Introduction of family rehabilitation training of low back pain

Background：Lowbackpainisacommonandfrequentdisease，oftenwithsevereischialgianeuralgia．Besidesnormalambulatorytreatmentssuchastractionoflumbarvertebra，computermiddlefre－quentandmassage，trainingoflumbodorsalmyodynamiaoffamilyauxiliarytreatmentisveryessential．Placingasupplementaryinstru－mentmadebyourselvesbelowlowback，lyingseveralhours，makinglumbarvertebralslideforwardandresumethenormalbiomechanicsrelationsoflumbarvertebrabystrentheningphysiologicallordo－sis．Improvethepathologicchangeo…     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose. To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods. A community-based longitudinal study. All inhabitants aged 22 - 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to 'localized LBP' and to 'LBP with additional sites of BP'. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results. Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported 'localized LBP' and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported 'Generalized BP' comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported 'localized LBP'. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions. Subjects with 'localized LBP' presented healthier lifestyle than subjects with 'Generalized BP'. The latter experienced higher degree of pain measures. It seems that 'Generalized BP' is not a different entity than 'localized LBP' but rather a more severe one.     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose.?To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods.?A community-based longitudinal study. All inhabitants aged 22 – 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to ‘localized LBP’ and to ‘LBP with additional sites of BP’. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results.?Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported ‘localized LBP’ and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported ‘Generalized BP’ comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported ‘localized LBP’. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions.?Subjects with ‘localized LBP’ presented healthier lifestyle than subjects with ‘Generalized BP’. The latter experienced higher degree of pain measures. It seems that ‘Generalized BP’ is not a different entity than ‘localized LBP’ but rather a more severe one.     

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.     

Validation of a French version of Roland–Morris questionnaire in chronic low back pain patients

ObjectiveTo validate a French version of the Roland–Morris Disability Questionnaire (RMDQ) in patients with chronic low back pain (LBP).Material and methodsFifty-eight patients due to participate in a functional rehabilitation programme for chronic low back pain were included prospectively. The RMDQ, the Quebec Back Pain Disability Scale (QBPDS) and the “daily activities” subscale of the Dallas Pain Questionnaire (DPQ) were administered. The RMDQ was assessed for internal consistency, reliability, criterion validity and sensitivity to change.ResultsCronbach's alpha for the RMDQ was 0.84. The intraclass correlation coefficient [95% confidence interval] was 0.89 [0.83–0.93]. The RMDQ score was correlated with the QBPDS score (r = 0.713) and the DPQ's “daily activities” subscore (r = 0.514). The results of assessments before and after functional rehabilitation showed that the French version of the RMDQ had very high sensitivity to change (effect size: 1.49) and was more sensitive than the QBPDS and the DPQ's “daily activities” subscore.ConclusionsOur study validated the French version of the RMDQ in patients suffering from chronic low back pain. Furthermore, we highlighted the questionnaire's very high sensitivity to change.     

Does physiotherapy management of low back pain change as a result of an evidence-based educational programme?

RATIONALE: The concept of evidence-based medicine is important in providing efficient health care. The process uses research findings as the basis for clinical decision making. Evidence-based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide. Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence. The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed. AIMS: The aim of this study was to investigate if physiotherapists' clinical management of patients with low back pain would change following an evidence-based education package, which utilized local opinion leaders and delivered the best evidence. METHOD: Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work, to two groups. The intervention group received an evidence-based programme on the management of low back pain, including advice regarding increasing activity levels and return to normal activity and challenging patients' fears and beliefs about their pain. The control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' clinical management of patients with low back pain was measured prior to training and 6 months post training. Outcome measures were based on physiotherapists completing 'discharge summary' questionnaires, which included information relating to the use and importance of therapies for treating their low back pain patients. RESULTS: There were few significant differences in treatment options between the intervention and control groups post training. Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain, there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention. CONCLUSIONS: Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain. This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice. Whilst there were some limitations in the overall size of the study, the results help to give an insight into the challenges faced by the health care system and researchers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care.     

The experience of patients with fear-avoidance belief hospitalised for low back pain – a qualitative study

Purpose: Severe pain, anxiety, depression, and fear-avoidance belief (FAB) are widespread among patients hospitalised for acute low back pain (LBP). Research shows that these psychological factors impact negatively on rehabilitation. This study aimed to investigate and develop an understanding of pain in patients with fear avoidance belief hospitalised for LBP. Method: Semi-structured interviews were conducted with nine patients selected by an FAB questionnaire: averaged FAB – physical activity score was 21 and FAB – work score was 30. All participants were recruited from a rheumatology ward. Analyses were based on the content analysis. Results: The analysis revealed two main categories: (1) back history until the pain became dominant, demonstrating the importance of the LBP histories before admission to hospital. (2) Being in a universe of pain verified, the severe pain expressed through metaphors and a need to be involved in the rehabilitation. During interviews, the participants did not indicate high FAB behaviour. Conclusions: Despite high scores, the FAB questionnaire might not be sufficient to detect FAB in patients hospitalised for acute LBP. It is important to include the deeper meaning of metaphors and the personal story behind the expression of pain as a way of understanding each individual with LBP.

• Implications for Rehabilitation

• FAB questionnaire is not sufficient either to detect fear avoidance in LBP patients hospitalised with acute conditions or to catch the complexities of individual pain experiences.

• It seems essential for health care professionals (HCP) to involve the patient in their treatment and development of a rehabilitation plan based on their individual histories and concerns about the future.

• The metaphors expressed are a way for HCPs to gain insight into the psychological aspect of pain for the individual patient.

     

The effectiveness of a functional training programme for patients with chronic low back pain – a pilot study

Introduction.?To investigate the effect of an individualised functional training programme for patients with low back pain (LBP).

Methods.?A randomised, controlled trial with single-blind design was conducted. Patients with non-specific LBP for at least 3 months were recruited and randomised into training and control groups. Both groups maintained their current treatment, and the training group participated in an additional programme for 100 h. Measures were performed initially and after completing the programme, and included rating determining impairment associated with pain, Oswestry disability index (ODI) and functional capacity evaluation (FCE).

Results.?Thirteen in the training group completed the training and measurements, and 12 in the control group completed their measurements. Twelve items in FCE had significant improvement in training group, but only one in control group. Severity of pain (11.8 ± 3.6–5.6 ± 3.6), activity limitation from pain (3.2 ± 1.5–1.5 ± 1.1) and emotional disturbance by pain (4.3 ± 1.7–2.2 ± 1.4) significantly decreased in the training group, no significant change in the control group. The ODI demonstrated a significant reduction (p = 0.044) in the training group (22 ± 9–16 ± 9), but not in the control group.

Conclusion.?An individualised functional training programme benefits chronic LBP patients.     

Case report: a case review of Lambert�CEaton myasthenic syndrome and low back pain

The following is a case report which reviews the essential aspects of Lambert–Eaton myasthenic syndrome (LEMS) in a patient with long standing back pain and gait dysfunction. The patient was referred to our electrodiagnostics laboratory for a 9-month history of low back pain and difficulty walking following a charity breast cancer walk. A workup including magnetic resonance imaging of the brain, entire spine, and EMG/NCS at another institution were reportedly normal. A detailed history revealed symptoms of proximal weakness and autonomic dysfunction. Physical findings were consistent with proximal weakness, a bilateral gluteus medius gait, and diffusely absent reflexes obtainable in the biceps after 3 s of contraction. Electrical testing revealed an initial low compound muscle action potential amplitude in the deep peroneal nerve recording from the extensor digitorum brevis. Repetitive stimulation at 2 Hz revealed a decremental response of 42% from the 1st response to the 4th response. Following 3 s of exercise, the amplitude increased by 300%. After 30 s of exercise followed by 1 min of rest, there was a return of the decremental response. The history, physical examination, and electrical findings were illustrative of a presynaptic neuromuscular junction disorder, specifically LEMS.     

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.     

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.     

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.     

Nature or nurture in low back pain? Results of a systematic review of studies based on twin samples

Twin studies are becoming popular to investigate risk factors for low back pain (LBP) because they consider the genetic factor and allow for more precise estimates of risks. We aimed to identify and summarize the results of studies based on twin samples investigating risk factors for LBP. The MEDLINE, CINAHL, LILACS, Web of Science and EMBASE databases were searched. Prospective and cross‐sectional observational studies of LBP involving twins were included. The exposure factors could be genetics (heritability) or environmental such as smoking, alcohol consumption, body mass index and medical history. Pooling was attempted using an inverse variance weighting and fixed effects model. Twenty‐seven studies were included. Estimates of heritability effects ranged from 21% to 67%. The genetic component was higher for more chronic and disabling LBP than acute and less disabling LBP. Smoking was significantly associated with LBP [pooled odds ratio (OR) = 3.0; 95% confidence interval (CI) 2.8–3.3] with a longitudinal and a cross‐sectional study also identifying a dose–response relationship in people with chronic LBP. Obesity was associated with LBP (pooled OR = 1.9; 95% CI 1.6–2.2) with a cross‐sectional study identifying a dose–response relationship. No association between alcohol consumption and LBP was identified. Co‐morbidities such as asthma, diabetes and osteoarthritis were associated with LBP (pooled OR ranging from 1.6 to 4.2). The contribution of genetics to LBP appears to be dependent on the severity of the condition. Twin studies could be better used to explore possible causation paths between lifestyle factors, co‐morbidities and LBP.     

Congenital ‘butterfly vertebra’ associated with low back pain: a case report

The butterfly vertebral defect is a rare congenital anomaly of the spine, which is generally considered benign. In this report we present the case of an active young man who presented with recurrent low back pain (LBP), and was found to have a butterfly vertebral defect at the symptomatic L4 lumbar spinal level. We describe the genesis of the butterfly vertebral defect, in the context of normal embryological development of the human vertebra and intervertebral disk. We report the clinical examination findings and therapeutic interventions undertaken prior to the radiographic discovery of the vertebral defect, and discuss the impact that the presence of a butterfly vertebral defect presented to therapeutic decision-making.     

Complementary and alternative medicine treatments for low back pain

Complementary and alternative medicine, often referred to as integrated medicine, is often used for the treatment of low back pain. This article presents 6 therapies (ie, behavioral treatment, acupuncture, manipulation, prolotherapy, neuroreflexotherapy, and herbal treatments), which are discussed in terms of the specifics of the modality, as well as the empirical evidence related to their effectiveness.     

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.