Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

Background contextIt is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.PurposeTo study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.Study designProspective nested cohort study based on a randomized controlled trial.Patient sampleOut of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study.Outcome measuresDegenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW).MethodsBy using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW.ResultsClinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.ConclusionsThe only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.     

The prognostic value of catastrophizing for predicting the clinical evolution of low back pain patients: a study in routine clinical practice within the Spanish National Health Service

Background contextExperimental studies suggest that catastrophizing may worsen the prognosis of low back pain (LBP) and LBP-related disability and increase the risk of chronicity.PurposeTo assess the prognostic value of baseline catastrophizing for predicting the clinical evolution of LBP patients in routine clinical practice and the association between the evolution of pain and catastrophizing.Study design/settingProspective study in routine clinical practice of the Spanish National Health Service.Patient sampleOne thousand four hundred twenty-two acute and chronic adult LBP patients treated in primary and hospital care.Outcome measuresPain, disability, and catastrophizing measured through validated instruments.MethodsPatients were managed according to routine clinical practice. Outcome measures were assessed at baseline and 3 months later. Logistic regression models were developed to estimate the association between baseline catastrophizing score and the improvement of LBP and disability, adjusting for baseline LBP and leg pain (LP) severity, disability, duration of the pain episode, workers' compensation coverage, radiological findings, failed back surgery, and diagnostic procedures and treatments undertaken throughout the study. Another model was developed to estimate the association between the evolution of LBP and the change in catastrophizing, adjusting for the same possible confounders plus the evolution of LP and disability. Models were repeated excluding the treatments undergone after the baseline assessment.ResultsRegression models showed that the degree of baseline catastrophizing does not predict the evolution of LBP and disability. Conversely, as the degree of pain improvement increases, so does the odds ratio for improvement in catastrophizing, ranging from three (95% confidence interval [95% CI], 2.00–4.50; p<.001) for improvements in pain between 1.1 and 4 visual analog scale (VAS) points, to 7.3 (95% CI, 3.49–15.36; p<.001) for improvements in pain more than 6.1 VAS points. Similar results were obtained when treatments were excluded from the models.ConclusionsIn routine practice, assessing the baseline score for catastrophizing does not help clinicians to predict the evolution of LBP and disability at 3 months.     

Catastrophization,fear of movement,anxiety, and depression are associated with persistent,severe low back pain and disability

BACKGROUND CONTEXTPsychological characteristics are important in the development and progression of low back pain (LBP); however, their role in persistent, severe LBP is unclear.PURPOSETo investigate the relationship between catastrophization, depression, fear of movement, and anxiety and persistent, severe LBP, and disability.STUDY DESIGN/ SETTINGOne-year prospective cohort study.PATIENT SAMPLEParticipants were selected from the SpineData registry (Denmark), which enrolls individuals with LBP of 2 to 12 months duration without radiculopathy and without satisfactory response to primary intervention.OUTCOME MEASURESPsychological characteristics, including catastrophization, depression, fear of movement, and anxiety, were examined at baseline using a validated screening questionnaire. Current, typical, and worst pain in the past 2 weeks were assessed by 11-point numeric rating scales and an average pain score was calculated. Disability was measured using the 23-item Roland-Morris Disability Questionnaire.METHODSParticipants completed baseline questionnaires on initial presentation to the Spine Center (Middelfart, Denmark), and follow-up questionnaires were sent and returned electronically. Statistical analysis involved multivariable Poisson regression to investigate the association between psychological factors and the number of episodes of severe pain or disability. This study received no direct funding.RESULTSOf the 952 participants at baseline, 633 (63.4%) provided data 1 year later. Approximately half of the participants reported severe LBP (n=299, 47.2%, 95% confidence interval [CI] 43.3%–51.2%) or disability (n=315, 57.6%, 95% CI 53.3%–61.8%) at a minimum of one time point, and 14.9% (n=94, 95% CI 12.2%–17.9%) and 24.3% (n=133, 95% CI 20.8%–28.1%) experienced severe LBP or disability at two time points, respectively. Multivariable Poisson regression showed a relationship between catastrophization, depression, fear of movement, and anxiety and a greater number of time points with severe LBP and disability, after adjusting for age, gender, body mass index, and duration of symptoms. However, when all psychological factors were added to the regression model, only catastrophization and depression remained significantly associated.CONCLUSIONSThis study showed that persistent, severe LBP, and disability is common in a secondary care population with LBP and is associated with a variety of psychological risk factors, in particular catastrophization and depression, highlighting the importance of considering these factors in the design and evaluation of outcomes studies for LBP.     

Using few and scattered time points for analysis of a variable course of pain can be misleading: an example using weekly text message data

Background contextBecause low back pain (LBP) is a fluctuating condition, the diversity in the prediction literature may be due to when the outcome is measured.PurposeThe objective of this study was to investigate the prediction of LBP using an outcome measured at several time points.Study design/settingA multicenter clinical observational study in Sweden.Patient sampleData were collected on 244 subjects with nonspecific LBP. The mean age of the subjects was 44 years, the mean pain score at inclusion was 4.4/10, and 51% of the sample had experienced LBP for more than 30 days the previous year.Outcome measuresThe outcome used in this study was the “number of days with bothersome pain” collected with weekly text messages for 6 months.MethodsIn subjects with nonspecific LBP, weekly data were available for secondary analyses. A few baseline variables were chosen to investigate prediction at different time points: pain intensity, the presence of leg pain, duration of LBP the previous year, and self-rated health at baseline. Age and gender acted as additional covariates.ResultsIn the multilevel models, the predictive variables interacted with time. Thus, the risk of experiencing a day with bothersome LBP varied over time. In the logistic regression analyses, the predictive variable's previous duration showed a consistent predictive ability for all the time points. However, the variables pain intensity, leg pain, and self-rated health showed inconsistent predictive patterns.ConclusionsAn outcome based on frequently measured data described the variability in the prediction of future LBP over time. Prediction depended on when the outcome was measured. These results may explain the diversity of the results of the predictor studies in the literature.     

Characteristics and outcomes of patients undergoing lumbar spine surgery for axial back pain in the Michigan Spine Surgery Improvement Collaborative

BACKGROUND CONTEXTThe indications for surgical intervention of axial back pain without leg pain for degenerative lumbar disorders have been limited in the literature, as most study designs allow some degree of leg symptoms in the inclusion criteria.PURPOSETo determine the outcome of surgery (decompression only vs. fusion) for pure axial back pain without leg pain.STUDY DESIGN/SETTINGProspectively collected data in the Michigan Spine Surgery Improvement Collaborative (MSSIC).PATIENT SAMPLEPatients with pure axial back pain without leg pain underwent lumbar spine surgery for primary diagnoses of lumbar disc herniation, lumbar stenosis, and isthmic or degenerative spondylolisthesis ≤ grade II.OUTCOME MEASURESMinimally clinically important difference (MCID) for back pain, Numeric Rating Scale of back pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), MCID of PROMIS-PF, and patient satisfaction on the North American Spine Surgery Patient Satisfaction Index were collected at 90 days, 1 year, and 2 years after surgery.METHODSLog-Poisson generalized estimating equation models were constructed with patient-reported outcomes as the independent variable, reporting adjusted risk ratios (RR_adj).RESULTSOf the 388 patients at 90 days, multi-level versus single level lumbar surgery decreased the likelihood of obtaining a MCID in back pain by 15% (RR_adj=0.85, p=.038). For every one-unit increase in preoperative back pain, the likelihood for a favorable outcome increased by 8% (RR_adj=1.08, p<.001). Of the 326 patients at 1 year, symptom duration > 1 year decreased the likelihood of a MCID in back pain by 16% (RR_adj=0.84, p=.041). The probability of obtaining a MCID in back pain increased by 9% (RR_adj=1.09, p<.001) for every 1-unit increase in baseline back pain score and by 14% for fusions versus decompression alone (RR_adj=1.14, p=.0362). Of the 283 patients at 2 years, the likelihood of obtaining MCID in back pain decreased by 30% for patients with depression (RR_adj=0.70, p<.001) and increased by 8% with every one-unit increase in baseline back pain score (RR_adj=1.08, p<.001).CONCLUSIONSOnly the severity of preoperative back pain was associated with improvement in MCID in back pain at all time points, suggesting that surgery should be considered for selected patients with severe axial pain without leg pain. Fusion surgery versus decompression alone was associated with improved patient-reported outcomes at 1 year only, but not at the other time points.     

Multiple somatic symptoms in employees participating in a randomized controlled trial associated with sickness absence because of nonspecific low back pain

Background contextThe prevalence of multiple somatic symptoms is high in primary and hospital outpatient populations. Multiple somatic symptoms may be present in patients sick-listed because of low back pain (LBP) and may be associated with increased risk of not returning to work (RTW).PurposeTo explore whether multiple somatic symptoms in a subset of patients with nonspecific LBP was associated with RTW, sickness absence (SA), or other social benefits.Study designThe study was a cohort study based on a randomized clinical trial with a prospective 2-year follow-up period. Patients were referred from general practices to the Spine Center, Regional Hospital Silkeborg, Denmark.Patient samplePatients were 285 sick-listed employees (4–12 weeks), with nonspecific LBP as their prime reason for SA. Exclusion criteria were unemployment, radiculopathy, LBP surgery within the past year, previous lumbar fusion, suspected cauda equina syndrome, progressive paresis or other serious back disease, pregnancy, known substance abuse, or primary psychiatric diagnosis.Outcome measuresSelf-reported health was assessed by the LBP rating scale and questions about pain and health in general. Disabilities were measured by the Roland Morris Questionnaire, the Short Form-36, and the Fear-Avoidance Beliefs Questionnaire. Work-related questions comprised expectations about RTW and risk of losing job because of SA. The Common Mental Disorder Questionnaire (subscale SCL-SOM) was used to assess multiple somatic symptoms (12 items). We categorized multiple somatic symptoms into four groups based on the SCL-SOM sum score: <6, 6 to 12, 13 to 18 and >18. Status of SA (>2 weeks) and RTW were gathered from a national database (DREAM).MethodsThe patients (N=285) were randomized into either multidisciplinary or brief intervention at the Spine Center (2004–2008). Both interventions comprised clinical examination and advice by a physiotherapist and a rheumatologist. Data were collected from questionnaires at baseline (inclusion) and 1 year after inclusion. Data on SA benefits were gathered from the DREAM database that contains data on all social transfer payments (such as sick leave benefits and other disability benefits) registered on a weekly basis.ResultsAll health factors, female gender, and poor work ability were significantly associated with a higher level of multiple somatic symptoms. The percentage of persons with SA increased significantly with the symptom score after 1 year, and the duration of SA remained significantly longer after 2 years of follow-up between the multiple somatic symptoms groups. The percentages with RTW after 1 and 2 years were negatively associated with a higher level of multiple somatic symptoms at baseline. We found no difference between the intervention groups.ConclusionsA higher level of multiple somatic symptoms was significantly associated with poor health and work ability at baseline and with longer duration of SA and unsuccessful RTW through a 2-year follow-up period.     

Back pain in surgically treated degenerative lumbar spondylolisthesis: what can we tell our patients?

Summary of background dataSurgery for degenerative lumbar spondylolisthesis (DLS) has traditionally been indicated for patients with neurogenic claudication. Surgery improves patients’ disability and lower extremity symptoms, but less is known about the impact on back pain.ObjectiveTo evaluate changes in back pain after surgery and identify factors associated with these changes in surgically-treated DLS.Study designRetrospective review of prospectively collected data.MethodsThere were 486 consecutive patients with surgically-treated DLS who were enrolled in the Canadian Spine Outcomes Research Network prospective registry and identified for this study. Patients had demographic data, clinical information, disability (Oswestry Disability Index), and back pain rating scores collected prospectively at baseline, and 12 months follow-upResultsOf the 486 DLS patients, 376 (77.3%) were successfully followed at 12 months. Mean age at baseline was 66.7 (standard deviation [SD] 9.2) years old, and 63% were female. Back pain improved significantly at 12 months, compared with baseline (p<.001). Improvement in Numeric Rating Scale (NRS)-back pain ratings was on average 2.97 (SD 2.5) points at one year and clinically significant improvement in back pain was observed in 75% of patients (minimal clinically important difference (MCID) NRS-Pain 1.2 points). Multivariable logistic regression revealed five factors associated with meeting MCID NRS-back pain at 12 month follow up: higher baseline back pain, better baseline physical function (higher SF-12 Physical Component Score), symptoms duration less than 1 to 2 years, and having no intraoperative adverse events.ConclusionsBack pain improved significantly for patients treated surgically for DLS at 1-year follow-up.     

Improvement in low back pain following spinal decompression: observational study of 119 patients

Study design

Prospective clinical observational study of low back pain (LBP) in patients undergoing laminectomy or laminotomy surgery for lumbar spinal stenosis (LSS).

Objectives

To quantify any change in LBP following laminectomy or laminotomy spinal decompression surgery.

Patients and methods

119 patients with LSS completed Oswestry Disability Index questionnaire (ODI) and Visual Analogue Scale for back and leg pain, preoperatively, 6 weeks and 1 year postoperatively.

Results

There was significant (p < 0.0001) reduction in mean LBP from a baseline of 5.14/10 to 3.03/10 at 6 weeks. Similar results were seen at 1 year where mean LBP score was 3.07/10. There was a significant (p < 0.0001) reduction in the mean ODI at 6 weeks and 1 year postoperatively. Mean ODI fell from 44.82 to 25.13 at 6 weeks and 28.39 at 1 year.

Conclusion

The aim of surgery in patients with LSS is to improve the resulting symptoms that include radicular leg pain and claudication. This observational study reports statistically significant improvement of LBP after LSS surgery. This provides frequency distribution data, which can be used to inform prospective patients of the expected outcomes of such surgery.     

Do preoperative clinical and radiographic characteristics impact patient outcomes following one-level minimally invasive transforaminal lumbar interbody fusion based upon presenting symptoms?

BACKGROUND CONTEXTPatients undergoing minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) frequently present with lower extremity neurologic symptoms with or without associated lower back pain. While symptomatic improvement of leg and back pain has been reported, the resolution of back pain when it is a predominant presenting symptom remains underreported following MI-TLIF.PURPOSEThe purpose of this study was to compare clinical outcomes at 1 year of patients undergoing MI-TLIF with lower extremity neurologic symptoms with and without a significant component of back pain.STUDY DESIGNA retrospective review of prospectively collected data from a single surgeon surgical database from 2017 to 2019 was performed.PATIENT SAMPLEFifty one patients undergoing MI-TLIF.OUTCOME MEASURESSelf-reported measures included the Oswestry Disability Index (ODI), Visual analog scale back pain (VAS-back), and VAS leg pain (VAS-leg).METHODSPatients were divided into two groups: Leg Pain Predominant (patients reported greater than 50% leg pain upon presentation) and Back Pain Predominant (patients reported 50% or greater back pain). Multivariate analysis was performed to determine differences between groups based upon any significantly baseline characteristics.RESULTSPreoperative demographic and radiographic outcomes were similar between the two groups. Both groups demonstrated significant improvement in ODI, VAS-Back and VAS-leg at 1-year postoperatively. On multivariate analysis, there were differences in ODI at 1-year, 1-year back pain, and 1-year leg pain between groups with those who initially presented with leg pain having a lower ODI, VAS Back, and VAS leg. Patients who presented with predominantly leg pain were more likely to meet minimal clinically important difference (MCID) criteria for ODI and VAS-back compared to those with predominantly back pain.CONCLUSIONFollowing MI-TLIF, patients with lower extremity neurologic symptoms with and without a significant component of back pain have improvements in back pain, leg pain, and ODI regardless of their primary presenting pain complaint; however, patients who presented with predominantly leg pain were more likely to meet MCID criteria for improvement in their back pain and ODI score.     

One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study

Background contextThe clinical entity “discogenic back pain” remains controversial at fundamental levels, including its pathophysiology, diagnostic criteria, and optimal treatment. This is true despite availability of four randomized trials comparing the efficacy of surgical and nonsurgical treatments. One trial showed benefit for lumbar fusion compared with unstructured nonoperative care, and three others showed roughly similar results for lumbar surgery and structured rehabilitation.PurposeTo compare outcomes of community-based surgical and nonsurgical treatments for patients with chronic back pain attributed to degeneration at one or two lumbar disc levels.DesignProspective observational cohort study.Patient samplePatients presenting with axial back pain to academic and private practice orthopedic surgeons and neurosurgeons in a large metropolitan area.Outcome measuresRoland-Morris back disability score (primary outcome), current rating of overall pain severity on a numerical scale, back and leg pain bothersomeness measures, the physical function scale of the short-form 36 version 2 questionnaire, use of medications for pain, work status, emergency department visits, hospitalizations, and further surgery.MethodsPatients receiving spine surgery within 6 months of enrollment were designated as the “surgical treatment” group and the remainder as “nonsurgical treatment.” Outcomes were assessed at 3, 6, 9, and 12 months after enrollment.ResultsWe enrolled 495 patients with discogenic back pain presenting for initial surgical consultation in offices of 16 surgeons. Eighty-six patients (17%) had surgery within 6 months of enrollment. Surgery consisted of instrumented fusion (79%), disc replacement (12%), laminectomy, or discectomy (9%). Surgical patients reported more severe pain and physical disability at baseline and were more likely to have had prior surgery. Adjusting for baseline differences among groups, surgery showed a limited benefit over nonsurgical treatment of 5.4 points on the modified (23-point) Roland disability questionnaire (primary outcome) 1 year after enrollment. Using a composite definition of success incorporating 30% improvement in the Roland score, 30% improvement in pain, no opioid pain medication use, and working (if relevant), the 1-year success rate was 33% for surgery and 15% for nonsurgical treatment. The rate of reoperation was 11% in the surgical group; the rate of surgery after treatment designation in the nonsurgical group was 6% at 12 months after enrollment.ConclusionsThe surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines.     

The prognosis of chronic low back pain is determined by changes in pain and disability in the initial period

Background context

The recovery of patients with chronic low back pain (LBP) is slow. Furthermore, it is recently proposed that chronic LBP needs a prognostic approach to determine who will develop clinically significant back pain. Therefore, it is imperative to identify prognostic factors that are mostly seen in chronic LBP patients at an early stage. This may give clinicians tailored advice to prevent chronicity or may refer to a specific intervention.

Purpose

To investigate the contribution of demographic, work, clinical, and psychosocial variables, including new prognostic variables as changes in pain intensity and disability status, on the development of chronic LBP.

Study design/setting

Prospective cohort data by merging data from three randomized trials (secondary analyses).

Patient sample

Workers (n=628) on sick leave because of subacute nonspecific LBP.

Outcome measures

Chronic LBP for longer than 6 months (functional measure).

Methods

Potential prognostic variables were demographic, work, clinical, and psychosocial characteristics (self-report measures). We also included as prognostic variables a clinically relevant change in pain intensity and disability status. For the selection of variables and prognostic models, bootstrapping techniques were used in combination with multivariable logistic regression. The explained variance and discrimination were used to evaluate the clinical performance of the models.

Results

The variables most strongly related to chronic LBP were as follows: no clinically relevant change in pain intensity and in disability status in the first 3 months, a higher pain intensity score at baseline, and a higher score for kinesiophobia. This prognostic model had a bootstrap-corrected explained variance of 37% and a discriminative ability (c index) of 0.80.

Conclusions

Clinical-, work-, and psychosocial-related variables contribute to the development of chronic LBP. The most promising variables are a clinically relevant decrease in pain intensity and in disability status in the first 3 months. These variables are relevant for clinicians to advise their patients with respect to preventive measures or treatment strategies.     

Disc degeneration could be recovered after chemonucleolysis with condoliase.-1 year clinical outcome of condoliase therapy-

BackgroundCondoliase-induced chemonucleolysis is a less-invasive alternative treatment for lumbar disc herniation (LDH); however, its long-term clinical outcome is still unclear. This study aimed to investigate 1-year clinical outcomes and assess radiographs after chemonucleolysis with condoliase.MethodsWe enrolled patients with LDH who received condoliase injection with a follow-up period of >1 year. Sixty patients (37 men, 23 women; mean age, 44.5 ± 18.9 years; mean follow-up period, 22.0 ± 6.0 months) were analyzed. Changes in disc height and degeneration were evaluated using magnetic resonance imaging. Visual analog scale (VAS) scores for leg and back pain and the Oswestry disability index (ODI) were obtained. All data were assessed at baseline, 1-month, 3-month, and 1-year follow-up.ResultsSurgical treatment was subsequently required in 8 patients (12.5%) after condoliase therapy. Their ODI and VAS scores for leg pain and back pain significantly improved at 1 year, as in those who received condoliase therapy only. On MRI, progression of Pfirrmann grade was observed in 23 patients (44.2%) at 3 months; however, 8 patients recovered to baseline at 1 year. The mean disc height decreased at 3 months; however, it recovered at 1 year. Disc height recovery (disc recovery rate >50%) was observed in 30.8% of the patients. Patients with disc height recovery were significantly younger than those without. Patients with longer symptom duration (≥1 year) showed significantly lower rates of effectiveness compared with those with shorter symptom durations (<1 year).ConclusionsChemonucleolysis with condoliase is a safe and minimally invasive treatment. Disc degeneration induced by chemonucleolysis could be recovered, particularly in younger patients. Prolonged symptom duration had adverse effects on outcome; thus, therapeutic intervention at the optimal time is needed.     

Association between physical activity,sedentary behaviour and the trajectory of low back pain

BACKGROUNDLow back pain (LBP) is one of the world's most prevalent health issues. Patients with LBP experience various intensities and durations of symptoms, which can lead to distinctive course patterns commonly described as symptom trajectories.PURPOSEThis study aimed to investigate the association between different amounts of physical activity and sedentary behavior and the trajectory of LBP, in people with a lifetime history of LBP.STUDY DESIGNThe study involved a secondary analysis of observational longitudinal data collected from the AUstralian Twin low BACK pain (AUTBACK) study.METHODSA total of 329 individual twins met the inclusion criteria for analysis. Latent Class Growth Analysis was used to identify distinct patterns of LBP and select the primary outcome (probability of having a severe LBP trajectory, 0%–100%). Linear regression models were used to investigate the association between different amounts of physical activity or sedentary behavior at baseline, and the probability of having a severe LBP trajectory. Results were expressed as β coefficients and 95% confidence intervals (CI).RESULTSModerate-to-vigorous intensity physical activity was significantly associated with the probability of having a severe LBP trajectory (unadjusted β -0.0276; 95%CI -0.0456 to -0.0097, p=.003). For every 1-minute increase in moderate-to-vigorous intensity physical activity per week, there was a 2.8%-point reduction in a participant's probability of having a severe LBP trajectory. No significant associations were identified between sedentary behavior or light intensity physical activity, and the probability of having a severe LBP trajectory.CONCLUSIONSIn people with a lifetime history of LBP, engagement in higher volumes of moderate to vigorous intensity physical activity at baseline was associated with a lower probability of developing a severe trajectory of LBP over 1 year.     

Endplate defects,not the severity of spinal stenosis,contribute to low back pain in patients with lumbar spinal stenosis

BACKGROUND CONTEXTIt is controversial whether lumbar spinal stenosis (LSS) itself contributes to low back pain (LBP). Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to LBP. However, whether these factors cause LBP in patients with LSS is unclear.PURPOSETo identify factors associated with LBP in patients with LSS.STUDY DESIGN/SETTINGCross-sectional design.PATIENT SAMPLEA total of 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication caused by LSS, as confirmed by magnetic resonance imaging (MRI).OUTCOME MEASURESRatings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-Item Short Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including slippage and lumbopelvic alignment. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were assessed on MRI.METHODSThe presence of LBP was defined as an NRS score ≥3. The demographic data, patient-reported outcomes, and radiological and MRI findings were compared between patients with and without LBP. Multivariate logistic regression analysis was used to identify the factors that were independently associated with the presence of LBP.RESULTSThere were significant differences between patients with and without LBP for buttock and leg pain and numbness on the NRS, general health on the SF-36, presence of endplate defects, presence of Modic changes, disc degeneration grading, and disc height grading (all p < .05). Multivariate logistic regression analysis showed significant associations between LBP and diabetes (OR 2.43; 95% CI 1.07–5.53), buttock and leg numbness on the NRS (OR 1.34; 95% CI 1.17–1.52), general health on the SF-36 (OR 0.97; 95% CI 0.95–0.99), and the presence of erosive endplate defects (OR 3.04; 95% CI 1.51–6.11) (all p < .05).CONCLUSIONSThese results suggest that LBP in patients with LSS should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.     

Prognosis of chronic low back pain in patients presenting to a private community-based group exercise program

Purpose

To examine the prognosis and prognostic factors for patients with chronic low back pain presenting to a private, community-based, group exercise program.

Methods

A total of 118 consecutive patients with chronic LBP were recruited. Baseline assessments included socio-demographic characteristics, back pain history and clinical examination findings. Primary outcome measures were pain intensity and disability at 3, 6 and 12 months. Potential prognostic factors to predict pain intensity and disability at 12 months were assessed using a multivariate regression model.

Results

112 (95 %) participants were followed up at 12 months. The majority of participants were female (73 %), had high educational levels (82 %) and resided in suburbs with a high socio-economic status (99 %). Pain intensity improved markedly during the first 6 months (35 %) with further minimal reductions up to 12 months (39 %). Interestingly, disability improved to a greater degree than pain (48 % improvement at 6 months) and continued to improve throughout the 12 months (60 %). Baseline pain intensity accounted for 10 % of the variance in the 1 year pain outcomes. Duration of current episode, baseline disability and educational level accounted for 15 % of the variation in disability at 12 months.

Conclusions

During a period of 12 months, patients with chronic LBP presenting to a private, community-based, group exercise program improved markedly, with greater improvements in disability than pain. The predictors investigated accounted for only 10 and 15 % of pain and disability outcomes, respectively.     

The association between compensation and chronic disabling back pain

BackgroundLow back pain (LBP) is a common and major health problem. Although it is known that psychosocial factors are important predictors of LBP outcome, some factors, including financial compensation, have not been fully studied in Japan. This cross-sectional study aimed to examine the association between LBP compensation (workers’ compensation and automobile insurance claims) and lifetime experience of chronic LBP and back pain disability (chronic disabling LBP) in a Japanese adult population.MethodsIn February 2011, 1,063,083 adults aged 20–79 years registered as Internet research volunteers were invited to complete an online questionnaire. We analyzed the data from 52,650 respondents who had ever experienced LBP. Multiple logistic regression analysis was used to examine the association between LBP compensation and lifetime experience of chronic disabling LBP, adjusting for age, sex, smoking habits, educational level, cause of LBP, history of radiating pain below the knee, and history of low back surgery.ResultsAmong the respondents, 2,039 (3.9 %) had experienced chronic disabling LBP. The prevalence of a history of receiving workers’ compensation or automobile insurance claims was 1.1 % for each. In multiple logistic regression, the odds of chronic disabling LBP were significantly higher among those who received LBP-related compensation (workers’ compensation or automobile insurance claims) compared with respondents who did not receive compensation.ConclusionsThe prevalence of compensated LBP was low. However, a history of compensated LBP was significantly associated with experiencing chronic disabling LBP.     

Relationship between systemic inflammation and recovery over 12 months after an acute episode of low back pain

BACKGROUND CONTEXTIndividual characteristics can influence outcomes after injury. Our previous work in individuals with early-acute low back pain (LBP) identified subgroups (clusters) with specific biopsychosocial features that recovered poorly or well by 6 months.PURPOSEThis study extends on that work by revealing the short- and long-term trajectories of recovery and systemic inflammation of these participant clusters: (1) “inflammatory & poor sleep” (Cluster 1), “high TNF & depression” (Cluster 2), “high pain & high pain-related fear” (Cluster 3), and “low pain & low pain-related fear” (Cluster 4).STUDY DESIGN/SETTINGLongitudinal cohort study.PATIENT SAMPLEEighty-three individuals within 2 weeks of an acute episode of LBP – grouped into their a priori-defined cluster.OUTCOME MEASURESGeneral participant characteristics (sex, age, body mass index, smoking history, previous LBP history); self-reported LBP (0–10 numerical rating scale, LBP-related disability (Roland-Morris Disability Questionnaire), depression (Center for Epidemiological Studies Depression Scale, pain catastrophizing (Pain Catastrophizing Scale), fear avoidance (Fear Avoidance Beliefs Questionnaire), pain self-efficacy (Pain Self-Efficacy Questionnaire), and sleep (Pittsburgh Sleep Quality Index); systemic inflammatory biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], interleukin-1β, tumor necrosis factor [TNF]).METHODSParticipants provided blood for the measurement of CRP/cytokines, and completed questionnaires related to their pain/disability, psychological and sleep status. Blood measures were repeated 3-monthly for 9 months, and pain/disability were self-reported fortnightly for 12 months. Recovery (change in pain) and CRP/cytokines were longitudinally compared between clusters using mixed-models. Associations between baseline factors and follow-up CRP/cytokines levels were assessed with multiple regression.RESULTSClusters 1 and 2 were associated, but oppositely, with recovery over the 12-months. Cluster 1 reported most recovery at every 3-monthly interval, whereas Cluster 2 reported least recovery. Cluster 1 had elevated CRP (and IL-6) at baseline that continued to decrease from 3 to 9 months. TNF was elevated early and persistently in Cluster 2. Baseline factors other than inflammation generally failed to predict follow-up inflammation.CONCLUSIONSFindings support the early role of CRP (and perhaps IL-6) in control of inflammation and recovery, and a pathological role of persistent TNF overexpression, which may be perpetuated by depressive-like behaviors.     

Neuromuscular exercises on pain intensity,functional disability,proprioception, and balance of military personnel with chronic low back pain

BackgroundDue to their occupational status, military personnel are a high-risk group for low back pain (LBP).PurposeThe aim of this study was to investigate the effect of neuromuscular exercises on the severity of pain, functional disability, proprioception, and balance in military personnel with LBP.MethodsMilitary personnel with LBP were randomly assigned into two groups: intervention (n=15) and control (n=15). The intervention group performed 60 minutes of neuromuscular exercises three times per week for eight weeks while the control group continued their routine physical activities.ResultsThe mean post-intervention pain intensity, disability, and proprioception error significantly decreased in the intervention group. Whereas their mean post-interventions static and dynamic balance scores significantly increased.ConclusionsThe results indicate eight weeks of neuromuscular exercise decreased pain intensity and improved functional ability, static and dynamic balance, and proprioception among military staff suffering chronic low back pain.     

The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise

STUDY DESIGN: Secondary analysis of a prospective cohort of patients with acute low back pain (LBP). OBJECTIVES: To determine if the centralization phenomenon and fear-avoidance beliefs predict measurement of pain and disability 6 months after entering the study. BACKGROUND: The centralization phenomenon and fear-avoidance are predictive of future pain and disability. However, previous prognostic studies have not routinely included both measures in homogenous subgroups of patients with acute LBP. METHODS AND MEASURES: Patients completed self-report questionnaires and were evaluated and treated with treatment-based classification guidelines. Only the patients classified for specific exercise were included in this analysis (n = 28). Measures of disability and pain intensity were reassessed at 6 months by mail. Separate hierarchical regression models predicted measures of disability and pain intensity with the centralization phenomenon, fear-avoidance beliefs, and prespecified covariates. RESULTS: There were no significant differences in duration of symptoms, fear-avoidance beliefs, and history of LBP based on the centralization phenomenon (P > .05). Patients reporting the centralization phenomenon were significantly more likely to have leg pain (P < .01). A regression model including initial disability, the centralization phenomenon, and fear-avoidance beliefs about work significantly predicted 6-month disability, explaining 49% of the total variance (P < .001). A regression model that included initial pain intensity and the centralization phenomenon significantly predicted 6-month pain intensity, explaining 29% of the total variance (P < .016). These factors also appeared to be clinically meaningful predictors of outcome, but lacked precision for immediate use in clinical settings. The following covariates were not included in the final regression models: presence of leg pain, history of LBP, and duration of LBP. CONCLUSIONS: Baseline elevation in fear-avoidance beliefs about work and lack of centralization phenomenon predicted higher disability. Baseline lack of centralization phenomenon predicted higher pain intensity. These results can only be generalized to patients with acute LBP classified for specific exercise. It will be necessary to independently validate these prediction models before they can be implemented in clinical settings.