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.     

Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group

The reported complication rates after various surgical techniques used to create a lumbar fusion vary within wide ranges. In a previous paper, the Swedish Lumbar Spine Study Group have reported on the clinical outcome of lumbar spine fusion for chronic low back pain in a comparably homogeneous patient population where there were no significant differences between baseline sociodemographic, clinical and paraclinical characteristics. In this report we compared the complication rates of the surgical procedures used in that study and analyzed the association between complications and baseline variables, and between outcome results and complications. A multicenter randomized study was conducted where 211 patients aged 25-65 were treated with lumbar fusion according to three different surgical techniques: noninstrumented posterolateral fusion (PLF, n=71), instrumented posterolateral fusion (VSP, n=68), and in the third procedure we added an interbody fusion with solid autogenous bone grafts ("360", n=72). We categorized complications as: early/late, major/minor. The association between complications and sociodemographic characteristics (age, gender, comorbidity, previous surgery, smoking), and technical variables (surgical technique, levels fused, hospital category) was analyzed. The association between outcome variables (patient global assessment, pain, disability, depressive symptoms) and complications was analyzed. A literature review was conducted. There was no mortality. There was no significant difference in clinical outcome between the surgical groups after 2 years, although the power to detect such a difference was low. The total complication rate after 2 years in the PLF group was 12%, compared with 22% in the VSP group, and 40% in the "360" group (P=0.0003). After exclusion of complications, there was still no difference in outcome between the groups. The odds ratio (confidence intervals) of having a complication was 5.3 (2.2-12.7) when "360" was used compared with PLF, and 2.4 (1.1-5.3) for "360" compared with VSP. There was no association between clinical outcome and complications on a group level. The reintervention rate was 6% in the PLF group, 22% in the VSP, and 17% in the "360" group (P=0.020). The odds ratio (confidence intervals) of having a reintervention was 4.0 (1.3-11.9) when instrumentation was used compared with non-instrumented fusion. In this prospective randomized study comparing three lumbar fusion techniques in a comparably homogeneous patient population, complications increased significantly with increasing technicality of the surgical procedure. Even though we did not find a significant association between clinical outcome and complications after 2 years, the increased morbidity inflicted on an individual patient was not negligible. In this light, and as no fusion technique produced superior clinical outcome irrespective of whether complications were included or excluded in the analyses, the patient and the treating physician should carefully discuss the possible advantages and drawbacks of the different surgical options before making a decision. In order to make valid comparisons of both complication and reintervention rates after lumbar fusion, there is a need for a consensus in the spinal society regarding the definition of these entities.     

Screening for malignancy in low back pain patients: a systematic review

To describe the accuracy of clinical features and tests used to screen for malignancy in patients with low back pain. A systematic review was performed on all available records on MEDLINE, EMBASE, and CINAHL electronic databases. Studies were considered eligible if they investigated a cohort of low back pain patients, used an appropriate reference standard, and reported sufficient data on the diagnostic accuracy of tests. Two authors independently assessed methodological quality and extracted data to calculate positive (LR+) and negative (LR−) likelihood ratios. Six studies evaluating 22 different clinical features and tests were identified. The prevalence of malignancy ranged from 0.1 to 3.5%. A previous history of cancer (LR+ = 23.7), elevated ESR (LR+ = 18.0), reduced hematocrit (LR+ = 18.2), and overall clinician judgement (LR+ = 12.1) increased the probability of malignancy when present. A combination of age ≥50 years, a previous history of cancer, unexplained weight loss, and failure to improve after 1 month had a reported sensitivity of 100%. Overall, there was poor reporting of methodological quality items, and very few studies were performed in community primary care settings. Malignancy is rare as a cause of low back pain. The most useful features and tests are a previous history of cancer, elevated ESR, reduced hematocrit, and clinician judgement.     

Can a pharmacological pain analysis in patients with chronic low back pain predict the outcome of lumbar fusion? Preliminary report

Chronic low back pain patients chosen for lumbar fusion surgery were entered into a prospective study with the aim of evaluating whether pre-operative pharmacological pain classification correlated with the outcome of surgical treatment. Twenty consectutive patients (mean age 39 years, range 29–50 years) with a mean pain duration of 4.6 years (range 1–8 years) participated. The patients' pain, disability and work situation were evaluated pre-and post-operatively. According to the results of pharmacological pain testing the patients were classified into five pain groups: (1) those with nociceptive pain, (2) those with neuropathic pain, (3) placebo responders, (4) non-responders and (5) unclassified. This classification was based on the following approaches: intravenous morphine, intravenous lidocaine, epidurally administered fentanyl and a local anaesthetic. Surgical treatment consisted of posterolateral fusion of the lower two functional lumbosacral spinal units combined, if necessary with appropriate decompression. The results of the pharmacological pain assessment were not disclosed until the end of the follow-up period and outcome was evaluated by an unbiased observer. The distribution of patients between pain groups was as follows; nine had nociceptive pain, two suffered neuropathic pain, there were no placebo responders and seven were non-responders. Two patients could not be classified into any of these groups. Outcome was rated at 6, 12 and 24 months as excellent/good in eight out of nine patients with nociceptive pain. In the group with nonresponding pain surgical outcome was significantly poorer (P<0.01), and was ranked as excellent/good in only one out of seven patients. There was a significant improvement (P<0.05) concerning both pain and disability in the nociceptive group, but not in the non-responding group. Pre-operative pharmacological pain testing may be useful as a predictor of surgical outcome and we suggest that it can be employed as a means to identify patients with non-responding pain and poor surgical prognosis.     

Identifying subsets of patients with single-level degenerative disc disease for lumbar fusion: the value of prognostic tests in surgical decision making

Background Context

Fusion surgery for degenerative disc disease (DDD) has become a standard of care, albeit not without controversy. Outcomes are inconsistent and a superiority over conservative treatment is debatable. Proper patient selection is key to clinical success, and a comprehensive understanding of prognostic tests does not currently exist.

Effectiveness of a short functional restoration program for patients with chronic low back pain: A cohort study of 193 patients

BackgroundFunctional restoration programs (FRPs) are integrative programs to improve function in chronic low back pain (cLBP). They are costly and time-consuming. The aim was to assess the effectiveness of a condensed FRP (CFRP) for patients with cLBP in professional activity.MethodsLongitudinal 3 months study of patients with cLBP in one tertiary care hospital, participating in a CFRP over 4 separate days. The primary outcome was the Oswestry Disability Index (ODI). Secondary outcomes included pain, quality of life (EQ5D), patient acceptable symptom state, presenteeism, absenteeism and psychological distress. Outcomes were compared using paired sample Student's t-test or Chi² between baseline and last follow-up. Logistic regression was used to identify factors associated with better response (improvement of ODI higher than 12.8).ResultsIn all, 193 patients were analysed, mean age 44.6 (standard deviation (SD) 10.4) years, mean cLBP duration 9.0 (SD 8.8) years. A small improvement was observed for ODI (mean difference −5.9, 95% confidence interval: −7.6, −4.1), as well as most other outcomes. Multivariate analysis showed an association between ODI improvement and higher duration of low back pain (odds ratio for 5 years: 1.41 (1.06,1.88)) and lower baseline back strength (Sorensen, odds ratio for 1 min: 0.54 [0.29,0.99]).ConclusionThis CFRP showed small effect to improve function, pain and other quality of life, in cLBP. Four-day programs may be an interesting option in cLBP patients still in professional activity for whom a long 1-month FRP is difficultly manageable. Further studies with randomized controlled designs are needed to confirm the benefits.     

Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review

Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.     

Active treatment programs for patients with chronic low back pain: a prospective,randomized, observer-blinded study

Summary Several new studies have indicated that an active approach to patients with chronic disabling low back pain (LBP) seems effective. Some of these studies emphasize the importance of dealing with the patient's total situation in comprehensive multidisciplinary programs — the bio-psycho-social model. However, these programs are expensive. The aim of this study was to evaluate the rehabilitation outcome from three different active programs in terms of: (1) return-to-work rate, (2) days of sick leave, (3) health-care contacts, (4) pain and disability scores, and (5) staying physically active. The subjects included 132 patients randomized to the study, of whom 123 started one of the treatment programs. They had all had at least 6 months of chronic LBP. The patients were randomized into one of three programs: group 1 — a full-time, intensive 3-week multidisciplinary program, including active physical and ergonomic training and psychological pain management, followed by 1 day weekly for the subsequent 3 weeks; group 2 — active physical training, twice a week for 6 weeks, for a total of 24h; group 3 — psychological pain management combined with active physical training, twice a week for 6 weeks, also for a total of 24h. The results presented here are based on data collected 4 months following treatment, which shows an 86% response rate. The initial examination and the follow-up evaluation were performed by a blinded observer. The results show that 4 months after treatment, the intensive multidisciplinary program is superior to the less intensive programs in terms of return-to-work rate, health-care contacts, pain and disability scores, and staying physically active. In conclusion, it seems that although the multidisciplinary program is initially expensive compared to the less intensive programs, the savings in sick pay, early retirement pensions, and health care contacts make it economically worthwhile. Long-term follow-up will show whether this effect continues.     

Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain

Although cost-effectiveness is becoming the foremost evaluative criterion within health service management of spine surgery, scientific knowledge about cost-patterns and cost-effectiveness is limited. The aims of this study were (1) to establish an activity-based method for costing at the patient-level, (2) to investigate the correlation between costs and effects, (3) to investigate the influence of selected patient characteristics on cost-effectiveness and, (4) to investigate the incremental cost-effectiveness ratio of (a) posterior instrumentation and (b) intervertebral anterior support in lumbar spinal fusion. We hypothesized a positive correlation between costs and effects, that determinants of effects would also determine cost-effectiveness, and that posterolateral instrumentation and anterior intervertebral support are cost-effective adjuncts in posterolateral lumbar fusion. A cohort of 136 consecutive patients with chronic low back pain, who were surgically treated from January 2001 through January 2003, was followed until 2 years postoperatively. Operations took place at University Hospital of Aarhus and all patients had either (1) non-instrumented posterolateral lumbar spinal fusion, (2) instrumented posterolateral lumbar spinal fusion, or (3) instrumented posterolateral lumbar spinal fusion + anterior intervertebral support. Analysis of costs was performed at the patient-level, from an administrator's perspective, by means of Activity-Based-Costing. Clinical effects were measured by means of the Dallas Pain Questionnaire and the Low Back Pain Rating Scale at baseline and 2 years postoperatively. Regression models were used to reveal determinants for costs and effects. Costs and effects were analyzed as a net-benefit measure to reveal determinants for cost-effectiveness, and finally, adjusted analysis (for non-random allocation of patients) was performed in order to reveal the incremental cost-effectiveness ratios of (a) posterior instrumentation and (b) anterior support. The costs of non-instrumented posterolateral spinal fusion were estimated at DKK 88,285(95% CI 81,369;95,546), instrumented posterolateral spinal fusion at DKK 94,396(95% CI 89,865;99,574) and instrumented posterolateral lumbar spinal fusion + anterior intervertebral support at DKK 120,759(95% CI 111,981;133,738). The net-benefit of the regimens was significantly affected by smoking and functional disability in psychosocial life areas. Multi-level fusion and surgical technique significantly affected the net-benefit as well. Surprisingly, no correlation was found between treatment costs and treatment effects. Incremental analysis suggested that the probability of posterior instrumentation being cost-effective was limited, whereas the probability of anterior intervertebral support being cost-effective escalates as willingness-to-pay per effect unit increases. This study reveals useful and hitherto unknown information both about cost-patterns at the patient-level and determinants of cost-effectiveness. The overall conclusion of the present investigation is a recommendation to focus further on determinants of cost-effectiveness. For example, patient characteristics that are modifiable at a relatively low expense may have greater influence on cost-effectiveness than the surgical technique itself--at least from an administrator's perspective.     

Management of facet joints osteoarthritis associated with chronic low back pain: A systematic review

IntroductionFacet joint injections (FJI) and medial branch blocks (MBB) can be employed for chronic low back pain (LBP) using different drugs such as corticosteroids, hyaluronic acid, sarapin and local anaesthetics. This systematic review compares the results of injections obtained with different compounds in the management LBP originating from facet joints.MethodsThe present systematic review was conducted according to the PRISMA statement. The literature search was performed in October 2020. All the randomized clinical trials concerning injection treatments for chronic LBP. Drugs rather than steroids, hyaluronic acid, anaesthetics and sarapin were not considered, as well as those reporting outcomes from combined treatments. The Oswestry Disability Index (ODI) and the numeric rating scale (NRS) were retrieved.ResultsData from 587 patients were retrieved. The mean follow-up was 12.4 ± 10.5 months. The mean age was 51.3 ± 9.6 years old. 57% (335/587) of patients were women. Steroids promoted a reduction of NRS by 28% (P < 0.0001) and an improvement of the ODI by 13.2% (P = 0.005), and local anaesthetics produced an improvement of the ODI by 9.8% (P < 0.0001). Sarapin resulted in a reduction of NRS by 44% (P = 0.04) and an improvement the ODI by 14.9% (P = 0.004); sarapin combined with steroids promoted a reduction of NRS by 47% (P = 0.04) and an improvement of the ODI by 11.7% (P = 0.001).ConclusionInjections for chronic LBP deriving from facet joints osteoarthritis are encouraging, especially when considering MBB.Level of evidenceI, systematic review of RCTs.     

The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis

Background Context

Clinicians regard lumbar lordotic curvature (LLC) with respect to low back pain (LBP) in a contradictory fashion. The time-honored point of view is that LLC itself, or its increment, causes LBP. On the other hand, recently, the biomechanical role of LLC has been emphasized, and loss of lordosis is considered a possible cause of LBP. The relationship between LLC and LBP has immense clinical significance, because it serves as the basis of therapeutic exercises for treating and preventing LBP.

The effectiveness of walking as an intervention for low back pain: a systematic review

As current low back pain (LBP) guidelines do not specifically advocate walking as an intervention, this review has explored for the effectiveness of walking in managing acute and chronic LBP. CINAHL, Medline, AMED, EMBASE, PubMed, Cochrane and Scopus databases, as well as a hand search of reference lists of retrieved articles, were searched. The search was restricted to studies in the English language. Studies were included when walking was identified as an intervention. Four studies met inclusion criteria, and were assessed with a quality checklist. Three lower ranked studies reported a reduction in LBP from a walking intervention, while the highest ranked study observed no effect. Heterogeneity of study design made it difficult to draw comparisons between studies. There is only low–moderate evidence for walking as an effective intervention strategy for LBP. Further investigation is required to investigate the strength of effect for walking as a primary intervention in the management of acute and chronic LBP.     

A systematic review of paracetamol for non-specific low back pain

The objective of this study was to assess the efficacy of paracetamol (acetaminophen) in the treatment of pain and disability in patients with non-specific low back pain. We conducted a systematic review of randomized controlled trials to assess the efficacy of paracetamol in the treatment of pain and disability in patients with non-specific low back pain. A search for randomized controlled trials was conducted using the Medline, Embase and CINAHL databases. Trials were eligible if they were randomized controlled trials comparing paracetamol to no treatment, placebo or another treatment in patients with non-specific low back pain. Two of the authors independently assessed trials for methodological quality on the PEDro Scale and extracted data. Continuous pain and disability data were converted to a common 0–10 scale; ordinal data were dichotomized (e.g., no pain, pain). The data was analyzed using the MIX version 1.61 meta-analysis software. Out of 205 unique articles found in the searches, 7 eligible trials were identified. The trials enrolled a total of 676 participants with 5 investigating acute low back pain, 1 investigating chronic low back pain and 1 investigating both. No trial provided data comparing paracetamol to placebo and only one trial compared paracetamol to no treatment. In general the trials were small (only 1 trial had >25 subjects per group) and of low methodological quality (only 2 had a score above 6 on the quality scale). All but one of the trials provided imprecise estimates of the effects of treatment with confidence intervals spanning clinically important beneficial and also harmful effects of paracetamol. No trial reported a statistically significant difference in favor of paracetamol. There is insufficient evidence to assess the efficacy of paracetamol in patients with low back pain. There is a clear need for large, high quality randomized controlled trials evaluating paracetamol, to provide reliable evidence of paracetamol’s effectiveness in patients with low back pain and to establish the validity of the recommendations in clinical guidelines.     

The lumbar spine and low back pain in golf: a literature review of swing biomechanics and injury prevention

BACKGROUND CONTEXT: The golf swing imparts significant stress on the lumbar spine. Not surprisingly, low back pain (LBP) is one of the most common musculoskeletal complaints among golfers. PURPOSE: This article provides a review of lumbar spine forces during the golf swing and other research available on swing biomechanics and muscle activity during trunk rotation. STUDY DESIGN: The role of "modern" and "classic" swing styles in golf-associated LBP, as well as LBP causation theories, treatment, and prevention strategies, are reviewed. METHODS: A PubMed literature search was performed using various permutations of the following keywords: lumbar, spine, low, back, therapy, pain, prevention, injuries, golf, swing, trunk, rotation, and biomechanics. Articles were screened and selected for relevance to injuries in golf, swing mechanics, and biomechanics of the trunk and lumbar spine. Articles addressing treatment of LBP with discussions on trunk rotation or golf were also selected. Primary references were included from the initial selection of articles where appropriate. General web searches were performed to identify articles for background information on the sport of golf and postsurgical return to play. RESULTS: Prospective, randomized studies have shown that focus on the transversus abdominus (TA) and multifidi (MF) muscles is a necessary part of physical therapy for LBP. Some studies also suggest that the coaching of a "classic" golf swing and increasing trunk flexibility may provide additional benefit. CONCLUSIONS: There is a notable lack of studies separating the effects of swing modification from physical rehabilitation, and controlled trials are necessary to identify the true effectiveness of specific swing modifications for reducing LBP in golf. Although the establishment of a commonly used regimen to address all golf-associated LBP would be ideal, it may be more practical to apply basic principles mentioned in this article to the tailoring of a unique regimen for the patient. Guidelines for returning to golf after spine surgery are also discussed.     

椎间盘源性腰痛合并下位椎间隙塌陷2例报告

腰痛为骨科临床常见症状,其可能源于腰椎椎间盘,而椎间盘源性腰痛（DLBP）最常见节段为L₄/L₅和L₅/S₁^[1-3]。DLBP是椎间盘内各种病变（如退行性变等）刺激椎间盘内疼痛感受器引起的功能丧失的下腰痛,不伴根性症状,无神经受压或节段过度活动的影像学证据^[4]。目前DLBP的诊断、治疗仍存在诸多疑问,特别是椎间隙塌陷且MRI显示塌陷节段为“黑间盘”时容易将塌陷节段臆断为责任节段,造成误诊。海军军医大学附属长征医院收治DLBP合并下位椎间隙塌陷患者2例,联合应用椎间盘造影和椎间盘阻滞确诊后行椎间融合术,术后患者腰痛均缓解。现将诊疗过程报告如下,并对诊断存在的争议进行讨论。     

Imperfect placebos are common in low back pain trials: a systematic review of the literature

The placebo is an important tool to blind patients to treatment allocation and therefore minimise some sources of bias in clinical trials. However, placebos that are improperly designed or implemented may introduce bias into trials. The purpose of this systematic review was to evaluate the adequacy of placebo interventions used in low back pain trials. Electronic databases were searched systematically for randomised placebo-controlled trials of conservative interventions for low back pain. Trial selection and data extraction were performed by two reviewers independently. A total of 126 trials using over 25 different placebo interventions were included. The strategy most commonly used to enhance blinding was the provision of structurally equivalent placebos. Adequacy of blinding was assessed in only 13% of trials. In 20% of trials the placebo intervention was a potentially genuine treatment. Most trials that assessed patients’ expectations showed that the placebo generated lower expectations than the experimental intervention. Taken together, these results demonstrate that imperfect placebos are common in low back pain trials; a result suggesting that many trials provide potentially biased estimates of treatment efficacy. This finding has implications for the interpretation of published trials and the design of future trials. Implementation of strategies to facilitate blinding and balance expectations in randomised groups need a higher priority in low back pain research. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Outcomes differ between subgroups of patients with low back and leg pain following neural manual therapy: a prospective cohort study

The objective is to determine if pain and disability outcomes of patients treated with neural mobilisation differ for sub-classifications of low back and leg pain (LB&LP). Radiating leg pain is a poor prognostic factor for recovery in patients with LBP. To improve outcome, a new pathomechanism-based classification system was proposed: neuropathic sensitization (NS), denervation (D), peripheral nerve sensitization (PNS) and musculoskeletal (M). Seventy-seven patients with unilateral LB&LP were recruited. Following classification, all subjects were treated seven times with neural mobilisation techniques. A successful outcome was defined as achieving a minimal clinically important change in pain intensity (11-point numerical rating scale), physical function (Roland Morris disability questionnaire) and global perceived change (7-point Likert scale: from 1 = “completely recovered” to 7 = “worse than ever”). The proportion of responders was significantly greater in PNS (55.6%) than the other three groups (NS 10%; D 14.3% and M10%). After adjusting for baseline differences, mean magnitude of improvement of the outcome measures were significantly greater in PNS compared to the other groups. Patients classified as PNS have a more favourable prognosis following neural mobilisation compared to the other groups.     

Cost-effectiveness of general practice care for low back pain: a systematic review

Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.     

Spinal mechanical load: a predictor of persistent low back pain? A prospective cohort study

Prospective inception cohort. To assess the prognostic value of spinal mechanical load, assessed with the 24-hour schedule (24HS), in subjects with acute non-specific low back pain (ALBP) and to examine the influence of spinal mechanical load on the course of ALBP. In view of the characteristics of the natural course of ALBP, this should be viewed as a persistent condition in many patients rather that a benign self-limiting disease. Therefore, secondary prevention could be beneficial. Spinal mechanical load is a risk factor for ALBP and possibly a (modifiable) prognostic factor for persistent (i.e. recurrent and/or chronic) LBP. One hundred patients from primary care with ALBP were eligible for inclusion. At 6 months, 88 subjects completed the follow-up. For the follow-up assessment a research assistant, unaware of our interest in the prognostic factors, contacted the subjects by telephone. Questionnaires were completed focusing on changes in demographic data and on the course and current status of ALBP. Persistent LBP occurred in 60% subjects. After multivariate regression analysis smoking (harmful) and advanced age (protective) were associated with persistent LBP. Differences in 24HS scores at baseline and follow-up were univariate-related to persistent LBP. Spinal mechanical load, quantified with the 24HS, is not a prognostic factor for persistent LBP. Modification of spinal mechanical load in terms of 24HS scores could be beneficial for secondary prevention in patients with acute LBP.