Lumbar lordosis: study of patients with and without low back pain

We used magnetic resonance imaging (MRI) to assess lumbar lordosis in 27 patients with low back pain and 19 patients and 10 volunteers with no known back pain. Our study aimed to investigate whether lordosis changes with age and is reduced in those with low back pain. Although our results confirm known observations that lumbar lordosis is more prominent in women (P < 0.01) and those with a higher body mass index (P < 0.04), we were unable to demonstrate any significant variation in lordosis with age. Nor could we demonstrate any difference in the degree of lordosis among women with or without back pain. Men with low back pain tended to have a less prominent lordosis, but this difference did not reach statistical significance. Therefore, a 'reduced lumbar lordosis' should be regarded as a very weak clinical sign.     

Predictors of disability in patients with chronic low back pain

IntroductionChronic low back pain (CLBP) is a common and disabling health problem. In this study, we aimed to assess the relationship between pain intensity, the components of catastrophizing, depression and disability in patients with chronic low back pain.Material and methodsSeventy-six patients diagnosed with CLBP (age range 25–77 years; 73.7% female) participated in the study. Participants’ socio-demographic data were collected: age, gender, height, weight, and work status (employed or retired). All participants were asked to complete the Pain Catastrophizing Scale (PCS), the visual analogue scale (VAS), the Oswestry Disability Questionnaire (ODQ), and the Beck Depression Inventory (BDI).ResultsThe mean group scores revealed moderate CLBP complaints (VAS – 4 [3–6]), mild depression (BDI – 10 [5–16]), a moderate level of catastrophizing (PCS total score 20.5 [10–34]) and moderate disability (Oswestry Disability Index [ODI] – 31 [14–38]). Positive significant correlations were found between ODI and age, residence, work status, VAS, PCS-rumination, PCS-magnification, PCS-helplessness and BDI, and also between PCS subscales and VAS. Our multivariate linear regression analysis showed that age, pain intensity, PCS-helplessness and depression can predict disability in patients with CLBP, explaining 84% of the variance of disability (R² = 0.851, adjusted R² = 0.843).ConclusionsA multidisciplinary approach is needed for patients with CLBP and should include physical, mental and social evaluation in order to offer an optimal treatment.     

压力生物反馈仪测试腰痛的信度评价

背景：关于下背痛的治疗方案种类繁多,至今仍没有一个确定的治疗手段。压力生物反馈仪是测量腹部肌肉活性的工具,对腰痛患者测试的信度研究较少。目的：探讨压力生物反馈仪用于评估腰痛患者的信度及可行性。方法：将符合入选条件的30例慢性腰痛患者作为受试者,选取4组动作,分别为动作A俯卧位,动作B仰卧屈膝位,动作C仰卧单侧屈髋屈膝位,动作D俯卧单侧肩关节前屈位,分别测试不同动作下的腹内压,由同一测试者在1周内对受试者进行前后两次测试。信度评价指标为组内相关系数(ICC)。结果与结论：动作A具有良好的信度,ICC值为0.853 (95%CI：0.691-0.930);动作B具有中等相关性,ICC值为0.751(95%CI：0.477-0.882);动作C具有中等相关性,ICC值为0.789(95%CI：0.557-0.900);动作D具有良好的相关性,ICC值为0.892(95%CI：0.641-0.919)。因此压力生物反馈用于评估腰痛具有良好的信度,可用于腰痛患者的评价。 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

Patterns of H-reflex abnormality in patients with low back pain.

H-reflex was studied in 43 patients with low back pain (including 20 patients with neurological deficit corresponding to S1 radix and 23 patients without deficit) and 20 control subjects. Among patients with neurological deficit the abnormality consisted of absent H-reflex (7 patients), increased H-latency (3 patients), reduced H/M maximal amplitude ratio (5 patients) or a combination of the latter two (2 patients). The H/M ratio was significantly reduced in this group as compared to control subjects and between affected and unaffected sides. Abnormal H-reflex correlated well with ankle jerk hypo- or areflexia, S1 sensory deficit and lumbar myelographic/CT abnormality. In 23 patients without deficit, increased H-latency and/or reduced H/M ratio was observed in 4 cases. Enhanced H/M ratio was noted in only 2 patients of this group. Use of H/M ratio seems to increase the sensitivity of H-reflex in the diagnosis of S1 radiculopathy.     

Ultrasound evidence of altered lumbar fascia in patients with low back pain

Different hypotheses have been proposed about the role of lumbar connective tissue in low back pain (LBP). However, none of the previous studies have examined the change in the elastic behavior of lumbar fascia in patients with LBP. The present study aimed to evaluate the changes in the elastic behavior of lumbar fascia in patients with chronic non-specific LBP based on ultrasound imaging. The sonographic strain imaging assessed the thoracolumbar fascia (TLF) of 131 human subjects (68 LBP and 63 non-LBP). Assessments were done at L2–L3 and L4–L5 levels bilaterally. The points were located 2 cm lateral to the midpoint of the interspinous ligament. There were no significant differences in age, sex, and BMI between LBP and healthy individuals. There is a strong inverse relationship between pain severity (r = −0.76, n = 68, p = 0.004) and the TLF elastic modulus coefficient. No significant relationship were observed between age (r = 0.053, n = 68, p = 0.600), BMI (r = −0.45, n = 68, p = 0.092), and gender (r = −0.09, n = 68, p = 0.231) with the TLF elasticity coefficient. The LBP group had a 25%–30% lower TLF elastic modulus coefficient than healthy individuals. The present study is the first to evaluate the elastic coefficient of TLF using the ultrasound imaging method. The study results showed that the TLF elastic coefficient in patients with LBP was reduced compared to healthy individuals and directly related to LBP severity.     

The association of perceived discrimination with low back pain

A handful of recent studies have documented perceived discrimination as a correlate of poor physical and mental health status among ethnic and racial minority groups. To date, however, despite a proliferation of research on ethnic disparities in the severity and impact of a number of persistent pain conditions, there have been no reports on associations between perceived discrimination and pain-related symptoms. Using data from a national survey (the National Survey of Midlife Development in the United States; MIDUS), we explore the relationships between perceived discriminatory events and the report of back pain among African-American and white men and women. As expected, African-American participants reported substantially greater perceptions of discrimination than white participants. Moreover, in models that included a variety of physical and mental health variables, episodes of major lifetime discriminatory events were the strongest predictors of back pain report in African-Americans, and perceived day-to-day discrimination was the strongest predictor of back pain report specifically in African-American women. Among white participants, perceptions of discrimination were minimally related or unrelated to back pain. To our knowledge, these are the first data documenting an association between perceived discrimination and report of back pain; the fact that perceptions of discrimination were stronger predictors than physical health variables highlights the potential salience and adverse impact of perceived discrimination in ethnic and racial minority groups.     

Multivariate analyses of the MMPI profiles of low back pain patients

A multivariate clustering procedure was used to identify replicable, homogeneous MMPI profile subgroups among three independent cohorts of male (N=233) and female (N=315) low back pain (LBP) patients. Three subgroups were replicated across all male cohorts and four subgroups were replicated across all female cohorts. Multiple discriminant analysis showed that for both male and female patients between-subgroup variability was significantly greater than within-subgroup variability. The results suggest that LBP patients may not be solely characterized by MMPI profiles featuring the conversion V configuration. Examination of the profile subgroups also suggests there may be distinct, pain-related, behavioral attributes associated with each subgroup which might have important implications for practitioners' choice of treatment modalities. Suggestions are made for research regarding the development of specific, optimal treatments for various LBP patient subgroups.The current study was originally presented at the meeting of the Southeastern Psychological Association, Hollywood, Florida, May 1977.     

Laboratory tests as indicators of alcohol consumption in patients with chronic low back pain

The use of laboratory screening tests for the detection of heavy drinking in outpatients implies among other things knowledge about their relation to the degree of alcohol consumption. In this study of 95 patients with chronic low back pain, serum gamma-glutamyltransferase demonstrated the best correlation with the mean daily amount of alcohol consumed (r = 0.74). Adding other serological tests, such as high density lipoprotein cholesterol, aminotransferases and linoleic acid content in lecithin, did not improve this correlation, although these tests also correlated well with the alcohol intake.     

Cocontraction of ankle dorsiflexors and transversus abdominis function in patients with low back pain

Context

The abdominal draw-in maneuver (ADIM) with cocontraction has been shown to be a more effective method of activating the transversus abdominis (TrA) in healthy adults than the ADIM alone. Whether such an augmented core stabilization exercise is effective in managing low back pain (LBP) remains uncertain.

Objective

To determine the effect of 2 weeks of ADIM and cocontraction training on abdominal muscle thickness and activation timing and to monitor pain and function in patients with LBP.

Design

Case-control study.

Setting

Local orthopaedic clinic and research laboratory.

Patients or Other Participants

Twenty patients with mechanical LBP (age = 27.20 ± 6.46 years, height = 166.25 ± 8.70 cm, mass = 58.10 ± 11.81 kg) and 20 healthy, age-matched people (age = 24.25 ± 1.59 years, height = 168.00 ± 8.89 cm, mass = 60.65 ± 11.99 kg) volunteered for the study.

Intervention(s)

Both the LBP and control groups received ten 30-minute sessions of ADIM and cocontraction training of the tibialis anterior (TA) and rectus femoris (RF) muscles over a 2-week period.

Main Outcome Measure(s)

A separate, mixed-model analysis of variance was computed for the thicknesses of the TrA, internal oblique (IO), and external oblique muscles. The differences in mean and peak electromyographic (EMG) amplitudes, onset time, and latency were compared between the groups. The visual analog pain scale, Pain Disability Index, and LBP rating scale were used to assess pain in the LBP group before and after the intervention.

Results

We found an interaction between the LBP and control groups and a main effect from pretest to posttest for only TrA muscle thickness change (F_1,38 = 6.57, P = .01). Reductions in all pain measures were observed after training (P < .05). Group differences in peak and mean EMG amplitudes and onset time values for TrA/IO and TA were achieved (P < .05). The RF peak (t₃₈ = −3.12, P = .003) and mean (t₃₈ = −4.12, P = .001) EMG amplitudes were different, but no group difference was observed in RF onset time (t₃₈ = 1.63, P = .11) or the cocontracted TrA/IO peak (t₃₈ = −1.90, P = .07) and mean (t₃₈ = −1.81, P = .08). The test-retest reliability for the muscle thickness measure revealed excellent correlations (intraclass correlation coefficient range, 0.95–0.99).

Conclusions

We are the first to demonstrate that a cocontraction of the ankle dorsiflexors with ADIM training might result in a thickness change in the TrA muscle and associated pain management in patients with chronic LBP.Key Words: core stability, electromyographic sequencing, ultrasound imaging

Key Points

• The abdominal draw-in maneuver followed by the cocontraction technique stimulated the selective recruitment of the transversus abdominis and internal oblique muscles, possibly leading to reduction of low back pain.
• Because the cocontraction was associated with improved activation of the transversus abdominis muscle, this novel technique might have therapeutic efficacy for the management of individuals with mechanical low back pain and core instability.
• Abdominal draw-in maneuver training is beneficial for the selective recruitment of the transversus abdominis muscle and its central mechanism of action of the lumbopelvic region, and the mechanism of deep musculofascial onset might be augmented further by the cocontraction technique.

Mechanical low back pain (LBP) is a common musculoskeletal impairment that often is associated with neuromuscular dysfunction of the transversus abdominis (TrA) muscle and spinal instability, affecting activities of daily living and physical activity.^1–3 Epidemiologic evidence has indicated that up to 70% of patients with acute LBP ultimately develop chronic LBP.⁴ Delayed onset time of TrA feed-forward activation during shoulder movement⁵ and altered muscle-activation patterns during locomotion⁶ have been identified in patients with LBP as important pathologic markers of abdominal neuromuscular dysfunction. Normally, the neuromuscular system is believed to maintain stability of the lumbar spine by increasing the active and passive stiffness of the deep abdominal and multifidus muscles or modulating muscle cocontraction, which increases the compressive loads.⁷ This lumbar spinal stability offsets the deleterious effects of stress imposed on the spine during lifting.^8–10Core stabilization exercises, including the abdominal draw-in maneuver (ADIM), lateral bridging, pelvic tilting, and abdominal bracing,^2,11,12 have been used widely to improve lumbopelvic stability.^5,13 Core stabilization exercises often incorporate a low degree of TrA activation loading (less than 30% maximal voluntary isometric contraction [MVIC]) with minimal activity of the superficial muscles, such as the external oblique (EO) and rectus abdominis, during the initial phase of rehabilitation.^9,14 One important mechanism by which core stabilization exercise increases the neuromuscular function of the TrA and associated lumbar spinal stability is neuromechanical stiffening of the thoracolumbar fascia (TLF).¹⁰ Specifically, the synergistic contraction of the TrA and posterior fibers of the internal oblique (IO) increases the posterolateral lumbar tension on the TLF that connects to the spinous and transversus processes of the lumbar spine.¹⁰ When the ADIM is performed, the activated TrA draws the abdominal wall inward while concurrently forcing the viscera upward into the diaphragm and downward into the pelvic floor. Coactivation of the TrA and IO (TrA/IO) together with the TLF generates intra-abdominal pressure, which transforms the abdomen into a mechanically rigid cylinder, providing spinal stability.¹⁵Administering core stabilization exercises to patients who have LBP and severe pain might result in a substitution or compensatory movement (eg, rotation and extension of the lumbopelvic complex) associated with neuromuscular inefficiency in the deep core muscles. Therefore, researchers^5,13 have suggested that abdominal or core stabilization exercise without proper pelvic stabilization might increase intradiscal pressure, anterior shearing, and compressive forces in the lumbar spine, accentuating LBP. A method to enhance the activation of the deep abdominal muscles might be advantageous.Resisted ankle dorsiflexion to augment the TrA/IO via cocontraction is a technique for improving the selective activation of deep core muscles, such as the TrA/IO, in populations without pain.¹⁶ This approach was derived from the concept of irradiation in proprioceptive neuromuscular facilitation, which emphasizes the important contribution of the relatively stronger distal muscle group by increasing the number of potential motor-unit recruitments involved or weakened. Chon et al¹⁶ reported that the coactivation of the ankle dorsiflexors and rectus femoris (RF) muscles effectively augmented the selective activation of the TrA muscle, as demonstrated by an increased mean electromyographic (EMG) amplitude of the TrA/IO muscles after the resisted ankle dorsiflexion. The EMG analysis showed that a strong contraction of the dorsiflexion muscles, specifically the tibialis anterior (TA), improved motor recruitment of the TrA/IO muscles during the ADIM.¹⁶ This finding suggests that cocontraction of the dorsiflexion muscles increases recruitment of the active motor units of the TrA/IO muscles.^6,16,17 Researchers have found that enhanced TrA neuromuscular control patterns in people with LBP play an important role in functional spinal mobility and back pain.^8,18,19Although evidence that core stabilization exercises can contribute to deep abdominal contraction exists,⁸ little information on effective ways to improve TrA muscle activation and timing in the population with LBP is available. Therefore, the purpose of our study was to determine the effect of 2 weeks of ADIM and cocontraction training on abdominal muscle thickness and activation timing and to monitor pain and function in people with LBP.     

The relative efficacy of two exercise methods for older adults with chronic low back pain: A preliminary randomized control study

The objective of the current study was to examine the relative efficacy of two exercise techniques—a multidimensional treatment (MDT) and a traditional senior exercise therapy treatment (TET)—in older adults diagnosed with chronic low back pain (CLBP). Participants (N = 16) were randomly assigned to either the MDT (n = 8) or TET (n = 8) groups after meeting the requirements for the presence of CLBP. Participants in the MDT group received an individualized exercise program, while participants in the TET participated in a group exercise program. A Mann–Whitney test was conducted to determine differences between psychosocial and physical variables pre- and post-intervention. Statistical analyses indicated no significant differences in physical or psychosocial variables at pre-intervention assessment. However, participants in the MDT group reported a decrease in fatigue and pain interference, with an increase in physical functioning, when compared to the TET group. Additionally, the MDT group displayed a significant decrease pain interference, while the TET group had an increase grip strength. Patients who received the MDT reported less fatigue and pain interference, and an increase in their overall physical functioning. Overall, the MDT was a more efficacious method to manage CLBP.     

Effect of experimentally induced low back pain on postural sway with breathing

Although breathing perturbs balance, in healthy individuals little sway is detected in ground reaction forces because small movements of the spine and lower limbs compensate for the postural disturbance. When people have chronic low back pain (LBP), sway at the ground is increased, possibly as a result of reduced compensatory motion of the trunk. The aim of this study was to determine whether postural compensation for breathing is reduced during experimentally induced pain. Subjects stood on a force plate with eyes open, eyes closed, and while breathing with hypercapnoea before and after injection of hypertonic saline into the right lumbar longissimus muscle to induce LBP. Motion of the lumbar spine, pelvis, and lower limbs was measured with four inclinometers fixed over bony landmarks. During experimental pain, motion of the trunk in association with breathing was reduced. However, despite this reduction in motion, there was no increase in postural sway with breathing. These data suggest that increased body sway with breathing in people with chronic LBP is not simply because of reduced trunk movement, but instead, indicates changes in coordination by the central nervous system that are not replicated by experimental nociceptor stimulation.     

Survey of general practitioners'' opinions on the role of radiology in patients with low back pain.

Ninety general practitioners responded to a questionnaire about the role of radiology in patients with low back pain. Their clinical indications for requesting radiographs were mostly in agreement with the opinions of radiologists, but nearly 80% requested investigations for their own or patients' reassurance. Understanding of the terms used by radiologists was good, although 25% thought that acute disc prolapse could be demonstrated on plain films. Previous training in radiology did not seem to influence knowledge. When general practitioners understood radiological terms they had clear therapeutic and specialist referral preferences. Poorly understood terms and those with which they were familiar but unclear about the implications for management were also identified.     

6-Month Results of Transdiscal Biacuplasty on Patients with Discogenic Low Back Pain: Preliminary Findings

Study Design: Prospective observational study.Objective: Our aim is to investigate the efficacy and safety of TransDiscal Biacuplasty.Summary of Background Data: Chronic discogenic pain is one of the leading causes of low back pain; however, the condition is not helped by most non-invasive methods. The results of major surgical operations for these patients are unsatisfactory. Recently, attention has shifted to disk heating methods for treatment. TransDiscal Biacuplasty is one of the minimally invasive treatment methods. The method was developed as an alternative to spinal surgical practices and Intradiscal Electrothermal Therapy for treatment of patients with chronic discogenic pain.Methods: The candidates for this study were patients with chronic discogenic pain that did not respond to conservative treatment. The main criteria for inclusion were: the existence of axial low back pain present for 6 months; disc degeneration or internal disc disruption at a minimum of one level, and maximum of two levels, in MR imaging; and positive discography. Physical function was assessed using the Oswestry Disability Index when measuring the pain with VAS. Patient satisfaction was evaluated using a 4-grade scale. Follow-ups were made 1, 3, and 6 months after treatment.Results: 15 patients were treated at one or two levels. The mean patient age was 43.1±9.2 years. We found the mean symptom duration to be 40.5±45.7 months. At the sixth month, 57.1% of patients reported a 50% or more reduction in pain, while 78.6% of patients reported a reduction of at least two points in their VAS values. In the final check, 78.6% of patients reported a 10-point improvement in their Oswestry Disability scores compared to the initial values. No complications were observed in any of the patients.Conclusions: TransDiscal Biacuplasty is an effective and safe method.     

Effectiveness of a standardized back school program for patients with chronic low back pain after implementation in routine rehabilitation care

ObjectiveTo evaluate the effectiveness of a standardized, patient-oriented, biopsychosocial back school after implementation in inpatient orthopedic rehabilitation.MethodsA multi-center, quasi-experimental controlled study of patients with low back pain (n = 535) was conducted. Patients in the control group received the traditional back school before implementation of the new program (usual care); patients in the intervention group received the new standardized back school after implementation into routine care. Patients’ illness knowledge and conduct of back exercises (primary outcomes) and secondary self-management outcomes and treatment satisfaction were obtained at admission, discharge, and 6 and 12 months after rehabilitation.ResultsWe found a significant small between-group intervention effect on patients‘ illness knowledge in medium- to long term (6 months: η² = 0.015; 12 months: η² = 0.013). There were trends for effects on conduct of back exercises among men (6 and 12 months: η² = 0.008 both). Furthermore, significant small effects were observed for treatment satisfaction at discharge and physical activity after 6 months.ConclusionsThe standardized back school seems to be more effective in certain outcomes than a usual care program despite heterogeneous program implementation.Practice implicationsFurther dissemination within orthopedic rehabilitation may be encouraged to foster self-management outcomes.     

Effectiveness of communicative and educative strategies in chronic low back pain patients: A systematic review

ObjectiveTo investigate the effectiveness of communicative and educative strategies on 1) patient’s low back pain awareness/knowledge, 2) maladaptive behavior modification and 3) compliance with exercise in patients with chronic low back pain.MethodsA systematic review was conducted. Searches were performed on 13 databases. Only randomized controlled trials enrolling patients ≥ 18 years of age were included. Risk of bias was assessed with the Cochrane Collaboration’s tool and interrater agreement between authors for full-texts selection was evaluated with Cohen’s Kappa. No meta-analysis was performed and qualitative analysis was conducted.Results24 randomized controlled trials which intervention included communicative and educative strategies were selected. Most of the studies were judged as low risk of bias and Cohen’s Kappa was excellent ( = 0.822). Interventions addressed were cognitive behavioral therapy as unique treatment or combined with other treatments (multimodal interventions), coaching, mindfulness, pain science education, self-management, graded activity and graded exposure.Conclusions, practice implicationPatient’s low back pain awareness/knowledge is still a grey area of literature. Pain science education, graded exposure and multimodal interventions are the most effective for behavior modification and compliance with exercise with benefits also in the long-term, while self-management, graded activity and coaching provide only short-term or no benefits.     

Anomalous reactions in the haemagglutination assay for anti-collagen antibodies: studies on patients with rheumatoid arthritis or chronic low back pain

Sera from 23 patients with chronic low back pain, 20 rheumatoid patients and 16 normal controls were tested for antibodies to collagen types I, II and III, both native and denatured, by haemagglutination. Weak reactions against denatured collagen types I and II were found in 30-40% of the sera. Sera from individuals with rheumatoid arthritis or chronic low back pain behaved similarly, while only one normal serum showed any positive reaction. Reactions to denatured collagen type III and to native collagen of all 3 types were largely negative. Non-antibody serum components were thought to be responsible for these haemagglutination reactions since weakly positive reactions were abolished by cryoprecipitation and could not be confirmed by a solid-phase fluorimetric assay. Using the latter technique sera from 62 rheumatoid patients were screened for antibodies to type II collagen (native and denatured) and only one positive serum found. We conclude that haemagglutination is subject to false positive reactions and that the incidence of anticollagen antibodies in sera from patients with rheumatoid arthritis or chronic low back pain is low.