退变性慢性腰痛的诊治

慢性腰痛 (chronic low back pain,CLBP)系指疼痛持续半年以上 ,迁延不愈 ,且经正规保守治疗无效 ,而不能手术或手术无效者。是临床诊疗中最难处理的一组腰背痛 ,由于患者久病 ,对治疗失去耐心 ,且多数对止痛药物有依赖性 ,过去说的“病人腰痛 ,医生头痛”,大概就是指的这一类。慢性腰痛所致的伤残仅次于心力衰竭与肿瘤 ,居第 3位[1] 。如何治疗慢性腰痛是对从事经腰痛防治者的挑战 ,慢性腰痛的疾病包括两大类 ,退变性疾病 ,及手术后失败综合征。本文只讨论退变性慢性腰痛。1　退变性慢性腰痛的病理基础退变性慢性腰痛的病理基础主要是椎…     

Outcome research in patients with chronic low back pain

Outcome research in chronic low-back pain is entering a new phase. In the past several years, several outcome measures have been evaluated for their psychometric properties, and databases for patients with low-back pain exist for some of them. A set of recommended and standardized outcome measures and questionnaires is now available for the different outcome domains. The use of computerized versions of these questionnaires will allow simplified data collection and analyses, which will not only help to formulate a more uniform design of research trials, but can be useful for clinicians interested in documenting multi-dimensional outcomes in their patient population.     

Treatment strategy for chronic low back pain

The management of non-specific low back pain relies chiefly on analgesics, education, and physical exercises. Of the many risk factors for chronicity, the most relevant are psychosocial and occupational. Identifying homogeneous patient subgroups helps to develop personalized treatment strategies, thus improving the outcomes. Current clinical research is focusing on subgroup identification via simple validated questionnaires that are suitable for use in everyday practice. We suggest a management approach leading from the individual patient profile to the treatment strategy.     

Effective physical treatment for chronic low back pain

It is now feasible to adopt an evidence-based approach when providing physical treatment for patients with chronic LBP. A summary of the efficacy of a range of physical treatments is provided in Table 1. The evidence-based primary care options are exercise, laser, massage, and spinal manipulation; however, the latter three have small or transient effects that limit their value as therapies for chronic LBP. In contrast, exercise produces large reductions in pain and disability, a feature that suggests that exercise should play a major role in the management of chronic LBP. Physical treatments, such as acupuncture, backschool, hydrotherapy, lumbar supports, magnets, TENS, traction, ultrasound, Pilates therapy, Feldenkrais therapy, Alexander technique, and craniosacral therapy are either of unknown value or ineffective and so should not be considered. Outside of primary care, multidisciplinary treatment or functional restoration is effective; however, the high cost probably means that these programs should be reserved for patients who do not respond to cheaper treatment options for chronic LBP. Although there are now effective treatment options for chronic LBP, it needs to be acknowledged that the problem of chronic LBP is far from solved. Though treatments can provide marked improvements in the patient's condition, the available evidence suggests that the typical chronic LBP patient is left with some residual pain and disability. Developing new, more powerful treatments and refining the current group of known effective treatments is the challenge for the future.     

The role of fusion for chronic low back pain

The demonstration of a rich nerve supply in the outer half of the disc and the occurrence of deep pain referred from the vertebral column to the leg without nerve root compression are both important aspects in understanding low back pain and in making a decision regarding its surgical management. Discography is invaluable as a diagnostic test in patients with chronic back pain if one is to demonstrate discogenic lesions. For sufferers of postlaminectomy syndrome, a difficult patient group, a simultaneous combined anterior and posterior fusion offers a real hope for relief of pain and rehabilitation.     

Methods of assessing progress in a chronic low back pain patient: a case report

It is important for the chiropractor to be able to assess and monitor the progress of patients with chronic pain syndromes This case demonstrates the use of verbal pain-scaling, the Revised Oswestry Disability Questionnaire (RODQ), orthopædic straight leg raise test and active range of lumbar motion as outcome measure and illustrates their relative advantages and shortcomings. The case describes the management of a Caucasian 51-year-old male with a long history of back pain and sciatica. His condition had been resistant to all forms of treatment to date. His activities of daily living and his quality of life had been significantly affected. He was assessed on initial presentation and again after one month of treatment and the results compared. The relative value and emphasis of different outcome measures is discussed along with their practical application in a clinical setting.     

Dose-response for chiropractic care of chronic low back pain.

BACKGROUND CONTEXT: There have been no trials of optimal chiropractic care in terms of number of office visits for spinal manipulation and other therapeutic modalities. PURPOSE: To conduct a pilot study to make preliminary identification of the effects of number of chiropractic treatment visits for manipulation with and without physical modalities (PM) on chronic low back pain and disability. STUDY DESIGN/SETTING: Randomized controlled trial with a balanced 4x2 factorial design. Conducted in the faculty practice of a chiropractic college outpatient clinic. PATIENT SAMPLE: Seventy-two patients with chronic, nonspecific low back pain of mechanical origin. MAIN OUTCOME MEASURES: Von Korff pain and disability (100-point) scales. METHODS: Patients were randomly allocated to visits (1, 2, 3 or 4 visits/week for 3 weeks) and to treatment regimen (spinal manipulation only or spinal manipulation with PM). All patients received high-velocity low-amplitude spinal manipulation. Half received one or two of the following PM at each visit: soft tissue therapy, hot packs, electrotherapy or ultrasound. RESULTS: Pain intensity: At 4 weeks, there was a substantial linear effect of visits favoring a larger number of visits: 5.7 points per 3 visits (SE=2.3, p=.014). There was no effect of treatment regimen. At 12 weeks, the data suggested the potential for a similar effect of visits on patients receiving both manipulation and PM. Functional disability: At 4 weeks, a visits effect was noted (p=.018); the slope for group means was approximately 5 points per 3 visits. There were no group differences at 12 weeks. CONCLUSIONS: There was a positive, clinically important effect of the number of chiropractic treatments for chronic low back pain on pain intensity and disability at 4 weeks. Relief was substantial for patients receiving care 3 to 4 times per week for 3 weeks.     

应高度重视对椎间盘源性腰痛的研究

慢性腰痛是一个严重的医学和社会问题,是引起劳动力丧失的常见原因之一。据估计,80%人口在一生中的某个时刻会患腰痛,任一时刻有18%的人群正患腰痛。     

Injection therapy for subacute and chronic benign low back pain

STUDY DESIGN: The Medline and Embase databases containing randomized controlled trials of injection therapy published to 1998 were systematically reviewed. OBJECTIVES: To evaluate the effectiveness of injection therapy with anesthetics, steroids, or both in patients with low back pain persisting longer than 1 month. METHODS: Two reviewers independently assessed the trials for the quality of their methods. The primary outcome measure was pain relief. Subgroup analyses were performed between trials with different control groups (placebo and active injections), with different injection sites (facet-joint, epidural, and local injections), and with timing of outcome measurement (short- and long-term). Within the resulting 12 (2 x 3 x 2) subcategories of studies, the overall relative risks and corresponding 95% confidence intervals were estimated, using the random effects model of DerSimonian and Laird. In the case of trials using active injections as a control, the results were not pooled. RESULTS: This review included 21 randomized trials. All the studies involved patients with low back pain persisting longer than 1 month. Only 11 studies compared injection therapy with placebo injections (explanatory trials). The methodologic quality of many studies was low: Only eight studies had a methodologic score of 50 points or more. There were only three well-designed explanatory clinical trials: one on injections into the facet joints with a short-term relative risk of 0.89 (95% confidence interval = 0.65-1.21) and a long-term relative risk of 0.90 (95% confidence interval = 0.69-1.17), one on epidural injections with a short-term relative risk of of 0.94 (95% confidence interval = 0.76-1.15) and a long-term relative risk of 1.00 (95% confidence interval = 0.71-1.41), and one on local injections with a long-term relative risk of 0.79 (95% confidence interval = 0.65-0.96). Within the six subcategories of explanatory studies, the pooled relative risks were as follows: facet joint, short-term: relative risk = 0.89 (95% confidence interval = 0.65-1.21); facet joint, long-term: relative risk = 0.90 (95% confidence interval = 0.69-1.17); epidural, short-term: relative risk = 0.93 (95% confidence interval = 0.79-1.09); epidural, long-term: relative risk = 0.92 (95% confidence interval = 0.76-1.11); local, short-term: relative risk = 0.80 (95% confidence interval = 0.40-1.59); and local, long-term: relative risk = 0.79 (95% confidence interval = 0.65-0.96). CONCLUSIONS: Convincing evidence is lacking regarding the effects of injection therapy on low back pain. Additional well-designed explanatory trials in this field are needed.     

慢性腰痛对脊旁多裂肌萎缩影响的临床研究

目的：明确慢性腰痛对脊旁多裂肌净横截面积大小及脂肪化程度的影响。方法：2010年3月至2013年8月对门诊治疗的腰痛患者进行回顾性分析,最终筛选出31例符合非特异性慢性腰痛患者,其中男19例,女12例;年龄23～55岁,平均36.4岁。主要症状是反复腰痛,病程大于1年,X线、CT、MRI均未见明显异常。采用MRI成像测量同一病例先后不同时间点多裂肌净横截面积及T2信号比率的变化,再获取2次MRI检查时VAS和Oswestry功能障碍评分,分析先后2次测量多裂肌净面积及T2信号比率的变化与腰痛的病程、VAS、Oswestry功能障碍评分的相关性,从而得出腰痛对脊旁多裂肌的影响。结果：同一病例第2次MRI检查多裂肌净横截面积明显小于第1次MRI检查,T2信号比率则明显高于第1次MRI检查（P<0.05）.多裂肌净横截面积减小率与VAS评分、病程和Oswestry功能障碍评分均呈正相关（P<0.001）,而T2信号比率增加率与VAS评分、病程和Oswestry功能障碍评分均无相关性（P>0.05）.结论：慢性腰痛是脊旁多裂肌萎缩和脂肪化的重要原因,腰痛时间、程度和功能障碍程度均与多裂肌萎缩呈正相关。     

Exercise as a treatment for chronic low back pain.

BACKGROUND CONTEXT: Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work. PURPOSE: The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain. STUDY DESIGN/SETTING: A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article. RESULTS: For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research. CONCLUSIONS: Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.     

Real-time force feedback during flexion-distraction procedure for low back pain: A pilot study

A form of chiropractic procedure known as Cox flexion-distraction is used by chiropractors to treat low back pain. Patient lies face down on a specially designed table having a stationery thoracic support and a moveable caudal support for the legs. The Doctor of Chiropractic (DC) holds a manual contact applying forces over the posterior lumbar spine and press down on the moving leg support to create traction effects in the lumbar spine. This paper reports on the development of real-time feedback on the applied forces during the application of the flexion-distraction procedure. In this pilot study we measured the forces applied by experienced DCs as well as novice DCs in using this procedure. After a brief training with real-time feedback novice DCs have improved on the magnitude of the applied forces. This real-time feedback technology is promising to do systematic studies in training DCs during the application of this procedure.