Comparing physical and behavior therapy for chronic low back pain on physical abilities,psychological distress,and patients' perceptions

A treatment-outcome study was conducted to study the impact of behavior and physical therapy on components of the chronic low back pain syndrome. Eighteen patients received behavior therapy and 15 patients received physical therapy. All patients had at least a 6-month history of seeking treatment for chronic low back pain. Prior to treatment patients were assessed in four principal areas of functioning: (1) physical abilities; (2) current physical functioning; (3) psychological and psychosocial functioning; and (4) pain intensity and pain perception. Treatments were conducted in a group (five to eight patients) outpatient setting. Both behavior therapy and physical therapy groups met for 10-weekly sessions, each lasting 2 hr. Behavior therapy was designed to address the environmental, social, and emotional components of the low back pain syndrome as well as the depression and decreased activity that result from chronic low back pain. Physical therapy was based upon traditional rehabilitation theory and was designed to improve low back function. Patients were reevaluated at posttreatment, 6 months, and 1 year. The results showed a general improvement for patients in both groups and a few treatment-specific differences in outcome measures.This research was supported by the Veterans Administration Medical Research Program. Portions of this paper were read at the Annual Meeting of the American Pain Society, New York, September 1980.     

The relative efficacy of two exercise methods for older adults with chronic low back pain: A preliminary randomized control study

The objective of the current study was to examine the relative efficacy of two exercise techniques—a multidimensional treatment (MDT) and a traditional senior exercise therapy treatment (TET)—in older adults diagnosed with chronic low back pain (CLBP). Participants (N = 16) were randomly assigned to either the MDT (n = 8) or TET (n = 8) groups after meeting the requirements for the presence of CLBP. Participants in the MDT group received an individualized exercise program, while participants in the TET participated in a group exercise program. A Mann–Whitney test was conducted to determine differences between psychosocial and physical variables pre- and post-intervention. Statistical analyses indicated no significant differences in physical or psychosocial variables at pre-intervention assessment. However, participants in the MDT group reported a decrease in fatigue and pain interference, with an increase in physical functioning, when compared to the TET group. Additionally, the MDT group displayed a significant decrease pain interference, while the TET group had an increase grip strength. Patients who received the MDT reported less fatigue and pain interference, and an increase in their overall physical functioning. Overall, the MDT was a more efficacious method to manage CLBP.     

The occurrence of maladaptive health-related behaviors and teacher-rated conduct problems in children of chronic low back pain patients

Chronic low back pain (CLBP) is often associated with a complex of behaviors in the patient which cause interference in adaptive functioning of both the patient and the patient's family. This study examined a group of children of CLBP patients, a control group of children of diabetic patients, and a general control group of children. The study supported the hypothesis that, as a group, children of CLBP patients would exhibit a higher frequency of behaviors hypothesized to be learned through observation of and interaction with a CLBP parent than would children in either of the control groups. Significant differences between the pain group and the control groups on each of the nine teacher-reported and child self-report measures were observed. Implications and limitations of the study are discussed.     

Comparison of Efficacy of Neural Therapy and Physical Therapy in Chronic Low Back Pain

The aim of this prospective study was to evaluate the effects of neural therapy, and physical therapy on level of pain, disability, quality of life, and psychological status in patients with chronic low back pain. Patients admitted to the physical therapy and rehabilitation outpatient clinic with the complaint of low back pain of at least 3 months duration. Group 1 (n=27), physical therapy (PT, hotpack, ultrasound, TENS 15 sessions), group 2 (n=33), neural therapy (NT, 1:1 mixture of 20 mg/mL Lidocaine HCl (Jetokain simplex®) and saline for 5 sessions. For pain, Visual Analogue Scale (VAS), for disability Roland Morris Disability Questionnaire (RMDQ), for quality-of-life Nottingham-Health-Profile (NHP), for depression, and anxiety, Hospital Anxiety-Depression Scale (HADS) were used before and after the treatment. Mean age was 47.3±11.32 years, symptom time was 13.78±11.98 months. There were no differences for demographic variables between groups. Significant improvements were detected for VAS, RMDQ, NHP-Pain, NHP-Physical activity, HADS for both of two groups after treatment. In addition to these findings, significant improvements were found for NHP-Energy, NHP-Social isolation in NT group. The differences of pre- and post-treatment values of parameters were evaluated for each group. Although there were no differences for VAS, NHP-sleep, NHP-Emotional reaction, HADS between groups, RMDQ, NHP-Pain, NHP-Physical activity, NHP-Social isolation were higher in NT than PT before treatment, the improvements for these parameters were better in NT than PT. In conclusion both of NT and PT are effective on pain, function, quality of life, anxiety, and depression in patients with chronic low back pain.     

Low back muscle fatigue during Sørensen endurance test in patients with chronic low back pain: relationship between electromyographic spectral compression and anthropometric characteristics

This study assessed low back muscle fatigue during S?rensen back endurance test in chronic low back pain (CLBP) patients and healthy controls, and investigated relationship between the erector spinae muscle fatigability and subject's anthropometric characteristics. Four groups (n = 10 per group) of middle-aged (47-52-year-old) subjects participated: 1) female CLBP patients, 2) healthy female subjects, 3) male CLBP patients and 4) healthy male subjects. Subjects performed S?rensen back endurance test until exhaustion, while electromyographic (EMG) power spectrum median frequency compression over time (MF slope) as indicator of the erector spinae muscle fatigability, and endurance time were recorded. The endurance time was shorter (p < 0.05) in male CLBP patients compared to the healthy male and female subjects. No significant gender differences in endurance time were found in CLBP patients and in healthy subjects. EMG power spectrum MF slope did not differ significantly in CLBP patients and in healthy subjects. However, MF slope was higher (p < 0.05) in healthy male than in female subjects. Body mass and BMI correlated moderately positively with MF slope (r = 0.40-0.67) in all measured groups. We conclude that male CLBP patients had lower back extensor muscle isometric endurance compared to the healthy subjects of both genders, whereas no gender differences in isometric endurance were found in CLBP patients and in healthy subjects. Healthy male subjects had greater lumbar erector spinae muscle fatigability compared to the healthy female subjects. Subjects with higher body mass and body mass index fatigued faster during S?rensen back endurance test.     

Kinesiophobia in chronic low back pain patients—does the startle paradigm support the hypothesis?

Pain research has shown that fear-avoidance beliefs determine disability from back pain to a significant degree. It is assumed that anxiety regarding certain movements or activities motivates avoidance behavior. It has not yet been established whether chronic low back pain (CLBP) patients actually experience fear of movement when confronted with back pain-related movements. Startle response measures reliably differentiate the affective quality of a stimulus. This study investigates whether CLBP patients show a startle response typical for aversive stimuli when confronted with pictures of back pain-related movements. In 36 patients with CLBP, 18 headache patients and 18 healthy controls, the startle response was examined in the presence of pictures of back pain-related movements (e.g., bending) and pleasant movements (e.g., taking a relaxed position). Back pain patients did not show the predicted startle potentiation when viewing back pain-related pictures, although they rated these pictures as more aversive than did the other two groups. Results may indicate that it is not fear of pain that motivates avoidance behavior and determines disability, but rather an individual’s beliefs and attitudes concerning back stressing movements.     

Recall Bias in Patients with Chronic Low Back Pain: Individual Pain Response Patterns Are More Important Than Pain Itself!

Background

Patients’ cognitive processing of pain-related information as well as their cognitive, affective and behavioral response pattern when experiencing pain in daily life has been shown to be associated with poorer prognosis in low back pain. However, the relationship between specific cognitive processes such as recall of pain-related material and individual pain responses remains unknown.

Purpose

The present study sought to investigate recall bias in patients with chronic low back pain (CLBP) compared to healthy controls. Furthermore, it was aimed to investigate the impact of patients’ individual pain-related responses on recall bias, comparing fear-avoidance response (FAR), endurance response (ER) and adaptive response (AR) patterns.

Method

Thirty-one CLBP patients and 31 controls were tested on a free recall task with three word lists comprising pain words and neutral words. Further, the CLBP group was classified into patients with a FAR, ER and AR pattern, using a short screening including the Avoidance-Endurance Questionnaire (AEQ). Group differences with pain status (CLBP vs. healthy) and AEQ responses (FAR, ER, AR) as between-group factors, word type (pain vs. neutral) as within-group factor and free recall as dependent variable were analysed by means of repeated-measures analysis of (co-) variance.

Results

Results revealed different pain processing of pain words between FAR and ER patterns, whereas CLBP patients as a whole did not differ from the healthy controls. FAR patients displayed significantly less recall than ER patients.

Conclusion

Recall biases in CLBP patients are not only a result of experiencing pain but also effected by patients’ pain response pattern with respect to fear-avoidance versus endurance.

     

Electromyographic activity of selected trunk muscles during bicycle ergometer exercise and walking

Recently, active treatment such as exercise has been increasingly advocated for CLBP (chronic low back pain). Specially, exercise to improve fitness has been recommended for the prevention of back injuries. The bicycle ergometer or walking have often been used to improve the fitness of CLBP patients. However, little is known about the activity levels of the trunk muscles during such exercise. In this study, the electromyographic (EMG) activities of the trunk muscles during bicycle ergometer exercises and walking were compared and the load level on these muscles during such exercises was investigated. The present study provides basic information concerning fitness exercise in CLBP patients. Eleven healthy male volunteers (21.7 +/- 2.5 years old) without low back pain participated in the study. Bipolar surface electrodes were attached to the right side of the rectus abdominis, the obliquus externus abdominis and lower back extensor muscles (L3). EMG signals were continuously recorded while walking and during gradual loading exercises and normalized to maximal voluntary contractions (% MVC). One way analysis of variance (ANOVA) was performed on the % MVC from each exercise and walking for each of the three trunk muscle sites (p < 0.05). The rectus abdominis muscle showed activity of about 6% MVC during any grade of exercise and walking and no significant differences were found between these forms of exercise. The obliquus externus abdominis muscle showed about 30% MVC during any grade of exercise and walking, but no significant difference was found between them. The low back muscles showed activity of about 12% MVC while walking, whereas activity level increased as the exercise load using the bicycle ergometer increased. More significant low back muscles activity was observed while walking than during exercises of 25 w and 50 w. The results of this study indicated that exercise using the bicycle ergometer should be useful for maintaining or improving fitness in CLBP patients, because it results in less load on the trunk muscles and relatively more oxygen uptake than walking.     

Anger Management Style and Hostility: Predicting Symptom-Specific Physiological Reactivity Among Chronic Low Back Pain Patients

It was hypothesized that anger management style (anger-in or anger-out) and hostility affect the aggravation of chronic low back pain (CLBP) through symptom-specific (i.e., lower paraspinal muscle) reactivity during stress. Subjects were 102 CLBP patients who performed mental arithmetic and an Anger Recall Interview (ARI) while trapezius and lower paraspinal EMG, SBP, DBP, and HR were recorded. Results showed anger-in × hostility and anger-out × gender interactions for lower paraspinal but not trapezius reactivity, and only during the ARI. Further analyses revealed that (1) hostility was related positively to lower paraspinal reactivity among high anger suppressors, (2) hostility was related negatively to lower paraspinal reactivity among low anger suppressors, and (3) anger expression was related positively to lower paraspinal reactivity only among men. Anger management style and hostility may contribute to the exacerbation of CLBP by influencing stress reactivity only in muscles near the site of pain or injury.     

A controlled trial of corticosteroid injections into facet joints for chronic low back pain.

BACKGROUND. Chronic low back pain is a common problem with many treatments, few of which have been rigorously evaluated. This randomized, placebo-controlled trial was designed to evaluate the efficacy of injections of corticosteroid into facet joints to treat chronic low back pain. METHODS. Patients with chronic low back pain who reported immediate relief of their pain after injections of local anesthetic into the facet joints between the fourth and fifth lumbar vertebrae and the fifth lumbar and first sacral vertebrae were randomly assigned to receive under fluoroscopic guidance injections of either methylprednisolone acetate (20 mg; n = 49) or isotonic saline (n = 48) in the same facet joints. Ninety-five patients were followed for six months and their condition assessed with scales of pain severity, back mobility, and limitation of function. RESULTS. After one month, none of the outcome measures evaluating pain, functional status, and back flexion differed clinically or statistically between the two study groups. Forty-two percent of the patients who received methylprednisolone and 33 percent of those who received placebo reported marked or very marked improvement (95 percent confidence interval for the difference, -11 to 28 percentage points; P = 0.53). The results were similar after three months. At the six-month evaluation, the patients treated with methylprednisolone reported more improvement, less pain on the visual-analogue scale, and less physical disability. The differences were reduced, however, when concurrent interventions were taken into account. Moreover, only 11 patients (22 percent) in the methylprednisolone group and 5 (10 percent) in the placebo group had sustained improvement from the first month to the sixth month (95 percent confidence interval for the difference, -2 to 26; P = 0.19). CONCLUSIONS. We conclude that injecting methylprednisolone acetate into the facet joints is of little value in the treatment of patients with chronic low back pain.     

An interpretative phenomenological analysis of living with chronic low back pain

Objectives A predominantly quantitative approach to the psychological study of chronic low back pain (CLBP) has shown that enduring negative emotional responses and passive coping strategies contribute towards disability. The main objective of this study was to extend existing knowledge by providing a detailed and contextualized understanding of the meaning of CLBP for participants with long‐standing experiences of chronic pain. Design This is a qualitative, semi‐structured interview study. The data were analysed using interpretative phenomenological analysis (IPA). This is the first of three sets of individual interviews comprising a longitudinal study of the same participants over 3 years. Methods Ten patients with CLBP were interviewed prior to their attendance at a medically staffed chronic pain clinic. The sample comprised seven females and three males. Ages ranged between 39 and 66 years. All had experienced CLBP for at least 4 years. Conclusions The participants' experiences are represented by three main themes: ‘maintaining integrity’, ‘the crucial nature of the pain’ and ‘managing the pain’ that highlight participants' understanding of their pain within a biomedical framework. The findings are discussed with reference to the role of illness beliefs in the management of CLBP.     

Occupational and nonoccupational risk indicators for incident and chronic low back pain in a sample of the swedish general population during a 4-year period: An influence of depression?

The objectives of this study were to examine the relation between occupational and nonoccupational conditions and both incident (IBLP) and chronic low back pain (CLBP), aswellasdepression, among women and men. Data from a4-year follow-up of a study group consisting of 420 participants of both genders from the general Swedish population were analysed. Occupational risk indicators were predictors for both ILBP and CLBP. Depression was not found to be a predictor for either IBLP or CLBP among women, but was a predictor for CLBP among men. Among women, depression had some risk indicators in common with ILBP and appeared to be a concurrent outcome rather than a risk indicator. Low back pain in 1993 was not a predictor for depression in 1997 in either women or men. Occupational conditions are of relevance in relation to both incident and CLBP. Nonoccupational conditions were stronger predictors for CLBP than for ILBP but had some predictive value also for ILBP.     

Potential mechanisms underlying the accelerated cognitive decline in people with chronic low back pain: A scoping review

A growing body of evidence has shown that people with chronic low back pain (CLBP) demonstrate significantly greater declines in multiple cognitive domains than people who do not have CLBP. Given the high prevalence of CLBP in the ever-growing aging population that may be more vulnerable to cognitive decline, it is important to understand the mechanisms underlying the accelerated cognitive decline observed in this population, so that proper preventive or treatment approaches can be developed and implemented. The current scoping review summarizes what is known regarding the potential mechanisms underlying suboptimal cognitive performance and cognitive decline in people with CLBP and discusses future research directions. Five potential mechanisms were identified based on the findings from 34 included studies: (1) altered activity in the cortex and neural networks; (2) grey matter atrophy; (3) microglial activation and neuroinflammation; (4) comorbidities associated with CLBP; and (5) gut microbiota dysbiosis. Future studies should deepen the understanding of mechanisms underlying this association so that proper prevention and treatment strategies can be developed.     

Sleep in depressed and nondepressed participants with chronic low back pain: electroencephalographic and behaviour findings

STUDY OBJECTIVES: To study the nature of sleep disturbance in depressed and nondepressed patients with chronic low back pain (CLBP). DESIGN: A controlled, consecutive 4-night polysomnographic study. PATIENTS: Participants were screened (psychologic, psychiatric, and physical) to determine their study group, and 21 participants (CLBP: 4 depressed, 6 nondepressed and 11 controls) were studied. MEASUREMENTS AND RESULTS: On all nights, standard polysomnographic sleep measures as well as midline occipital and frontal electroencephalography and respiration were recorded on a Grass Model 7 polygraph. Pain, sleep quality, and depression were also measured. Participants with CLBP reported significant levels of pain and sleep disturbance as compared to controls, but all groups had equivalent amounts of sleep and comparable sleep architecture. The electroencephalographic power spectral analyses revealed significant differences, with controls having more sigma across sites, more low beta activity occipitally and frontally than nondepressed patients with CLBP, and more occipital sigma and less high beta activity than depressed participants. Between pain subgroups, the depressed participants showed more occipital delta, more occipital and central alpha, and more high beta activity across all sites than did the nondepressed participants. CONCLUSIONS: Lower sigma power in participants with CLBP suggests less-effective sensorimotor gating that may contribute to poor sleep quality. Pain subgroup differences underscore the need to consider the influence of depression in the evaluation of sleep in clinical populations. This study controlled for many factors other than pain that may contribute to the sleep complaints in this population. Consequently, the absence of signs of major sleep disturbance must not be interpreted as evidence of a lack of a true sleep problem in CLBP but more likely reflects control of these factors as well as the difficulty in measuring sleep quality.     

Radiography for low back pain: a randomised controlled trial and observational study in primary care.

BACKGROUND: Lumbar spine radiography has limited use in diagnosing the cause of acute low back pain. Consensus-based guidelines recommend that lumbar spine x-rays are not used routinely. However there have been no studies of the effect of referral for radiography at first presentation with low back pain in primary care. AIM: To compare short and long-term physical, social, and psychiatric outcomes for patients with low back pain who are referred or not referred for lumbar spine x-ray at first presentation in general practice. DESIGN OF STUDY: A randomised unblinded controlled trial with an observational arm to enable comparisons to be made with patients not recruited to the trial. SETTING: Ninety-four general practices in south London and the South Thames region. METHOD: Patients consulting their general practitioner (GP) with low back pain at first presentation were recruited to a randomised controlled trial (RCT) or to an observational group. Patients in the trial were randomly allocated to immediate referral for x-ray or to no referral. All patients were asked to complete questionnaires initially, and then at six weeks and one year after recruitment. RESULTS: Six hundred and fifty-nine patients were recruited over 26 months: 153 to the randomised trial and 506 to the observational arm. In the RCT referral for x-ray had no effect on physical functioning, pain or disability, but was associated with a small improvement in psychological wellbeing at six weeks and one year. These findings were supported by the observational study in which there were no differences between the groups in physical outcomes after adjusting for length of episode at presentation; however, those referred for x-ray had lower depression scores. CONCLUSIONS: Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning, pain or disability. The possibility of minor psychological improvement should be balanced against the high radiation dose involved.     

Back extensor muscle oxygenation and fatigability in healthy subjects and low back pain patients during dynamic back extension exertion

The purpose of this study was to assess if chronic low back pain patients have impaired paraspinal muscle O₂ turnover and endurance capacity as compared to healthy control subjects during dynamic exercise. Middle-aged healthy male subjects (n = 12, control) and male patients with chronic low back pain (n = 17, CLBP) participated in the study. L4–L5 level paraspinal muscle fatigue was objectively assessed during earlier validated 90 s dynamic back endurance test (spectral EMG, MPF_slope). Also EMG amplitude (EMG_amplitude) and initial MPF (MPF_initial) were assessed from the initial 5 s of the endurance contraction. Simultaneously near infrared spectroscopy (NIRS) was used for quantitative measurement of local L4–L5 paraspinal muscle O₂ consumption. Subcutaneous tissue thickness (ATT) was measured from the EMG and NIRS recording sites. The results indicated that control and CLBP groups were compatible as regarding anthropometric variables, paraspinal muscle activation levels (EMG_amplitude), initial MPF (MPF_initial) and ATT. When the ATT was used as a covariate in the ANOVA analysis, CLBP group did not show significantly greater paraspinal muscle fatigability (right MPF_slope – 12.2 ± 10.7%/min, left right MPF_slope – 12.6 ± 13.3%/min) or O₂ consumption (right NIRS_slope – 52.8 ± 79.6 μM/l/s) as compared to healthy controls (right MPF_slope – 11.9 ± 7.6%/min, left MPF_slope – 12.7 ± 8.6%/min, right NIRS_slope – 53.7 ± 95.2 μM/l/s). As a conclusion, these CLBP male patients did not show any impaired rate of paraspinal muscle oxygen consumption or excessive paraspinal muscle fatigability during dynamic exercise as compared with healthy controls. Subcutaneous tissue thickness has a strong influence on the NIRS and EMG amplitude measurements and, if unchecked, it could result in the false interpretation of the results.     

A cognitive dual task affects gait variability in patients suffering from chronic low back pain

Chronic pain and gait variability in a dual-task situation are both associated with higher risk of falling. Executive functions regulate (dual-task) gait variability. A possible cause explaining why chronic pain increases risk of falling in an everyday dual-task situation might be that pain interferes with executive functions and results in a diminished dual-task capability with performance decrements on the secondary task. The main goal of this experiment was to evaluate the specific effects of a cognitive dual task on gait variability in chronic low back pain (CLBP) patients. Twelve healthy participants and twelve patients suffering from CLBP were included. The subjects were asked to perform a cognitive single task, a walking single task and a motor-cognitive dual task. Stride variability of trunk movements was calculated. A two-way ANOVA was performed to compare single-task walking with dual-task walking and the single cognitive task performance with the motor-cognitive dual-task performance. We did not find any differences in both of the single-task performances between groups. However, regarding single-task walking and dual-task walking, we observed an interaction effect indicating that low back pain patients show significantly higher gait variability in the dual-task condition as compared to controls. Our data suggest that chronic pain reduces motor-cognitive dual-task performance capability. We postulate that the detrimental effects are caused by central mechanisms where pain interferes with executive functions which, in turn, might contribute to increased risk of falling.     

盐酸氨基葡萄糖联合非类固醇类抗炎药治疗小关节退变伴下腰痛

背景：盐酸葡萄糖胺对骨关节炎的治疗作用在膝关节已经得到证实,然而盐酸氨基葡萄糖与非类固醇类抗炎药物联用的治疗腰背痛鲜有报道。 目的：探讨盐酸氨基葡萄糖与小剂量非类固醇类抗炎药物联用治疗腰椎小关节退变伴下腰痛的临床效果。 方法：纳入35例小关节退变伴下腰痛患者,给予口服盐酸氨基葡萄糖750 mg,2次/d,外加双氯酚酸钠缓释片75 mg,1次/d,周期8周。使用Oswestry残疾指数、目测类比疼痛评分和SF-36量表在治疗前,治疗完成时和完成治疗后8周进行评估。 结果与结论：33例完成最终的随访,男女比例为1∶2,平均(41.2±10.3)岁。经过治疗,患者的腰痛和腿痛症状,腰椎功能和生活质量均有显著改善和提高(P < 0.05)。提示,盐酸氨基葡萄糖与小剂量非类固醇类抗炎药物联用对小关节退变伴腰痛患者有一定治疗作用。     

Chronic low back pain and depression

It is not clear whether the psychological disturbances associated with chronic low back pain are the cause or the result of the chronicity. It is also not clear whether increasing duration of low back pain is associated with depression. Three groups of patients (N = 148), with recent (0-6 months), relatively longstanding (6-24 months) and chronic (more than 24 months) low back pain were given the MMPI, Multiple Affect Adjective Check List (MAACL), State Trait Anxiety Inventory (STAI) and Low Back Pain Questionnaire (LBPQ). Increasing chronicity is associated with significant increases on MMPI Hs, D, HY, PT and MA scales, and on STAI Trait Anxiety scale. These results suggest that chronicity leads to the development of psychopathological characteristics and that these characteristics include a heightened awareness of somatic functioning and the vegetative aspects of the depressive syndrome, but that there is no increase in depressive mood or in the perception of the pain itself.