was found in 16.4%, lysis in 10.5% and olisthesis in 2%. No relation between prelysis and lysis, and low back pain was found. Lysis seemed to be associated with a higher severity of low back pain. All the subjects with olisthesis suffered from low back pain. Based on these findings, it is concluded that lysis or pre-lysis should not be a ground for the exclusion of candidates to any occupation, but that olisthesis should, and that both lysis and olisthesis should be accepted as roentgenological findings in which the severity of low back pain may be higher, thus justifying a more prolonged sick leave.     

Epidemiology and natural history of low back pain

Low back pain is a common problem affecting most adults at some point during their lifetime. At any one time, around 1 in 5 adults will report symptoms of low back pain, rising to 40% when asked if they have experienced symptoms during the previous month. The majority of people who experience an episode of low back pain will improve over time. However a sizeable proportion experience repeated episodes or recurrences, and some report continuous symptoms for many years. A wide range of factors are linked to both the onset and persistence of low back pain. Some studies have related age and gender to low back pain, but the link overall is equivocal. Work-related factors such as heavy lifting, and socio-demographic factors such as smoking and obesity have been linked with the onset of low back pain. High levels of functional impairment and the presence of pain radiating to the leg have been cited as factors associated with a poor prognosis among primary care consulters with low back pain. Other characteristics associated with both the development and the persistence of low back pain include psychological factors such as depression and anxiety and workplace factors such as job satisfaction. Low back pain places large demands on health, social and welfare systems. Further research is needed to identify practical interventions to reduce this burden from low back pain.     

In the system: the lived experience of chronic back pain from the perspectives of those seeking help from pain clinics

Narrative accounts of their lived experiences were collected from twenty back pain patients who were seeking help from two pain clinics in the UK. Following analysis using a phenomenological approach, five themes emerged which tell a typical story of back pain. One prominent emergent theme, ‘in the system', is reported in which participants tell how they became entrapped within the medical, social security and legal systems. These systems, designed to treat or support those who are ill or disabled, effectively rendered participants powerless, helpless and angry. It is suggested that these accounts may help clinicians and researchers to gain a better understanding of the origins and nature of the negative attitudes exhibited by many back pain patients who seek help from pain treatment centres.     

Back pain from the epidemiological point of view

Summary In the last decades back pain has reached dramatic proportions in industrialized countries. Disorders of the back are nowadays the leading cause of direct and indirect health care costs. Accurate prevalence estimates are needed to serve as a basis for health care evaluations. A review of epidemiologic studies in the general population reveals that back pain has reached a prevalence of 40 % for current pain. 7 to 18 % are “frequently”, “often”, “daily” or “constantly” affected. 75 % of the adult population suffers from back pain during the last year. 80 to 90 % of the adult population in industrialized countries experience back pain ever. Gender specific differences are only present in severe, chronic forms which are more often experienced by women. Back pain has a prevalence maximum at 50 to 64 years. Older persons display lower prevalence estimates. The prevalence maximum in men is one decade earlier than in women. There are several potential explanations for this prevalence pattern that are discussed in the article. Back pain can be classified by location, temporal characteristics, pain intensity and pain history. Currently, for none of these dimensions generally accepted, uniformly employed and validated definitions are available. In most of the industrialized countries back pain is one of the most expensive symptoms. 75–90 % of the direct and indirect health care costs were caused by those 5–10 % of patients who are disabled. As predictors of back pain a history of back pain and job satisfaction play by far a more important role than the extensively studied mechanical factors. For a first episode of back pain the prognosis is favorable. If the pain persist for more than three months the prognosis is unfavorable. After six months of absenteeism because of back pain more than half of the afflicted never return to work. Rarely back pain is present as a single symptom. In more than 80 % back pain is associated with pain in at least one joint. It remains to be studied if back pain may be viewed as an entity or as part of a more complex pain syndrome.      

The evaluation of neuropathic components in low back pain

Chronic low back pain is highly prevalent in Western societies. Large epidemiological studies show that 20% to 35% of patients with back pain suffer from a neuropathic pain component. Presently, chronic lumbar radicular pain is the most common neuropathic pain syndrome. The pathophysiology of back pain is complex and nociceptive, and neuropathic pain-generating mechanisms are thought to be involved, which established the term mixed pain syndrome. Neuropathic pain may be caused by lesions of nociceptive sprouts within the degenerated disc (local neuropathic), mechanical compression of the nerve root (mechanical neuropathic root pain), or by action of inflammatory mediators (inflammatory neuropathic root pain) originating from the degenerative disc even without any mechanical compression. Its diagnosis and management remain an enigma, mainly because there is no gold standard for either. Accuracy of diagnostic tests used to identify the source of back pain and their usefulness in clinical practice, particularly for guiding treatment selection, is unclear. In connection with the specific instance of back pain (one of the single most costly disorders in many industrialized nations), neuropathic pain components are a significant cost factor.     

Application of 24-hour burst TENS in a back school

The Back School program consists of exercises and education designed to reduce back pain. Sixty-six percent of the patients had too much back pain to participate. The purpose of this clinical report is to describe how 24-hour burst transcutaneous electrical nerve stimulation (TENS) treatment enabled these patients with severe back pain to participate in the Back School. Patients recovering from a laminectomy, chemonucleolysis, or scoliosis surgery were used to determine that 24-hour burst TENS was the most effective TENS protocol for reducing pain. Twenty-four-hour burst TENS was then prescribed for 129 patients with severe back pain to enable them to complete the Back School program. Eighty percent of these patients returned to their usual activities within 12 months. The Back School program has been shown to be an effective and safe treatment for back pain, and 24-hour burst TENS treatment allows patients with severe back pain to participate in it.