ACR Appropriateness Criteria Low Back Pain

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.     

Associations of physical activity and inactivity with low back pain in adolescents

Low back pain (LBP) is a common health problem already in adolescence. Physical activity has been suggested as a risk factor for LBP in adolescents, but the current evidence is conflicting. This study examined the association of physical activity and amount of sitting with LBP. The study population consisted of 5999 boy and girl members of the Northern Finland 1986 birth cohort who responded to mailed questions at the age of 15-16 years. LBP during the past 6 months was classified as "no LBP,"reporting LBP" (not seeking medical help), or "consultation for LBP." Odds ratios and 95% confidence intervals obtained by multinomial logistic regression were adjusted for smoking and body mass index. Being physically very active (more than 6 h of brisk physical activity per week) was associated with increased prevalence of "consultation for LBP" in both sexes, and with "reporting LBP" in girls, compared with being moderately active (2-3 h of brisk physical activity per week). High amount of sitting associated with "consultation for LBP" and "reporting LBP" in girls, but not in boys. We conclude that very active participation in physical activities in both sexes and a high amount of sitting in girls are related to self-reported LBP.     

Resistance band training or general exercise in multidisciplinary rehabilitation of low back pain? A randomized trial

Multidisciplinary biopsychosocial rehabilitation has been recommended for chronic low back pain (LBP ), including physical exercise. However, which exercise modality that is most advantageous in multidisciplinary biopsychosocial rehabilitation is unclear. In this study, we investigated whether multidisciplinary biopsychosocial rehabilitation could be more effective in reducing pain‐related disability when general physical exercise was replaced by strength training in the form of progressive resistance training using elastic resistance bands. In this single‐blinded (researchers), randomized controlled trial, 99 consenting adults with moderate‐to‐severe non‐specific LBP were randomized to three weeks of multidisciplinary biopsychosocial rehabilitation with either general physical exercise or progressive resistance band training and were then instructed to continue with their respective home‐based programs for nine additional weeks, in which three booster sessions were offered. The primary outcome was between‐group difference in change on the Oswestry Disability Index (ODI ) at 12 weeks. Due to early dropouts, data from 74 participants (mean age: 45 years, 57% women, mean ODI : 30.4) were obtained at baseline, 61 participants were followed‐up at 3 weeks, and 46 at 12 weeks. There was no difference in the change in ODI score between groups at 12 weeks (mean difference 1.9, 95% CI : −3.6, 7.4, P  = .49). Likewise, the change in secondary outcomes did not differ between groups, except for the patient‐specific functional scale (0‐10), which favored general physical exercise (mean difference 1.4, 95% CI : 0.1, 2.7, P  = .033). In conclusion, this study does not support that progressive resistance band training compared to general physical exercise improve outcomes in multidisciplinary biopsychosocial rehabilitation for patients with non‐specific LBP .     

Exercise programs for subjects with low back disorders

Exercise has played a central role in rehabilitation of subjects with low back pain. The research in this field has intensified since the 1980s. Low back pain has been associated with both physically stressful and sedentary occupations. There is no clear association between low back pain and physical activity during leisure time. Many studies have shown that subjects with back pain have impairments in muscular and connective tissue, functional limitations in muscular strength, endurance, speed, and neuromuscular functions, and physical, social and psychological disabilities. The ultimate aims of the exercise-based programs are to reduce and prevent these impairements, functional limitations and disabilities. The results of controlled studies with exercise programs have shown a positive effect on physical impairments and functional limitations for subjects with chronic low back pain. The outcome of exercise programs has not been so positive for disability, defined as an inability or a limitation in performance in social interactions including occupational activities.     

The influence of exercise on musculoskeletal disorders of the lumbar spine

AIM: This review, through a survey of the relevant research, examines the role of exercise in the natural course of symptoms in the preventive category, as well as in acute, subacute, chronic and postoperative categories of low back pain. The purpose of this study was to examine the evidence for cause and effect relationships between exercise and acute, subacute, and chronic low back pain, as well as for any dose-response relations involved. METHODS: Computer database research and personal retrieval systems were used to locate the relevant literature. RESULTS: Exercise can be effective in preventing LBP (Category A). Specific exercise has not been found effective in treatment of acute LBP (Category B), but exercise can be effective in subacute and chronic LBP (Category C, D), especially for diminishing the effects of deconditioning. To attain the effects mentioned above the types of exercise are known except in the case of the prevention of LBP, but little is known about dose-response relationships; at best, semi quantitatively on the basis of just a few studies. CONCLUSIONS: Given the demonstrated primary and/or secondary preventative effectiveness of exercise regarding LBP, the subjects who would most benefit from specific exercise have not yet been identified.     

Pain catastrophizing and trunk muscle activation during walking in patients with chronic low back pain

It has been hypothesized that individuals with low back pain (LBP) will have higher trunk muscle activity during gait, in an attempt to limit spine motion, and that this “guarding strategy” may be influenced by the person’s psychological response to pain. This study investigated whether the amplitude of trunk muscle activation differs between persons with chronic LBP and healthy individuals during walking, and whether changes in muscle activation were related to pain catastrophizing. Thirty persons with chronic non-specific LBP, stratified into 2 groups of high (HLBP) and low (LLBP) pain catastrophizing, were contrasted with a control group of 15 healthy individuals during walking on a treadmill at a self-selected speed. Surface electromyographic (EMG) data were recorded from 10 trunk muscles. The effects of Group and gait Sub-phase on EMG activation amplitudes were assessed. The HLBP group exhibited higher activation of certain muscles throughout the gait cycle, and reduced variability of others at specific sub-phases of gait. A significant correlation was found between activation amplitude and pain catastrophizing in most muscles, when controlling for gait speed and pain intensity. These data indicate that altered trunk muscle activation is present in some patients with LBP during walking, but does not represent a universal increase in activation for all muscles. This altered neuromotor control is, however, more strongly associated with pain catastrophizing than with pain intensity, and appears to represent a non-functional, maladaptive behavior, as it alters the normal, phasic pattern of activation in certain trunk muscles.     

冲和药物速渗治疗仪与正骨、针刀联合治疗腰软组织伤病研究

 目的 研究冲和药物速渗治疗仪与正骨、针刀疗法联合治疗腰软组织训练伤病的临床疗效、作用机制和不良反应.方法 将腰部软组织训练伤病患者80例随机分为冲和组和常规组.冲和组40例,采用每日1次冲和治疗,7次为一疗程;常规组40例,采用理疗、按摩等常规治疗方法;应用脊柱运动范围(Taimela test)测量腰椎活动度评估疗效.结果 经治疗2周后两组有效率:冲和组86.5%、常规组74.6%,差别虽无统计学意义,但观察随访1年,冲和组腰部损伤事件发生率明显低于常规组(P<0.01);治疗前后两组腰椎活动度相比较有统计学意义(P<0.01).结论 药械冲和疗法具有疏理肌丝,改善病理性骨骼肌细胞重构的作用,可有效地改变推拿、针刀术后肌丝修复过程中的粘连、结节和瘢痕形成等的病理过程,是正骨、针刀术后的连续性治疗方法.     

冲和药物速渗疗法对腰部软组织伤病患者生理功能位及代偿功能位的影响

目的评价冲和疗法(CHT)对腰部伤病患者生理功能位及代偿功能位的影响。方法将80例患者随机分为冲和组和常规组,应用VAS疼痛视觉模拟量尺、SF-36健康状况调查问卷、脊柱运动范围测量腰椎活动度观察CHT对其的影响;观察随访1年腰部损伤事件发生率。结果治疗前后两组VAS指数、SF-36得分、腰椎活动度均有统计学意义(P<0.01);观察随访1年,冲和组腰部损伤事件发生率明显低于常规组(P<0.01)。结论CHT能引导损伤肌组织向生理功能位修复和阻止损伤代偿功能位的形成,从而调节腰椎活动的力学平衡,能有效地控制腰痛发作,减少腰部损伤事件发生率。     

Vertebral Endplate Changes Are Not Associated with Chronic Low Back Pain among Southern European Subjects: A Case Control Study

BACKGROUND AND PURPOSE: Data on the association between vertebral endplate changes and low back pain are contradictory. This study was designed to assess whether this association exists among Southern European subjects. MATERIALS AND METHODS: Patients in this study serving as cases were 35-50 years of age with low back pain lasting >90 days, for whom a lumbar MR imaging had been prescribed. Controls were subjects 35-50 years of age, having a cranial MR imaging for headache with normal findings, and no history of clinically relevant LBP. Two hundred forty cases and 64 controls were recruited consecutively in the radiology services across 6 cities in Spain. Imaging findings and subject characteristics were gathered through previously validated instruments. Radiologists who interpreted MRI were blinded to the subject characteristics. A multivariate logistic regression model was developed to assess the association of vertebral endplate changes with LBP, adjusting for sex, age, body mass index, lifetime exposure to smoking, physical activity, disk degeneration, and the interaction between disk degeneration and vertebral endplate changes. RESULTS: Vertebral endplate changes were found in 80.4% of the cases and in 87.5% of the controls. In the regression model, disk degeneration was the only variable showing a confounding effect. Results showed that after adjusting for disk degeneration, the presence of vertebral endplate changes is associated with the absence of chronic LBP (OR for LBP: 0.31; 95% CI, 0.10-0.95). CONCLUSIONS: In Southern European subjects, vertebral endplate changes are not associated with chronic LBP.     

Associations between activities and low back pain in adolescents

The aim of this cross-sectional study was to explore associations between self-reported leisure activities and low back pain (LBP). The material included all adolescents in eighth and ninth grade in two geographical areas in the school year 1996-1997. Eighty-eight adolescents participated (mean age 14.7 years), making the response rate 84%. LBP during the preceding year was reported by 57%. Sixty-six percent reported physical activity 3 times weekly or more. The median time spent on television or computer was 15 h. In multivariate analyses, LBP was inversely associated with time spent on physical activity, in particular with regular walking or bicycling. LBP was associated with the use of television or computer more than 15 h weekly, but not with the time spent reading. The results confirm studies showing inverse associations between walking and LBP. Future research should involve prospective studies of the potential effects of walking or bicycling and other specific activities on LBP.     

Physical therapy and changes in disability for patients with low back pain

OBJECTIVE: The purpose of this study was to describe the changes in disability for patients being treated for low back pain (LBP) at a military physical therapy clinic from the time of initial evaluation to discharge from physical therapy and to compare those changes across categories of symptom duration and location. METHODS: Three hundred four consecutive patients who completed a course of physical therapy for LBP were evaluated with the Oswestry LBP Disability questionnaire at the time of initial evaluation and discharge from physical therapy. RESULTS: In all of the patient groups, mean Oswestry scores had decreased significantly from the time of initial evaluation to discharge from physical therapy, indicating that patients experienced significantly decreased levels of disability at the time of discharge from physical therapy. However, patients with LBP without lower extremity symptoms generally had greater decreases in disability than patients with LBP with lower extremity symptoms. Furthermore, whereas patients in the acute groups had the greatest decrease in disability, patients in the chronic groups had the smallest decrease in disability. CONCLUSION: Clinicians should use LBP symptom duration, as well as the presence or absence of lower extremity symptoms, to assist in developing treatment prognoses for patients with LBP.     

Clinical benefit of intensive dynamic exercises for low back pain

Over the years there has been an apparent contradiction between the widely utilized treatment of low back pain through exercise, and the often apparently disappointing results reported in the scientific literature. Recently published studies have shown that the most important factor regarding the training effects of chronic low back patients is the administration of a high training stimulus (number of repetitions of the exercise, exercise resistance, and the total number of sessions). This would explain why several of the previously published studies regarding training show insignificant results. Simply stated, in many low-dosage or short-time studies, the positive effects of training have not had adequate opportunity to take hold in the chronic low back pain patient. The patient group which has been operated on for disc prolapse often exhibits considerable functional deteriorations post-operatively. Rehabilitation studies have shown that many of these patients also benefit from post-operative rehabilitation including high dosage exercise programs. Exercise programs are generally free of side-effects.     

慢性腰痛推拿治疗前后默认脑网络功能连接变化研究

目的:探讨慢性腰痛患者推拿治疗前、治疗后静息态下默认脑网络的功能连接变化。方法:收集20例慢性腰痛患者和20名健康对照者的静息态功能磁共振(MRI)数据。采用SPM8软件对脑功能数据进行预处理,并以后扣带回为种子点,分析默认脑网络(DMN)功能连接,比较慢性腰痛组与健康对照组、慢性腰痛组推拿治疗前后DMN功能连接的差异。结果:慢性腰痛人群存在DMN与左侧颞下回、左侧小脑前叶、左恻枕中回、左侧背外恻额上回功能连接异常。推拿治疗后主要变化表现为DMN与左恻背外侧额上回连接恢复,DMN与左侧内侧额上回、后扣带皮质连接增强,DMN与左侧楔前叶、左侧回直肌、中脑功能连接降低。结论:静息状态下腰痛受试者DMN存在特定脑功能异常连接区域,推拿治疗主要影响了慢性腰痛人群的感觉、情绪和认知水平的区域。     

Influence of imaging on clinical decision making in the treatment of lower back pain

PURPOSE: To assess the impact of cross-sectional imaging with magnetic resonance (MR) imaging or computed tomography (CT) on clinical decision making for patients with lower back pain (LBP). MATERIALS AND METHODS: A randomized controlled before-and-after study was performed in 145 patients who had symptomatic lumbar spinal disorders and had been referred to orthopedists or neurosurgeons. Participants were a subgroup within a multicenter pragmatic randomized comparison of two imaging policies on LBP treatment: "imaging" versus "no imaging," unless a clear indication developed. Paired assessments were made of diagnosis, diagnostic confidence, proposed treatment, treatment confidence at trial entry and follow-up, and expectations of imaging. Data were analyzed according to the groups as randomized. RESULTS: At follow-up, there were no statistically significant differences between the groups with respect to diagnosis or treatment plans. Significant increases in diagnostic and therapeutic confidence between trial entry and follow-up were observed for both groups, with a significantly greater increase in diagnostic confidence (P =.01) in the imaging group. CONCLUSION: Imaging may increase diagnostic confidence but has minimal influence on diagnostic or therapeutic decisions for patients with LBP. The results highlight the need for evidence-based guidelines for imaging in LBP treatment.     

Transversus abdominis and core stability: has the pendulum swung?

In the past decade there has been a focus on isolated transversus abdominis activation and how it contributes to lumbo-pelvic stability. This rationale has not only influenced the management of chronic low back pain (LBP); it has also been included in exercises for many other pathologies of the lower and upper limb and also for prophylaxis in pain-free subjects.     

Relationship between low back pain, disability, MR imaging findings and health care provider

Objective To determine the association between the self-report of pain and disability and findings on lumbar MR images, and to compare two different health care providers in Spanish patients with low back pain (LBP).Design Cross-sectionalMaterial and methods A total of 278 patients, 137 men and 141 women aged 44±14 years submitted with low back pain (LBP) were studied. One hundred and nine patients were from the National Health System (NHS) and 169 from private practice. Patients with previous discitis, surgery, neoplasm or traumatic episodes were excluded. Every patient completed a disability questionnaire with six core items, providing a score of disability from 2 to 28. All patients had sagittal spin-echo T1 and turbo spin-echo T2, axial proton-density and MR myelography weighted images. MR images of the two most affected disc levels were read, offering an MR imaging score from 0 to 30.Results Patients with a combination of LBP and sciatica showed the highest levels of disability (p=0.002). MR imaging scores only correlated with pain interference with normal work (p=0.04), but not with other disability questions. Patients from the NHS showed greater disability scores than private ones (p=0.001) and higher MR imaging scores (p=0.01).Conclusion In patients with LBP, MR imaging only correlates with pain interference with work but not with other disability questions. Differences are found between private and NHS patients, the latter being more physically affected.This work was presented as a scientific exhibit at the European Congress of Radiology, 7-11 March 2003, Vienna, Austria.     

The young adult spine in sports

In summary, LBP is a common problem for the young adult athlete, with discogenic pain being the most common of all etiologies. Although rare, more serious etiologies such as tumor or infection should be included in the differential diagnosis until effectively ruled out. Regardless of the cause, nonoperative and conservative strategies should be the cornerstone of treatment, owing to the favorable natural history of most LBP etiologies. Short-term non-narcotic medications are helpful, and avoidance of bed rest is critical for the athletic population. Rehabilitation should focus on stabilization and strengthening of the core and pelvic muscle groups, and biomechanical imbalances should be addressed. Surgical intervention ought to be utilized as a last resort in this population. Return to play should be considered only when the athlete is pain free with full range of motion and daily medications have been discontinued. Careful monitoring of the training regimen should always be undertaken,especially with chronic pain or recurrent injuries.     

中度高原地区坦克乘员腰痛的现患调查

目的：了解中度高原地区坦克乘员腰痛的发病情况、流行病学特点。方法：采用问卷调查、实地考察、物理检查、统计分析等方法，对中度高原地区1041名坦克乘员腰痛情况进行横断面调查。结果：1041名坦克乘员中腰痛患病率45．9％，各工种驾驶员检出率最高（P〈0．05）。腰痛随兵龄增加而明显升高，5年以上驾驶员患病率高达87．5％。经多元回归分析，吸烟、反复高举重物、训练中反复弯腰3种因素与腰痛相关。结论：中度高原地区坦克驾驶员腰痛患病率高，发病率随从业时间而增大。     

Association between lower back pain and lower extremity pain among young volleyball players: A cross-sectional study

BackgroundLower back pain (LBP), as well as lower extremity injuries, are major problems among young volleyball players. Nevertheless, only few studies have focused on the relationship between lower extremity injuries and LBP.ObjectiveThis study investigated the association between LBP and lower extremity pain, including knee and ankle pain, among young volleyball players.DesignCross-sectional study.SettingAmateur sports association.ParticipantsElementary and middle school-aged athletes (6–15 years of age).Main outcome measuresLBP and lower extremity pain.ResultsA total of 566 young volleyball players participated in this study. The point prevalence of LBP among young volleyball players was 9.5%. Using absence of lower extremity pain as a reference, the adjusted odds ratio (95% confidence interval) for LBP was 11.07 (5.64–21.71) in the presence of lower extremity pain.ConclusionsLBP is associated with Lower extremity pain among young volleyball players. Careful attention should be paid to lower extremity complaints to prevent and treat LBP among young volleyball players.