BACK PAIN AND SCIATICA: CONTROLLED TRIALS OF MANIPULATION, TRACTION, SCLEROSANT AND EPIDURAL INJECTIONS

Four treatment regimens for patients with specified combinationsof low back pain and sciatica were evaluated. The largest groupstudied had low back pain with limited straight-leg raising(SLR) and in them the beneficial effect of manipulation in hasteningpain relief was highly significant. In similar patients withoutlimitation of SLR, the effect was of borderline significance.In all the other groups, treated patients also recovered morequickly than their controls. Traction, for patients with lowback pain and sciatica, and epidural injections when a rootpalsy was present also produced some significant pain relief.The effect of sclerosants for back pain was less clear. KEY WORDS: Spine, Treatment, Pain-relief, Outcome     

LUMBAR TRACTION: A DOUBLE-BLIND CONTROLLED STUDY FOR SCIATICA

A double-blind control study of lumbar traction for sciaticahas been carried out. Although there is a tendency for tractionto produce improvement in pain and straight-leg raise the extentdoes not achieve statistical significance. Changing ’control‘patients to ’treatment‘ seemed to produce worthwhilerelief of pain for all who were not already improving. It issuggested that a large trial using more discriminating criteriamight delineate a group of patients susceptible to help by traction. ^* Paper read at the Annual Meeting of the British Associationfor Rheumatology and Rehabilitation, London, April 1975.     

A COMPARISON OF THE TYPES OF EPIDURAL INJECTION COMMONLY USED IN THE TREATMENT OF LOW BACK PAIN AND SCIATICA

Patients with low back pain and sciatica were treated by epiduralinjection of normal saline or 0.5% lignocaine, with or withouttriamcinolone hexacetonide (Lederspan), given at weekly intervalsin random order. Subjective and objective criteria of progresswere measured. Greatest improvement was noted after the injectioncontaining steroid. Lignocaine (0.5%) and normal saline usedindividually produced less marked improvement. No specific benefitsof local anaesthesia were found other than comfort during injection.The results suggest that the action of a successful epiduralinjection is primarily anti-inflammatory and to a lesser extenthydro-dynamic. ^*Present address: Hope Hospital (University of Manchester Schoolof Medicine), Salford, Lancs. M6 8HD.     

LUMBAR EPIDURAL INJECTIONS IN THE TREATMENT OF SCIATICA

A randomized trial of lumbar epidural injections for the treatmentof acute sciatic pain was carried out. All the patients hadunilateral sciatica for less than six months and had never previouslybeen treated in hospital for their backs. The treatments usedwere 20 ml normal saline, 80 mg Depomedrone in normal salinemade up to 20 ml, 20 ml 0.25% bupivacaine solution and needlingwith a standard Touhy injection needle into the interspinousligament but with no injection. The patients improved at aboutthe same rate for all four treatments. Overall, 75% of the patientsimproved or were cured. As some of these were in the group treatedby needling of the interspinous ligament, it seems likely thatthe epidural injections administered achieved effects partiallyas a placebo and partially by virtue of the natural historyof the acute sciatic syndrome. KEY WORDS: Sciatica, Lumbar epidural injections     

CHIROPRACTORS AND THE TREATMENT OF BACK PAIN

In a survey of British chiropractors and their practices, itwas found that the majority of their patients attended for backpain. The average age of patients was 47 years, the sex ratiowas equal, and most had had their complaints for longer thanthree months and had access to the chiropractor within a fewdays. They were largely housewives and persons from the executiveand managerial occupations. The main investigative proceduresused were static and motion palpation of the spine, and vitalsystems, orthopaedic, neurological, and radiological examination.Treatment was mostly manual and directed at the spinal column,and the benefit obtained, as assessed by the chiropractors,was comparable to that reported in other studies. Maximum benefitwas usually recorded within seven attendances, although 39 %of patients made further visits for maintenance treatment. The chiropractors are seen to be a young, growing, and largelymale group, and their new patient numbers are at present likelyto be at least one-twentieth that of hospital out-patient departmentswhich deal with back pain.     

A CONTROLLED TRIAL OF FRUCTOSE IN THE TREATMENT OF ACUTE ALCOHOLIC INTOXICATION

In a controlled study of patients with acute alcoholic intoxication, the intravenous infusion of fructose caused a small but statistically significant increase in the rate of fall of blood-ethanol levels. It is concluded that fructose may be beneficial in shortening the effects of alcoholic intoxication.     

THE VALUE OF EXERCISES IN THE TREATMENT OF LOW BACK PAIN

The results of treatment with short-wave diathermy were comparedwith those achieved by short-wave diathermy combined with backextension or lumbar isometric flexion exercises in 43 patientswith back pain. Subjects were relatively young and normallyengaged in sporting activities. Marginally more patients improvedamongst those receiving extension exercises. Significant reductionof pain and increase of spinal flexion occurred with each treatmentand the periods taken to resume work or sport were similar ineach group. Neither exercise regime appeared to have a majorinfluence on recovery. Isometric flexion exercises did not seemto be more beneficial for those with a prominent lumbar lordosis. Paper read at the Annual Meeting of the British Associationfor Rheumatology and Rehabilitation, London, April 1979     

AZAPROPAZONE IN THE TREATMENT OF ANKYLOSING SPONDYLITIS: A CONTROLLED CLINICAL TRIAL

In a controlled clinical trial the effect of azapropazone (900mg. daily) was compared with placebo in 18 out-patients withankylosing spondylitis. The trial was of "crossover" design,and results suggest that azapropazone may be of value in thesymptomatic management of ankylosing spondylitis. The side-effectsof the drug were mild and occurred with similar frequency duringboth drug and placebo periods. ^*Paper read at a combined meeting of the British Associationfor Rheumatology and Rehabilitation with the Royal Society ofMedicine, Section of Rheumatology and Rehabilitation, Cardiff,September 1973.     

PSYCHOLOGICAL FACTORS IN THE TREATMENT OF BACK PAIN BY SPINAL MANIPULATION

Ninety patients with low back pain completed a short form ofthe Minnesota Multiphasic Personality Inventory (MMPI) and,subsequently, received spinal manipulative therapy. Most (84%)of the patients reported immediate relief following manipulationbut the extent of that relief was not correlated with any psychologicalmeasure. However, several days after treatment, the percentageof patients reporting improvement was much lower (55%) and lackof improvement was associated with elevated scores on hypochondriasis(Hs), hysteria (Hy), and functional low back pain (Lb). Unimprovedpatients also tended to report longer durations of back painprior to treatment. Multiple regression analyses indicated thatpain duration and the psychological factors were independentpredictors of the response to treatment. It is suggested that,although a single manipulative treatment will often relievethe immediate cause of back pain, underlying psychosomatic factorsmay predispose the condition to recur. KEY WORDS: Low back pain, Spinal manipulation, Psychological factors     

OUTPATIENT LUMBAR EPIDURAL CORTICOSTEROID INJECTION IN THE MANAGEMENT OF SCIATICA

The value of epidural injections of corticosteroid as an outpatienttreatment of sciatica has been hitherto uncertain. An epiduralinjection of 80 mg methylprednisolone in 10 ml physiologicalsaline was compared with an interspinous injection of 2 ml physiologicalsaline in a double blind fashion amongst 39 outpatients. Significantdifferences of pain relief were seen between the two groupswithin 2 weeks. This benefit disappeared for six (35%) patientswithin 6 months of treatment although 11 (65%) successfullytreated subjects had sustained improvement up to this time.Outpatient epidural injections of corticosteroid are thus auseful short-term means of relieving pain in sciatica but probablyhave little effect on the long-term natural history of symptoms.Factors associated with a failure to respond to epidural steroidinjections are discussed. KEY WORDS: Nerve root, Disc prolapse, Methylprednisolone, Pain relief ^* Present address: Department of Rheumatology, St Thomas' Hospital,London, SE1.     

西沙必利治疗功能性消化不良的多中心临床疗效观察

本项多中心临床试验旨在对西沙必利（ｃｉｓａｐｒｉｄｅ）治疗功能性消化不良的疗效和安全性进行评估。其中治疗组４１４例，对照组１６９例。西沙必利的服药方法为每次５ｍｇ，每日３次，共服４周。结果显示西沙必利能使早饱、腹胀、上腹痛、恶心等多种消化道症状有明显改善，总有效率为９２．９９％，明显优于对照组的４１．４２％，且两组病人间差异有显著性。西沙必利的副作用主要为腹痛、腹泻，多数病人对其可以耐受。以上研究结果表明西沙必利为一种安全、有效的促动力药物。     

A COMPARISON BETWEEN EPIDURAL ANAESTHESIA WITH AND WITHOUT CORTICOSTEROID IN THE TREATMENT OF SCIATICA

Comparison of the results of treatment with epidural injectionof procaine alone with that of procaine plus Depo-Medrone inpatients with unilateral sciatica showed no definite differencebetween the two groups. Of 48 patients, there was improvementin about 70%, whichever solution was used. However, it is ofinterest that in patients with a long history of severe sciaticathe injection of procaine plus Depo-Medrone appeared to givebetter results. This finding should be noted, and a furthercomparative trial in this group is worth undertaking. ^*Paper read at the Annual Meeting of the British Associationof Physical Medicine and Rheumatology, London, April 16, 1970.     

PAIN IN THE BACK AND LEG: A GENERAL PRACTICE SURVEY

Over a two-year period, the data on all patients in a generalpractice with back and leg pain were recorded in a standardizedway. Two broad categories were distinguished, those with low-backpain syndromes and those with back and leg pain syndromes. Withinthe former, four patterns of pain distribution could be identified,and the latter were sub-divided according to severity, history,and neurological involvement. History, clinical features, andoutcome correlated with these various types. The majority ofthese patients may be managed conservatively at home, only asmall proportion requiring referral for specialist advice ortreatment. It is suggested that the intervertebral disc canaccount for only a small proportion of these problems. ^* Based on a paper presented to a scientific meeting of theSociety for Back Pain Research at Bristol on 26th March 1976.     

舒巴坦－头孢哌酮与头孢噻肟随机对照治疗细菌性感染207例多中心临床试验

本项临床试验旨在评价舒巴坦与头孢哌酮联合制剂（ｓｕｌｐｅｒａｚｏｎｅ，舒普深）的安全性与有效性。试验方法为区组随机化开放式平行对照多中心试验设计，并选用头孢噻肟作为对照药。本次试验共治疗细菌性感染２０７例，其中联合制剂组与头孢噻肟组分别为１０３与１０４例。两组痊愈率分别为７３．７９％和６６．３５％；有效率分别为９５．１５％和９０．３８％；细菌清除率分别为８４．７１％和８０．６４％。不良反应发生率分别为７．７７％和８．６５％，差异均无显著性；但临床分离到的致病菌对联合制剂敏感率为９０．９０％，显著高于对头孢噻肟的敏感率（６９．３２％）。表明该联合制剂治疗细菌性感染安全有效，可提供临床广泛应用。     

A CLINICAL AND RADIOLOGICAL STUDY OF BACK PAIN IN RHEUMATOID ARTHRITIS

Five hundred and three patients with RA were questioned aboutthe symptom of back pain. Chronic back pain, lasting more than3 months, occurred in 33 per cent of the group. A group of 100back pain patients were studied in more detail using a structuredquestionnaire, clinical examination and radiology. Ninety-fourof these patients had low back pain. Particular clinical patterns(such as that of the facet syndrome) were sought but no clearcharacteristics were found. Fifty-two lumbar spine X-rays wereavailable from the RA population and these were compared to52 age and sex matched X-rays from outpatients with chronicmechanical low back pain. Significant differences between thesegroups radiologically were a higher frequency of osteoporosisand a higher frequency of disc narrowing without associatedosteophytes in the RA population. This study differs from previousreports which found other characteristic radiological featuresof RA of the lumbar spine (spondylolisthesis, facet erosions,and vertebral fracture), a discrepancy possibly resulting fromthe use of a control group having low back pain. KEY WORDS: Low back pain, Rheumatoid arthritis, Osteoporosis, Facet syndrome     

OBJECTIVE FUNCTIONAL ASSESSMENT OF THE EFFICACY OF TENOXICAM IN THE TREATMENT OF ACUTE LOW BACK PAIN. A DOUBLE-BLIND PLACEBO-CONTROLLED STUDY

The efficacy of an NSAID (tenoxicam) in the treatment of acutelow back pain (LBP) was assessed in a double blind controlledstudy by using an objective functional evaluation. Seventy-threepatients consulting for acute LBP were randomized into two groups:Group I was treated with tenoxicam for 14 days and Group IIwas given a placebo. Trunk function was measured with a computerized isoinertialdynamometric trunk testing device (Isostation B200). Isometricand dynamic torques, range of motion and movement velocitieswere measured before treatment and after 14 days. Clinical evaluationwas realized by the patient on a pain visual analogue scale(VAS) on days 1,8 and 15 and by the investigator on a five-pointscale on days 8 and 15. The functional evaluation showed significantdifferences in favour of the tenoxicam treatment for velocityand extension isometric torque. VAS and investigator evaluationsshowed a significant difference in favour of tenoxicam on day8 but no difference on day 15. This study shows that the useof tenoxicam in acute LBP is of interest. Tenoxicam has an effecton pain during the first part of the treatment and may helpto restore full function even if the symptoms have disappeared. KEY WORDS: Trunk function, Trunk strength, Isoinertial assessment, Isostation B200     

甲氨蝶呤治疗类风湿关节炎临床疗效评价—随机对照临床试验

目的：应用随机对照临床试验（ｒａｎｄｏｍｚｉｅｄｃｏｎｔｒｏｌｌｅｄｔｒｉａｌ，ＲＣＴ）方法比较在非甾类抗炎镇痛药基础上用和不用甲氨蝶呤（ＭＴＸ）对成年人活动性类风病人临床疗效的影响，方法：１３２例病人采用区组随机化方法以２：１比例分为ＭＴＸ和对照组，后者服用与ＭＴＸ外形，颜色，味道要贞的安慰剂，两组病人每周服用３粒～６粒研究药物，共１２周，结果：ＭＴＸ组有效率８８％，对照组６５％，两者有显著差别     

A RANDOMIZED DOUBLE-BLIND CONTROLLED TRIAL OF SULPHASALAZINE COMBINED WITH PULSES OF METHYLPREDNISOLONE OR PLACEBO IN THE TREATMENT OF RHEUMATOID ARTHRITIS

Thirty-eight patients with rheumatoid arthritis meeting AmericanCollege of Rheumatism (ACR) criteria were entered in a randomizedcontrolled trial (RCT) of 6 months to assess whether monthlytreatment with i.v. methylprednisolone (MP) enhances or acceleratesthe efficacy of sulphasalazine (SSZ). All patients had failedat least one second-line agent and were randomized to receiveSSZ (2 g/day) and pulses of MP (5 mg/kg), or SSZ (2 g/day) andpulses of saline (SA). A single infusion of 2 h was carriedout in both groups for a total of three times (0, 1 and 2 months).The two groups were comparable at baseline regarding their demographicand clinical characteristics. Disease activity was evaluatedevery 2 months by means of: (1) joint count; (2) morning stiffness;(3) grip strength; (4) visual analogue pain score; (5) healthassessment questionnaire; and (6) erythrocyte sedimentationrate. All outcome measures improved significantly in both groups(P < 0.001). Evaluation at each follow-up visit showed nosignificant differences between the groups in any of the adverseeffects attributable to SSZ therapy (one SA vs two MP). Adverseeffects attributable to SA/MP therapy were rare and mild. Weconcluded that repeated pulses of MP during the first 3 monthsof treatment did not improve the efficacy of SSZ. Therefore,there is no justification for using MP in this way during theinduction phase of SSZ therapy. KEY WORDS: Sulphasalazine, Methylprednisolone, Combination therapy, Rheumatoid arthritis