Does spinal manipulative therapy help people with chronic low back pain?

A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain.     

Health care providers communicate less well with patients with chronic low back pain – A study of encounters at a back pain clinic in Denmark

We aimed to study the quality of communication between health care providers and patients with low back pain with emphasis on information giving in a back pain clinic, including if characteristics of patients could be associated with communication quality. We videotaped 79 encounters in which 21 providers informed patients about the results of magnetic resonance imaging of the back. Background information about the patients was collected by questionnaires and interview after the encounter. Videotapes were analysed with the Four Habits Coding Scheme (4HCS) in which higher scores mean better communication. There were strong negative correlations between 4HCS scores and the duration of back pain, and patient age. The results were significant for all professional subgroups (doctors, physiotherapists, chiropractors). Communication quality in encounters with back pain patients is worse, the longer the patient has suffered pain. Poor communication quality also seems to be associated with patients being older.     

Comparing spinal manipulation with and without Kinesio Taping® in the treatment of chronic low back pain

Objectives

Chronic non-specific low back pain (CNLBP) is a prevalent problem among athletes that can cause long-lasting disability and time lost from sporting activities. Thus far, a variety of methods have been suggested to address this problem, including spinal manipulation (SM) and Kinesio Tape^® (KT). The aim of this study was to investigate whether adding KT to SM can provide any extra effect in athletes with CNLBP or not.

Does osteoarthritis of the lumbar spine cause chronic low back pain?

The lumbar spine is a common location for osteoarthritis. The axial skeleton demonstrates the same classic alterations of cartilage loss, joint instability, and osteophytosis characteristic of symptomatic disease in the appendages. Despite these similarities, questions remain regarding the lumbar spine facet joints as a source of chronic back pain. The facet joints undergo a progression of degeneration that may result in pain. The facet joints have sensory input from two spinal levels that makes localization of pain difficult. Radiographic studies describe intervertebral disc abnormalities in asymptomatic individuals that are associated with, but not synonymous for, osteoarthritis. Patients who do not have osteoarthritis of the facet joints on magnetic resonance scan do not have back pain. Single photon emission computed tomography scans of the axial skeleton are able to identify painful facet joints with increased activity that may be helped by local anesthetic injections. Low back pain is responsive to therapies that are effective for osteoarthritis in other locations. Osteoarthritis of the lumbar spine does cause low back pain.     

Exercise and chronic low back pain: what works?

The aim of this review was to investigate current evidence for the type and quality of exercise being offered to chronic low back pain (CLBP) patients, within randomised controlled trials (RCTs), and to assess how treatment outcomes are being measured. A two-fold methodological approach was adopted: a methodological assessment identified RCTs of 'medium' or 'high' methodological quality. Exercise quality was subsequently assessed according to the predominant exercise used. Outcome measures were analysed based on current recommendations. Fifty-four relevant RCTs were identified, of which 51 were scored for methodological quality. Sixteen RCTs involving 1730 patients qualified for inclusion in this review based upon their methodological quality, and chronicity of symptoms; exercise had a positive effect in all 16 trials. Twelve out of 16 programmes incorporated strengthening exercise, of which 10 maintained their positive results at follow-up. Supervision and adequate compliance were common aspects of trials. A wide variety of outcome measures were used. Outcome measures did not adequately represent the guidelines for impairment, activity and participation, and impairment measures were over-represented at the expense of others. Despite the variety offered, exercise has a positive effect on CLBP patients, and results are largely maintained at follow-up. Strengthening is a common component of exercise programmes, however, the role of exercise co-interventions must not be overlooked. More high quality trials are needed to accurately assess the role of supervision and follow-up, together with the use of more appropriate outcome measures.     

Does anterior trunk pain predict a different course of recovery in chronic low back pain?

Patient characteristics associated with the course and severity of low back pain (LBP) and disability have been the focus of extensive research, however, known characteristics do not explain much of the variance in outcomes. The relationship between anterior trunk pain (ATP) and LBP has not been explored, though mechanisms for visceral referred pain have been described. Study objectives were: (1) determine prevalence of ATP in chronic LBP patients, (2) determine whether ATP is associated with increased pain and disability in these patients, and (3) evaluate whether ATP predicts the course of pain and disability in these patients. In this study, spinal outpatient department patients mapped the distribution of their pain and patients describing pain in their chest, abdomen or groin were classified with ATP. Generalized estimating equations were performed to investigate the relationship between ATP and LBP outcomes. A total of 2974 patients were included and 19.6% of patients reported ATP. At all time points, there were significant differences in absolute pain intensity and disability in those with ATP compared with those without. The presence of ATP did not affect the clinical course of LBP outcomes.     

Reconditioning in groups: an effective programme for the rehabilitation of patients with low back pain?]

The article reports on a study in which elements of a group-oriented reconditioning programme for patients with low back pain were incorporated into the routine of an in-patient orthopaedic rehabilitation clinic. The specific elements of the new programme consisted of stable group structures during the whole stay of 3 to 4 weeks, and of 3 to 7 hrs. walks in hilly ground three times a week. The effects of this programme were tested against a standard programme with a mix of passive and active elements using a controlled study design. 92 persons participated in an experimental group and 81 persons in a control group with no significant differences found between the two groups at admission. Effects were measured by means of a physicians' questionnaire and a multidimensional patients' questionnaire (IRES) answered at admission, at discharge, and at six- and twelve-month follow-up. The results of a two-factorial analysis of variance with repeated measures showed that the interaction between group and time on the summary score of the IRES was not significant, although the experimental group showed somewhat better effects at all times of measurement. The discussion focuses on the reasons for this result, among which the unexpectedly good effects in the control group are named, as well as certain difficulties with the implementation of a strongly activity-oriented programme into the course of a "normal" rehabilitation clinic.     

Effects of meditation on pain intensity,physical function,quality of life and depression in adults with low back pain – A systematic review with meta-analysis

BackgroundLow back pain (LBP) is a common biopsychosocial health problem. Meditation may provide a complementary treatment option for LBP patients.ObjectivesThe aim of this systematic review with meta-analysis was to examine the effects of meditation on pain intensity, functional disability, quality of life, and depression in LBP populations.MethodsThis systematic review was conducted according to the PRISMA Guidelines. PubMed, Web of Science, CENTRAL, CamQuest and PubPsych were searched up to a publication date of June 2020. Inclusion criteria were RCTs or non-RCTs with LBP patients, aged at least 18 years, the application of a specific meditation technique, and pain intensity and/or functional disability as outcomes. Pooled SMDs were calculated at post-treatment and follow up. The Cochrane risk-of-bias tool was used to estimate risk of bias. The overall quality of evidence was assessed using the GRADE approach.Results12 studies with a total of 1005 participants were included in this review. Compared to controls, meditation solely showed a significant positive effect on pain intensity (SMD = −0.27 [CI −0.43; −0.11]; p = 0.001; based on 10 studies with 934 participants) and physical quality of life (SMD = 0.21 [CI 0.07; 0.36]; p = 0.005; based on 5 studies with 756 participants) at post-treatment. At follow up (mean 20 weeks, range 4–52) there were no significant effects anymore. The quality of the evidence was moderate due to study limitations and imprecision.ConclusionsMeditation seems to be promising with regard to reducing short-term pain intensity in patients with LBP. However, additional well-designed and large trials are required in order to draw more reliable conclusions.     

Does pain-catastrophising mediate the effect of tai chi on treatment outcomes for people with low back pain?

ObjectivesThere is evidence to support the effectiveness of tai chi for reducing pain-related symptoms across multiple musculoskeletal conditions, however, the mechanism(s) are unclear. This study explores the role of pain-catastrophising as a possible mediator in the relationship between practising tai chi and back pain symptoms.DesignExploratory mediation analyses using a Baron and Kenny approach and bootstrapping methods were employed as a secondary analysis of data from a previously published randomised controlled trial.SettingAdults with persistent low back pain were recruited via community advertisement in Sydney, NSW, Australia.InterventionsA 10-week tai chi intervention and a wait-list control.Main outcome measuresPatients completed self-assessments of pain intensity and bothersomeness using 0–10 numerical rating scales, disability using the Roland Morris Disability Questionnaire and pain catastrophising using the Pain Coping Strategies Questionnaire pre and post intervention.ResultsThe results suggest partial mediation, by which a reduction in catastrophising explained approximately 1/3 of the effect on pain intensity and bothersomeness and 2/3 of the effect on disability.ConclusionAs the first known mediation analysis of tai chi for reducing low back pain-symptoms, it provides initial evidence that it may do so by having an effect on cognitive appraisal outcomes such as pain-catastrophising and information for choosing appropriate process measures for future studies. As tai chi is growing in popularity as an alternative treatment for patients with chronic musculoskeletal conditions, it is important to gain a better understanding of how it might work using confirmatory mediation analysis alongside future RCTs.     

How effective is the acute low back pain screening questionnaire for predicting 1-year follow-up in patients with low back pain?

OBJECTIVES: The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain. STUDY DESIGN: A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective. PATIENTS: Ninety patients (76% response rate) returned the completed questionnaire package. RESULTS: The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation). CONCLUSIONS: The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.     

Impaired trunk muscle function in sub-acute neck pain: etiologic in the subsequent development of low back pain?

Low back pain (LBP) and neck pain are associated with dysfunction of the trunk and neck muscles, respectively, and may involve common or similar mechanisms. In both cases, dysfunction may compromise spinal control. Anecdotally, neck pain patients commonly develop LBP. This study investigated the possibility that trunk muscle function is compromised in neck pain patients and that compromised trunk muscle function is associated with increased risk of LBP. Fifty-four neck pain patients and 52 controls were assessed on an abdominal drawing-in task (ADIT) and on self-report tests. Performance on the ADIT was able to detect neck pain patients with 85% sensitivity and 73% specificity. Catastrophizing and McGill pain questionnaire (affective) scores were higher in patients with an abnormal task response than in patients with an uncertain or normal response, although the self-report data did not predict task performance. Fifty subjects from each group were contactable by telephone at 2 years. They were asked whether they had experienced persistent or recurrent LBP since the assessment. Subjects (patients and controls) who obtained an abnormal response on the ADIT were 3 to 6 times more likely to develop persistent or recurrent LBP than those who obtained an uncertain or normal response. ADIT performance was the main predictor of development of LBP in patients. The results suggest that reduced voluntary trunk muscle control in neck pain patients is associated with an increased risk of developing LBP.     

Physical capacity tasks in chronic low back pain: what is the contributing role of cardiovascular capacity, pain and psychological factors?

PURPOSE: To explore the association of personal and body functions with physical capacity tasks used in the evaluation of chronic low back pain (CLBP) treatment. METHOD: Cross-sectional study in which 221 patients with non-specific CLBP participated. Physical capacity was assessed by six capacity tasks, and several personal and body functions were assessed by questionnaires (age, gender, pain intensity, duration of pain, radiating pain to leg, fear of injury/movement, depression, pain catastrophizing and internal control of pain). Cardiovascular capacity was measured by a modified Astrand submaximal bicycle test. The association of these hypothetically influential personal and body function factors with capacity tasks was examined with multiple linear regression analyses. RESULTS: The total explained variance was low to moderate (9 - 19%), except for stair climbing for which the variance just reached 30%. Many putative factors did not contribute significantly to the level of outcome of several different tasks. CONCLUSIONS: Cardiovascular capacity, pain intensity, fear of injury/movement, cognitions, and depression had statistically significant but clinically minor effects on several, but not all capacity tasks. Radiating pain, age and duration of complaints had no significant influence at all. Due to anthropometric differences men outperformed women on most tasks. Apparently the influence of many personal, physical but especially psychological factors on the selected capacity tasks is not high at all. This might indicate that these tasks are more objectively measuring physical capacity than expected.     

Physical capacity tasks in chronic low back pain: What is the contributing role of cardiovascular capacity,pain and psychological factors?

Purpose. To explore the association of personal and body functions with physical capacity tasks used in the evaluation of chronic low back pain (CLBP) treatment.

Method. Cross-sectional study in which 221 patients with non-specific CLBP participated. Physical capacity was assessed by six capacity tasks, and several personal and body functions were assessed by questionnaires (age, gender, pain intensity, duration of pain, radiating pain to leg, fear of injury/movement, depression, pain catastrophizing and internal control of pain). Cardiovascular capacity was measured by a modified Åstrand submaximal bicycle test. The association of these hypothetically influential personal and body function factors with capacity tasks was examined with multiple linear regression analyses.

Results. The total explained variance was low to moderate (9 – 19%), except for stair climbing for which the variance just reached 30%. Many putative factors did not contribute significantly to the level of outcome of several different tasks.

Conclusions. Cardiovascular capacity, pain intensity, fear of injury/movement, cognitions, and depression had statistically significant but clinically minor effects on several, but not all capacity tasks. Radiating pain, age and duration of complaints had no significant influence at all. Due to anthropometric differences men outperformed women on most tasks. Apparently the influence of many personal, physical but especially psychological factors on the selected capacity tasks is not high at all. This might indicate that these tasks are more objectively measuring physical capacity than expected.