Relationship between physical activity and disability in low back pain: a systematic review and meta-analysis

It is often assumed that patients with pain-related disability due to low back pain (LBP) will have reduced physical activity levels, but recent studies have provided results that challenge this assumption. The aim of our systematic review was to examine the relationship between physical activity and disability in LBP. The literature search included 6 electronic databases and the reference list of relevant systematic reviews and studies to May 2010. To be included, studies had to measure both disability (eg, with the Roland Morris Disability Questionnaire) and physical activity (eg, by accelerometry) in patients with non-specific LBP. Two independent reviewers screened search results and extracted data, and authors were contacted for additional data. Correlation coefficients were pooled using the random-effects model. The search identified 3213 records and 18 studies were eligible for inclusion. The pooled results showed a weak relationship between physical activity and disability in acute or subacute (<3 months) LBP (r = −0.08, 95% confidence interval = −0.17 to 0.002), and a moderate and negative relationship in chronic (>3 months) LBP (r = −0.33, 95% confidence interval = −0.51 to −0.15). That is, persons with acute or subacute LBP appear to vary in the levels of physical activity independent of their pain-related disability. Persons with chronic LBP with high levels of disability are also likely to have low levels of physical activity.     

A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain

A preliminary report of clinical study revealed that chronic discogenic low back pain could be treated by intradiscal methylene blue (MB) injection. We investigated the effect of intradiscal MB injection for the treatment of chronic discogenic low back pain in a randomized placebo-controlled trial. We recruited 136 patients who were found potentially eligible after clinical examination and 72 became eligible after discography. All the patients had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-six were allocated to intradiscal MB injection and 36 to placebo treatment. The principal criteria to judge the effectiveness included alleviation of pain, assessed by a 101-point numerical rating scale (NRS-101), and improvement in disability, as assessed with the Oswestry Disability Index (ODI) for functional recovery. At the 24-month follow-up, both the groups differed substantially with respect to the primary outcomes. The patients in MB injection group showed a mean reduction in pain measured by NRS of 52.50, a mean reduction in Oswestry disability scores of 35.58, and satisfaction rates of 91.6%, compared with 0.70%, 1.68%, and 14.3%, respectively, in placebo treatment group (p < 0.001, p < 0.001, and p < 0.001, respectively). No adverse effects or complications were found in the group of patients treated with intradiscal MB injection. The current clinical trial indicates that the injection of methylene blue into the painful disc is a safe, effective and minimally invasive method for the treatment of intractable and incapacitating discogenic low back pain.     

Efficacy and safety of tanezumab in the treatment of chronic low back pain

Increased nerve growth factor levels are associated with chronic pain conditions, including chronic low back pain (LBP). This study examined safety and analgesic efficacy of tanezumab, a humanized anti-nerve growth factor antibody, in adults with chronic LBP. Patients received intravenous tanezumab 200 μg/kg plus oral placebo (n = 88), intravenous placebo plus oral naproxen 500 mg twice a day (n = 88), or intravenous placebo plus oral placebo (n = 41). Primary outcome was average LBP intensity (aLBPI) at Week 6. Secondary outcomes were proportion of patients with ?30% or ?50% reduction in aLBPI, Roland-Morris Disability Questionnaire and Brief Pain Inventory-short form scores, Patients’ Global Assessment of LBP, Patients’ Global Evaluation of study medication, and rescue medication use. Mean aLBPI change from baseline to Week 6 was greater with tanezumab vs naproxen (P = 0.004) and placebo (P < 0.001). Greater proportions of patients reported ?30% and ?50% reduction in aLBPI with tanezumab vs naproxen (P ? 0.013) and placebo (P < 0.001), and greater improvements in Roland-Morris Disability Questionnaire (P < 0.001) and other secondary outcomes except rescue medication use. Tanezumab was associated with adverse events (AEs) of abnormal peripheral sensation that were generally mild and resolved before study completion; however, there were no serious AEs. Nine patients (4 of whom were tanezumab-treated) discontinued due to AEs. In conclusion, tanezumab resulted in analgesic efficacy that was clinically and statistically superior to placebo and naproxen in patients with chronic LBP. Tanezumab clinical development is on regulatory hold due to AEs in osteoarthritis patients.     

Effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis

[Purpose] This study examined the effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis. [Subjects] Thirty patients with lumbar spinal stenosis were divided into two groups: a conservative treatment group (n=15) and a flexion-distraction manipulation group (n=15). [Methods] The conservative treatment group received conservative physical therapy, and the flexion-distraction group received both conservative physical therapy and flexion-distraction manipulation therapy. Both groups received treatment 3 times a week for 6 weeks. The Visual Analog Scale was used to measure pain intensity, and the Oswestry Disability Index was used to evaluate the level of disability caused by the pain. [Results] The Visual Analog Scale scores for pain were significantly decreased in both groups. In the between-group comparison, the decrease in pain was more significant in the flexion-distraction group. According to the Oswestry Disability Index, the level of disability was significantly decreased in both groups, but the decrease was more significant in the flexion-distraction group. [Conclusion] Flexion-distraction manipulation appears to be an effective intervention for pain and disability among patients with lumbar spinal stenosis.Key words: Spinal stenosis, Flexion-distraction manipulation, Disability     

The relationships between measures of stature recovery, muscle activity and psychological factors in patients with chronic low back pain

Individuals with low back pain (LBP) often exhibit elevated paraspinal muscle activity compared to asymptomatic controls during static postures such as standing. This hyperactivity has been associated with a delayed rate of stature recovery in individuals with mild LBP. This study aimed to explore this association further in a more clinically relevant population of NHS patients with LBP and to investigate if relationships exist with a number of psychological factors. Forty seven patients were recruited from waiting lists for physiotherapist-led rehabilitation programmes. Paraspinal muscle activity while standing was assessed via surface electromyogram (EMG) and stature recovery over a 40-min unloading period was measured on a precision stadiometer. Self-report of pain, disability, anxiety, depression, pain-related anxiety, fear of movement, self-efficacy and catastrophising were recorded.Correlations were found between muscle activity and both pain (r = 0.48) and disability (r = 0.43). Muscle activity was also correlated with self-efficacy (r = −0.45), depression (r = 0.33), anxiety (r = 0.31), pain-related anxiety (r = 0.29) and catastrophising (r = 0.29) and was a mediator between self-efficacy and pain. Pain was a mediator in the relationship between muscle activity and disability. Stature recovery was not found to be related to pain, disability, muscle activity or any of the psychological factors. The findings confirm the importance of muscle activity within LBP, in particular as a pathway by which psychological factors may impact on clinical outcome. The mediating role of muscle activity between psychological factors and pain suggests that interventions that are able to reduce muscle tension may be of particular benefit to patients demonstrating such characteristics, which may help in the targeting of treatment for LBP.     

Fear-avoidance beliefs and distress in relation to disability in acute and chronic low back pain

Patients with chronic low back pain (LBP) frequently demonstrate high scores for fear-avoidance beliefs and distress. We need better knowledge about fear-avoidance beliefs and distress in early stages of LBP. The objectives of this study were to compare the level of fear-avoidance beliefs and distress in patients with acute LBP to patients with chronic LBP, and to assess the relationship of fear-avoidance beliefs and distress to disability in acute and chronic LBP. Two different back pain groups including 123 patients with acute and 233 patients with chronic LBP were studied. Main outcome measures were Oswestry Disability Index and work loss. The scores for fear-avoidance beliefs and distress in patients with acute LBP were significantly lower than among patients with chronic LBP. The results of the multivariate regression analyses, adjusting for sociodemographic, pain and clinical variables, demonstrated that whereas fear-avoidance beliefs for physical activity and distress were significantly associated with the Oswestry Disability Index, fear-avoidance beliefs for work and distress were significantly associated with work loss. The associations showed the same pattern in acute and chronic LBP. In addition, several of the pain and clinical variables were significantly associated with the Oswestry Disability Index and fingertip-floor distance was associated with work loss. In conclusion, fear-avoidance beliefs and distress influence pain-related disability both in early acute and long-term chronic LBP. The results replicate previous reports on the association between pain experience, fear-avoidance beliefs, distress, and disability in chronic LBP, and extend the findings to patients at an early stage of acute LBP.     

Effects of eight-week water versus mat pilates on female patients with chronic nonspecific low back pain: Double-blind randomized clinical trial

ObjectiveTo evaluate the effects of water and mat Pilates on pain, disability, and static and dynamic balance in patients with chronic nonspecific low back pain (CNLBP).MethodsTwenty-four participants with CNLBP were randomly allocated into two groups (n = 12) that perform water and mat Pilates exercises for 24 sessions (8-week, 3 sessions per week). The value for pain, disability and balance were measured before and after the exercise program using the Visual Analogue Scale, Oswestry Disability Questionnaire and Biodex Balance System respectively.ResultsA paired t-test revealed significant differences in pain severity and disability in both groups after they performed the Pilates program (P ≤ 0.05). Mat Pilates improved static balance as the participants performed the tests with their eyes open and closed (P = 0.02, P = 0.04). Its effect on dynamic balance, however, was not statistically significant (ES = 0/33, P = 0/34). The same Pilates program performed in water did not show significant effects on balance despite a decline in body sway (P˃0/05). There was no difference between the two groups (P˃0/05).ConclusionThe results suggest that both mat and water Pilates exercise program have beneficial effects on the treatment of LBP. Nevertheless, the low impact of the mat and water Pilates program on balance improvement suggests more investigation on Pilates training or complementary exercises to improve balance in patients with CNLBP.     

The role of fear of movement in subacute whiplash-associated disorders grades I and II

Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders (WAD). This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear. People still symptomatic from WAD grade I-II injuries approximately 3 months previously (n = 191) completed questionnaires (eg, Neck Disability Index [NDI]) and were randomized to 1 of the treatments: (1) informational booklet (IB) describing WAD and the importance of resuming activities, (2) IB + didactic discussions (DD) with clinicians reinforcing the booklet, and (3) IB + imaginal and direct exposure desensitization (ET) to feared activities. DD and ET participants received three 2-hour treatment sessions. Absolute improvements in NDI were in predicted direction (ET = 14.7, DD = 11.9, IB = 9.9). ETs reported significantly less posttreatment pain severity compared with the IB (Mean = 1.5 vs 2.3, P < .001, d = 0.6) and DD (M = 1.5 vs 2.0, P = .039, d = 0.6) groups. Reduction in fear was the most important predictor of improvement in NDI (β = 0.30, P < .001), followed by reductions in pain (β = 0.20, P = .003) and depression (β = 0.18, P = .004). The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome. Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and/or educational interventions to improve function.     

Effects of a Remotely Delivered Cognitive Behavioral Coaching Program on the Self-Rated Functional Disability of Participants with Low Back Pain

PurposeA remotely delivered cognitive behavioral coaching (CBC) program was offered as a service benefit for commercial health plan members with low back pain (LBP). This study describes changes in self-rated functional disability in a sample of plan members participating in the program (N=423).MethodsIndependent measures included demographics, length of program enrollment, total CBC sessions, and baseline self-reported patient activation and presenteeism levels. Participants rated their functional disability level due to LBP using the Oswestry Disability Index (ODI). Dependent outcomes quantified change in participant functional disability rating (final ODI score minus baseline ODI score). Nonparametric tests compare differences between groups and within-group ODI score change. Two generalized linear models test for associations between independent variables and the ODI change score.ResultsA significant difference between baseline and final ODI scores was observed at the overall program level (p<.001) and within all independent variable categories of interest. Over 68% of total participants (n=289) reported improved functional ability from baseline to final (decrease in ODI score). Participants who completed more CBC sessions demonstrated significantly greater improvement in functional ability (p=.038) compared to those who completed fewer sessions. Participants aged 55 and older were significantly more likely to show deterioration in functional ability from baseline to final (p=.021).ConclusionOutcomes suggest that program participation can influence self-rated functional disability in the management of LBP.     

Psychometric properties of the Roland-Morris Disability Questionnaire compared to the Oswestry Disability Index: a systematic review

Abstract

Objectives: To compare the psychometric properties of the Roland-Morris Disability Questionnaire and the Oswestry Disability Index used to measure physical ability in people with low back pain.

Methods: A literature search of computerised databases from 1980 through June 2009 was performed using search terms: clinical assessment tools, Roland-Morris, questionnaires, back, spine, back pain, Oswestry Disability Index, psychometrics, reliability, validity, specificity and sensitivity. Twenty-three articles were reviewed using an adult population over 18 years old with acute, sub-acute and chronic low back pain.

Results: The Roland-Morris Disability Questionnaire and the Oswestry Disability Index demonstrate good reliability in test–retest performance clinically at initial evaluation and up to 6 weeks following interventions. Two studies described the construct validity of the two measures as highly correlated with each other. Overall, it appears that both questionnaires have similar responsiveness rates of 0·76–0·78 but two studies report a responsiveness rate of 0·94 for the Oswestry.

Discussion/Conclusion: The Roland-Morris Disability Questionnaire is most sensitive for patients with mild to moderate disability while the Oswestry Disability Index is most effective for persistent severe disability. Clinically, both questionnaires should be considered depending on the patient's objective presentation of disability. The clinician needs to determine either 'mild to moderate' or 'severe persistent disability' after a thorough history and physical exam is completed so that the appropriate questionnaire can be administered. This helps support the clinician's assessment of function, determine a patient's level of disability and provide outcome information.