A PROSPECTIVE STUDY OF LOW BACK PAIN

Consecutive patients attending hospital for the first time withbackache were entered into a prospective study, provided thatcertain defined causes (infective, neoplastic, metabolic andinflammatory etc.) were not apparent at the first visit. Amongst188 available for analysis, 65% were discharged and 28% defaulted,together making a total of 93% who ‘recovered uneventfully’(in the sense that they were no longer attending hospital) onaverage in about three months, 4% came to ‘myelography’(radiculography using Dimer-X or Amipaque) including 2% to discectomy,1.5% proved to have treatable underlying diseases accountingfor their backache while 1.5% became ‘qchronic attenders’.Information available at the first visit (patient characteristics,history, examination, radiographs and psychological questionnaire)provided few pointers to what the outcome would be or how longthe patient would attend hospital. In particular, routine X-rayexamination did not provide clues to any important conditionsnot already suspected by the clinicians. A case is made forreserving routine radiography for patients who have not recoveredwithin about three months.     

A CLINICAL AND RADIOLOGICAL STUDY OF BACK PAIN IN RHEUMATOID ARTHRITIS

Five hundred and three patients with RA were questioned aboutthe symptom of back pain. Chronic back pain, lasting more than3 months, occurred in 33 per cent of the group. A group of 100back pain patients were studied in more detail using a structuredquestionnaire, clinical examination and radiology. Ninety-fourof these patients had low back pain. Particular clinical patterns(such as that of the facet syndrome) were sought but no clearcharacteristics were found. Fifty-two lumbar spine X-rays wereavailable from the RA population and these were compared to52 age and sex matched X-rays from outpatients with chronicmechanical low back pain. Significant differences between thesegroups radiologically were a higher frequency of osteoporosisand a higher frequency of disc narrowing without associatedosteophytes in the RA population. This study differs from previousreports which found other characteristic radiological featuresof RA of the lumbar spine (spondylolisthesis, facet erosions,and vertebral fracture), a discrepancy possibly resulting fromthe use of a control group having low back pain. KEY WORDS: Low back pain, Rheumatoid arthritis, Osteoporosis, Facet syndrome     

A PROSPECTIVE CONTROLLED STUDY OF LOW BACK SCHOOL IN THE GENERAL POPULATION

There are no data on the efficacy of a back school in primaryprevention of back pain in the general population or on thecharacteristics of the population who volunteers. After announcementin the local press, 494 healthy adults volunteered and paidfor a back school course in Switzerland. A total of 371 controlswere matched for sex, age, profession, nationality and backpain. A statistically significant decrease in numbers of doctor'svisits was found by the participants during the following 6months compared with the controls. However, there were no significantbetween-group differences in the four remaining parameters (presenceand intensity of back pain, drug intake and sick leave). Three-quartersof participants changed their attitudes after the back school.Volunteering for a back pain prevention programme was associatedwith the presence of back pain problems. Reasons for volunteeringare further discussed. Overall, the results of this study showedthat a back school for the general population may not solvethe problem of low back pain, but improves self-help in a subgroupof the population. KEY WORDS: Back school, Low back pain, Education programmes, Back injury prevention     

PAIN IN THE BACK AND LEG: A GENERAL PRACTICE SURVEY

Over a two-year period, the data on all patients in a generalpractice with back and leg pain were recorded in a standardizedway. Two broad categories were distinguished, those with low-backpain syndromes and those with back and leg pain syndromes. Withinthe former, four patterns of pain distribution could be identified,and the latter were sub-divided according to severity, history,and neurological involvement. History, clinical features, andoutcome correlated with these various types. The majority ofthese patients may be managed conservatively at home, only asmall proportion requiring referral for specialist advice ortreatment. It is suggested that the intervertebral disc canaccount for only a small proportion of these problems. ^* Based on a paper presented to a scientific meeting of theSociety for Back Pain Research at Bristol on 26th March 1976.     

BACK PAIN IN OSTEOPATHIC PRACTICE

The case records of 5310 patients attending Registered Osteopathswere examined in this retrospective study. Analysis of the datarevealed that over half presented with low back pain and werecomparable to those normally seen in orthodox medical practice,except that their symptoms were of longer duration. The patientswere generally examined in a conventional manner but it wasnot possible to identify specific diagnostic categories. Themajority received one or more manual therapeutic techniquesbut 6% were rejected as unsuitable for treatment. The implicationsof the results for future research are discussed.     

CAPILLARY RESISTANCE AND BACK PAIN

A rapid clinical and epidemiological method of grading CapillaryResistance (CR) based on the appearance of petechiae followingnegative pressure on the skin of the forearm is described, andthe results of testing 469 postmen aged 22 to 63 years are given.CR is shown to be increased in men who have had back pain within24 hours of testing and no difference was found between menwho had had back pain in the past and those who denied everhaving had back pain. A separate series of 35 post-laminectomy patients examined atleast 10 months after operation and who were shown to have discdisease at operation and/or on myelogram were found to havelow CR. This work suggests that the changes involved in disc diseaseare not limited solely to the discs, but may involve collagen/elastictissue or ground substance elsewhere, as for example in thiscase when detectable in a test on the forearm. Secondly, itis suggested that CR grading could be a helpful discriminatingtest for ‘disc disease’ among those presenting withback pain of undetermined diagnosis. ^*Paper presented at a combined meeting of the British Associationfor Rheumatology and Rehabilitation, the Heberden Society, theRheumatology and Rehabilitation Section of the Royal Societyof Medicine, and the Swiss Society for Rheumatology, Bristol,June 1974.     

A CLINICAL EPIDEMIC-LOGICAL STUDY IN LOW BACK PAIN. DESCRIPTION OF TWO CLINICAL SYNDROMES

In 100 patients with mainly chronic low back pain (LBP) signsand symptoms were evaluated prospectively and without preconceivedexpectation of particular findings. Two clinical syndromes weredistinguished, both characterized by 'typical local tenderness'and associated with specific clinical features; these syndromes,described previously in the literature but receiving scant attention,were named the greater trochanteric pain syndrome (trochantericbursitis) and the iliac crest pain syndrome (iliolumbar syndrome),and occurred in 35% and 43% of the patients, respectively. Therecognition of these syndromes may enable us to study aetiology,prognosis, and therapy of LBP in more homogeneous groups ofpatients KEY WORDS: Low back pain, Regional pain syndromes, Greater trochanteric pain syndrome, Trochanteric bursitis, Iliac crest pain syndrome, Iliolumbar ligament syndrome     

A PSYCHIATRIC STUDY OF PATINTS WITH PERSISTENT LOW BACK PAIN

Psychological screening with the Middlesex Hospital Questionnaireat initial assessment failed to identify those patients withlow back pain who became persistent attenders or those laterjudged to have psychiatric disorder. Of those whose symptomshad failed to respond to conventional rheumatological treatmentand who were still attending after 90 days, 35% were diagnosedas having definite psychiatric morbidity. In the absence ofa control group the significance of this finding is uncertain,but its possible implications are discussed. ^*Present addresses: Institute of Psychiatry, De Crespingny Park,Denmark Hill, London SE5 8AF Present addresses: Clinical Research Centre, Watford Road, Harrow,Middlesex HA1 3UJ Present addresses: Ottawa General Hospital, Ottawa, Ontaria,Canada     

CHIROPRACTORS AND THE TREATMENT OF BACK PAIN

In a survey of British chiropractors and their practices, itwas found that the majority of their patients attended for backpain. The average age of patients was 47 years, the sex ratiowas equal, and most had had their complaints for longer thanthree months and had access to the chiropractor within a fewdays. They were largely housewives and persons from the executiveand managerial occupations. The main investigative proceduresused were static and motion palpation of the spine, and vitalsystems, orthopaedic, neurological, and radiological examination.Treatment was mostly manual and directed at the spinal column,and the benefit obtained, as assessed by the chiropractors,was comparable to that reported in other studies. Maximum benefitwas usually recorded within seven attendances, although 39 %of patients made further visits for maintenance treatment. The chiropractors are seen to be a young, growing, and largelymale group, and their new patient numbers are at present likelyto be at least one-twentieth that of hospital out-patient departmentswhich deal with back pain.     

SHORT AND LONG-TERM EFFECT OF SPA THERAPY IN CHRONIC LOW BACK PAIN

The effect of spa therapy on chronic low back pain (LBP) wasassessed in a randomized trial comparing patients undergoinga 3-week therapy programme in a spa resort in France (n = 50)with patients receiving ambulatory care (n = 52). After 3 weeks,patients in the spa group had significant improvement in theirspine mobility and functional score (Waddell index) and a reductionin their daily duration of pain, pain intensity and drug consumption.The long-term effect was assessed after 9 months and showedcontinued reduction in pain and drug consumption, and improvementin spine mobility but no longer in functional score which returnedto baseline level. It is concluded that spa therapy has a positiveshort-term and a moderate long-term effectiveness on chronicLBP. KEY WORDS: Balneotherapy, Clinical trial, Low back pain     

A CONTROLLED TRIAL OF CONTINUOUS LUMBAR TRACTION IN THE TREATMENT OF BACK PAIN AND SCIATICA

A controlled trial of continuous lumbar traction in the treatmentof back pain and sciatica showed similar improvements in boththe treated group (weighted traction) and the control group(simulated traction). The findings of this study question thejustification of admitting patients with back pain into hospitalsfor purposes of traction alone. KEY WORDS: Back pain, Treatment     

INFRARED THERMOGRAPHIC IMAGING, MAGNETIC RESONANCE IMAGING, CT SCAN AND MYELOGRAPHY IN LOW BACK PAIN

Sixty-five cases of chronic low back pain were studied. Infraredthermography (IRT) was abnormal in 92%, magnetic resonance imaging(MRI) in 89%, computerized tomography (CT) in 87% and myelographyin 80%. IRT correlated with MRI in 94% of cases, and with CTin87% of cases. Of 22 MRI positive disc and root cases, 21 (95%)had significant leg abnormalities on IRT. All 19 cases withradicular involvement on CT and all 18 with radicular involvementon myelography demonstrated significant leg changes on IRT. KEY WORDS: Imaging, Spine, Skin temperature, Lumbar nerve root, Comparisons, Thermography     

MASKED DEPRESSION IN MEN WITH LOW BACK PAIN

Fifty male patients with low back pain attending a RheumatologyDepartment completed the Middlesex Hospital Questionnaire beforetreatment. Scores on three sub-scales distinguished betweenpatients with a good outcome and with a poor outcome. Comparingthe scores of these two groups with those of a normal populationsuggests that there are distinct populations of patients withlow back pain. Examination of individual questions revealedthat the "poor response" group was characterized by a depressivesyndrome described principally in somatic terms. In these patientsdepression was unrecognized; it is concluded that the low backpain can be seen as a depressive equivalent. The questionnairedemonstrated an ability to predict response to treatment; itis felt that it may play a part in the further investigationof patients not responding to conventional treatment.     

COMBINATION THERAPY WITH GOLD AND HYDROXYCHLOROQUINE IN RHEUMATOID ARTHRITIS: A PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED STUDY

We studied combination therapy with two slow-acting antirheumaticdrugs given concurrently in active rheumatoid arthritis (RA).A 12-month prospective randomized controlled trial comparedgold and hydroxychloroquine in 52 patients to gold and placeboin 49. The patients continued to receive non-steroidal anti-inflammatorydrugs and analgesics. They were selected from three rheumatologycentres in the West Midlands. Combination therapy led to a greaternumber of withdrawals due to adverse reactions (18 cases comparedto 10 receiving gold/placebo). Patients completing 12 months'therapy (27 taking gold/ hydroxychloroquine and 32 on gold/placebo)were compared using five clinical, seven laboratory, and oneradiological measure. All 13 variables favoured gold/hydroxychloroquinewith an overall advantage of 20–25% for the combination.This only reached statistical significance (at the 1% level)for C-reactive protein. An overall disease activity index wasbetter at 12 months (at the 5% level) and showed a more rapidresponse with gold/hydroxychloroquine. This is the first randomizedprospective placebo-controlled trial to show a significant advantagefrom a combination of two slow-acting drugs. There are manydifferent ways of giving such combinations and we consider theseshould be explored to maximize the effectiveness of treatmentfor RA. KEY WORDS: Rheumatoid arthritis, Treatment, Antimalarials, Sodium aurothiomalate     

BACK PAIN AND SCIATICA: CONTROLLED TRIALS OF MANIPULATION, TRACTION, SCLEROSANT AND EPIDURAL INJECTIONS

Four treatment regimens for patients with specified combinationsof low back pain and sciatica were evaluated. The largest groupstudied had low back pain with limited straight-leg raising(SLR) and in them the beneficial effect of manipulation in hasteningpain relief was highly significant. In similar patients withoutlimitation of SLR, the effect was of borderline significance.In all the other groups, treated patients also recovered morequickly than their controls. Traction, for patients with lowback pain and sciatica, and epidural injections when a rootpalsy was present also produced some significant pain relief.The effect of sclerosants for back pain was less clear. KEY WORDS: Spine, Treatment, Pain-relief, Outcome     

INFLUENCE OF PHYSICAL, PSYCHOLOGICAL AND BEHAVIOURAL FACTORS ON CONSULTATIONS FOR BACK PAIN

Over 34 000 questionnaires were used to study occurrence andconsultations for back pain in the community. The 12-month periodprevalence was 24% and 13% of the sample consulted a doctor.Elderly women were at greatest risk of back pain. The consultationrate increased in both sexes throughout middle age, but declinedin men over the age of 55 yr. Back pain was associated withthe Goldberg General Health Health Questionnaire score suggestingpsychiatric morbidity [odds ratio (OR) = 2.05; confidence interval(CI) 1.89–2.23], obesity (OR = 1.59; CI 1.40–1.79),and cigarette smoking (OR = 1.52; CI 1.36=1.70). Vigorous dailyactivity was positively associated with back pain in men aged18–39 yr (OR = 1.37; CI 1.02–1.85), and women aged18–39 yr (OR = 1.50; CI 1.08–2.09), but was negativelyassociated with back pain in women aged over 65 yr (OR = 0.35;CI 0.16–0.76). Alcohol consumption was also negativelyassociated with back pain (OR = 0.72; CI 0.62–0.85). Theprevalence of arthritis, constipation and respiratory disorderswas increased in those who consulted for back pain correctedfor the other variables. Thus back pain was substantially morecommon in women compared to men over 55 yr. Psychiatric morbidity,cigarette smoking and obesity were associated with back painat all ages, but the effect of physical exercise appeared tochange with age. Further studies are required to explain thesex differences and nature of the associations. KEY WORDS: Back pain, Postal survey, Consultations, Epidemiology     

CHRONIC IDIOPATHIC MEDIASTINAL FIBROSIS PRESENTING WITH MALAISE, PLEURITIS AND THORACIC BACK PAIN

A patient with chronic idiopathic mediastinal fibrosis (MF)without concomitant retroperitoneal fibrosis is reported. Hepresented with pleuritis, malaise and pain and stiffness inthe thoracic spine. During the 3.5 years of observation no clinicalsigns of obstruction of adjacent visceral structures in thechest cavity have developed. The diagnosis was made by CF, X-raysof the chest remained normal throughout the observation period,except for thickening of the involved pleura. The administrationof high doses of oral corticosteroids did not appear to influenceeither clinical symptoms or the manifestations of MF as seenby CT. KEY WORDS: Mediastinal fibrosis, Pleuritis, Back pain     

A CONTROLLED STUDY OF ACUPUNCTURE IN NECK PAIN

Twenty-five out-patients with chronic neck pain participatedin a prospective, randomized trial of acupuncture versus placebotranscutaneous nerve stimulation. A single-blind, non-cross-overdesign incorporated several outcome measures in an attempt todetermine any particular facet of pain that responded to acupuncture.No significant difference between the two treatments was foundeither post-treatment or at follow-up. Whilst the small populationstudied limits the conclusions that may be drawn, these findingssuggest that acupuncture may have no greater effect than thatof a powerful placebo. KEY WORDS: Acupuncture, Neck pain, Placebo effect ^*Present address: Waikato Hospital, Hamilton, New Zealand