Health literacy and beliefs among a community cohort with and without chronic low back pain

Health literacy, the ability to seek, understand and utilise health information, is important for good health. Suboptimal health literacy has been associated with poorer health outcomes in many chronic conditions although this has not been studied in chronic low back pain (CLBP). We examined the health literacy of individuals with CLBP using a mixed methods approach. One-hundred and seventeen adults, comprising 61 with no history of CLBP and 56 with CLBP (28 with low and high disability, respectively, as determined by a median split in Oswestry scores) participated. Data regarding severity of pain, LBP-related disability, fear avoidance, beliefs about LBP and pain catastrophizing were collected using questionnaires. Health literacy was measured using the Short-form Test of Functional Health Literacy in Adults (S-TOFHLA). A sub-sample of 36 participants with CLBP also participated in in-depth interviews to qualitatively explore their beliefs about LBP and experiences in seeking, understanding and using information related to LBP. LBP-related beliefs and behaviours, rather than pain intensity and health literacy skills, were found to be important correlates of disability related to LBP. Individuals with CLBP-high disability had poorer back pain beliefs and increased fear avoidance behaviours relating to physical activity. Health literacy (S-TOFHLA) was not related to LBP beliefs and attitudes. Qualitatively, individuals with CLBP-high disability adopted a more passive coping style and had a pathoanatomic view of their disorder compared to individuals with CLBP-low disability. While all participants with CLBP had adequate health literacy scores (S-TOFHLA), qualitative data highlighted difficulties in seeking, understanding and utilising LBP information.     

Yoga and pilates in the management of low back pain

Many interventions for the management of low back pain exist, however most have modest efficacy at best, and there are few with clearly demonstrated benefits once pain becomes chronic. Therapeutic exercise, on the other hand, does appear to have significant benefits for managing patients with chronic low back pain (CLBP) in terms of decreasing pain and improving function. In addition, because chronic pain is complex and does not fit a simple model, there have also been numerous trials investigating and demonstrating the efficacy of multidisciplinary pain programs for CLBP. It follows that interventions that treat more than one aspect of LBP would have significant benefits for this patient population. Yoga and Pilates which have, both been gaining in popularity over the last decade are two mind–body exercise interventions that address both the physical and mental aspects of pain with core strengthening, flexibility, and relaxation. There has been a slow evolution of these nontraditional exercise regimens into treatment paradigms for LBP, although few studies examining their effects have been published. The following article will focus on the scientific and theoretical basis of using yoga and Pilates in the management of CLBP.     

Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain

INTRODUCTION: Research concerning the development of low back pain (LBP) has traditionally focused on risk factors in search of explanations. This review focuses on comorbidity as a first step in identifying a frail subpopulation with a higher risk of developing low back pain, in particular persistent low back pain. Research into comorbidity might yield a greater understanding of the underlying mechanism for low back pain.Data sources Medline was searched from the beginning of the data base to December 2000, followed by a search through the authors' personal collections of epidemiologic literature regarding low back pain. All articles written in English were included if they related LBP to at least one other physical disorder. Articles were excluded if the prevalence of such disorders could not be compared to that of a control group or to the expected prevalence in a normal population.Data extraction The retrieved articles were evaluated for quality based on predefined methodological criteria, whereupon information about associations between low back pain and other physical disorders was extracted. RESULTS: Twenty-three articles were included. They showed positive associations to all disorders investigated (headache/migraine, respiratory disorders, cardiovascular disease, general health, and others) with the exception of diabetes. There was very little information regarding temporality, therefore there are no clues as to causal mechanisms. CONCLUSION: The literature leaves no doubt that diseases cluster in some individuals and that low back pain is part of this pattern. However, the nature of the relationship between low back pain and other disorders is still unclear.     

Definitions of Chronic Low Back Pain From a Scoping Review,and Analyses of Narratives and Self-Reported Health of Adults With Low Back Pain

Among those with low back pain (LBP), individuals with chronic LBP (CLBP) face different treatment recommendations and incur the majority of suffering and costs. However, the way CLBP has been defined varies greatly. This study used a scoping review and qualitative and quantitative analyses of data from LBP patients to explore this variation. CLBP in most recent randomized controlled trials (RCTs) was defined by duration of pain, most commonly ≥3 months. However, individuals with LBP most often define CLBP by frequency. CLBP has also been defined using a combination of duration and frequency (16% of RCTs and 20% of individuals), including 6% of recent RCTs that followed the NIH Pain Consortium research task force (RTF) definition. Although not a defining characteristic of CLBP for individuals, almost 15% of recent RCTs required CLBP to have a healthcare provider diagnosis. In our LBP sample moving from ≥3 months to the RTF definition reduced the CLBP group size by 25% and resulted in a group that used more pain management options and reported worse health across all outcome measures. A pain duration definition offers ease of application. However, refinements to this definition (eg, RTF) can identify those who may be better intervention targets.PerspectiveThis article presents the definitions used for CLBP by researchers and individuals, and the impact of these definitions on pain management and health outcomes. This information may help researchers choose better study inclusion criteria and clinicians to better understand their patients’ beliefs about CLBP.     

Acetaminophen selectively suppresses peripheral prostaglandin E2 release and increases COX-2 gene expression in a clinical model of acute inflammation

For years, physical deconditioning has been thought to be both a cause and a result of back pain. As a consequence physical reconditioning has been proposed as treatment-goal in patients with chronic low back pain (LBP). However, it is still unclear whether a patient’s physical fitness level really decreases after pain-onset. The objectives of the present study were, firstly, to test the assumption that long-term non-specific LBP leads to a decrease of the level of physical activity (disuse), secondly, to evaluate any development of physical deconditioning as a result of disuse in CLBP, and thirdly, to evaluate predictors for disuse in CLBP. A longitudinal cohort study over one year including 124 patients with sub-acute LBP (i.e., 4–7 weeks after pain onset) was performed. Main outcome measures were change in physical activity level (PAL) and physical fitness (measured by changes in body weight, body fat and muscle strength) over one year. Hypothesized predictors for disuse were: pain catastrophizing; fear of movement; depression; physical activity decline; the perceived level of disability and PAL prior to pain. Results showed that only in a subgroup of patients a PAL-decrease had occurred after the onset of pain, whereas no signs of physical deconditioning were found. Negative affect and the patients’ perceived physical activity decline in the subacute phase predicted a decreased level of PAL over one year. Based on these results, we conclude that as to the assumption that patients with CLBP suffer from disuse and physical deconditioning empirical evidence is still lacking.     

Clinical Perspective: How Do Clinical Test Results Differentiate Chronic and Subacute Low Back Pain Patients from “Non-Patients”?

Our limited understanding of underlying conditions for back pain is reflected in the common use of pain-duration-based groupings. The aim of this paper was to investigate typical clinical tests used in examining low back pain (LBP) patients in order to discover how tests distinguish between chronic low back pain patients (CLBP) and subacute low back pain patients (SLBP) and if they distinguish these groups from those with no “patient status.” CLBP patients in this study were from a university hospital and SLBP patients were from five occupational health care centers. Control subjects were recruited from a university. Determination of the best predictors between CLBP and SLBP patients and between CLBP and SLBP patients and non-patients was made by a forward stepwise logistic model. A total of 157 subjects were included in the study. Of all the clinical tests, several tests in each category had high odds ratio, differentiating CLBP patients from controls. Only a few tests differentiated between CLBP and SLBP patients. The only clinical differences between SLBP patients and controls were in the mobility test and in one test of muscle tightness. The best predictor for CLBP was the lumbar spine flexion test. SLBP patients seemed to differ from the control group in lumbar flexion, in a specific anterior-posterior mobility test, and in tightness of hip flexor muscles. CLBP patients differed from SLBP patients in functional tests, in the presence of sensation in the feet, and in different pain provocation tests. Whether these tests are sufficiently sensitive to classify a more specific diagnostic or clinical subgroup remains untested, and further studies with clinical tests to differentiate among pathological conditions are necessary.KEYWORDS: Clinical Tests, Low Back Pain, Odds Ratios, Orthopedic Manipulative Therapy, Sensitivity, SpecificityLow back pain (LBP) is one of the most common reasons for people to seek medical treatment in Western societies, with the majority of LBP sufferers having non-specific low back pain. This definition includes any type of back pain or referred leg pain or both that does not fall into the category of nerve root pain or serious spinal pathology¹. Our limited understanding of underlying conditions for back pain is reflected in the common use of pain-durationbased groupings: LBP lasting for 6 weeks or less has been defined as acute, from 7 to 12 weeks as subacute, and for 12 weeks or more as chronic back pain2,3. Still, classification according to LBP duration is questionable, because of evidence that new, acute LBP is rare among adults and that most experiences of all LBP will reoccur⁴.There is a consensus about the duration of the symptoms approach toward the standardization of back pain definitions for use in prevalence studies⁵. Although inter-country differences also exist in the management of LBP sufferers from differing cultural backgrounds, clinical guidelines in different countries are mostly based on the pain-duration classification (acute, subacute, and chronic), or a classification into a diagnostic triage: serious pathology or sciatic syndrome or non-specific LBP⁶.Several physical characteristics have been associated with LBP development. Physiologic changes such as muscle dysfunction occur in the lumbar spine at the same time as do initial episodes of pain: changes that remain after the pain has subsided^7,8. Knowing the degree of relationship between each of these factors and LBP will guide prevention treatment strategies⁹. Pengel et al¹⁰ suggested placing more emphasis on change in pain and disability scores than on physical impairment. Substantial evidence also exists that psychosocial variables are strongly linked to the transition from acute to chronic LBP disability¹¹.To date, there is only marginal literature that describes variations in clinical findings between duration-based classifications. Subsequently, the purpose of this study was to investigate typical clinical tests used in examining LBP patients in order to discover which tests distinguish between chronic low back pain patients (CLBP) and subacute low back pain patients (SLBP), and how clinical findings distinguish these groups from those with no “patient status”.     

Opioids Versus Physical Therapy for Management of Chronic Back Pain

Chronic low back pain (CLBP) is a common disabling disorder managed by a variety of interventions. The purpose of this article was to review the literature and critique the evidence to determine if opioid analgesics improved patient outcomes compared with physical therapy. No research was found that directly compared the efficacy of opioid analgesics with physical therapy. Although the evidence supports the use of physical therapy in chronic back pain, the study results are conflicting regarding the usefulness of opioid analgesics in CLBP management. More research involving the efficacy of opioid analgesic in treating CLBP is needed.     

Prevalence, onset, and risk of psychiatric disorders in men with chronic low back pain: a controlled study.

This study used structured diagnostic interviews and DSM-III criteria to assess lifetime prevalence and pre-morbid risk of psychiatric disorder in a sample of men with long-standing chronic back pain (CLPB) attending a primary care clinic. A control group of age and demographically matched men without history of back pain was also studied. Compared to controls, men with CLBP had significantly higher lifetime rates of major depression (32% vs. 16%), alcohol use disorder (64.9% vs. 38.8%), and a major anxiety disorder (30.9% vs. 14.3%). Almost all CLBP men ever experiencing a mood disorder reported recurrent, not single, episodes. The 6 month point prevalence of major depression, but not other disorders, was also significantly elevated for men with CLBP. In CLBP, the first episode of major depression generally (58.1%) followed pain onset. While the initial major depressive episode usually commenced within the first 2 years of established pain, late onset mood disorder was also common. By comparison in most cases (81%) onset of alcohol use disorders considerably preceded pain. When an age-matching procedure was used to gauge relative vulnerability to psychiatric illness in patients and controls, CLBP patients had significantly higher pre-pain rates of alcohol use disorder but not depression. After age of pain onset, CLBP subjects had over 9 times the risk of developing major depression, but had similar rates of developing alcoholism. We conclude that (1) alcohol use disorders rather than depression may increase risk of developing CLBP, and (2) risk of new onset and recurrent major depression remains high for men throughout their pain career. This suggests that psychological adaptation to long-standing pain may be less successful than previously thought, especially with regard to recurrent mood disorder.     

Physical activity and low back pain: A critical narrative review

BackgroundNon-specific low back pain (LBP) is the leading cause of years lived with disability worldwide. Physical activity is an integral part of LBP treatment.ObjectiveTo critically review available evidence regarding the efficacy of physical activity for people with LBP.MethodsUp to date critical narrative review of the efficacy of physical activity for the managment LBP. The process of article selection was unsystematic; articles were selected based on authors’ expertise, self-knowledge and reflective practice.ResultsTherapeutic physical activity for LBP includes a wide range of non-specific and specific activities. The efficacy of physical activity on pain and activity limitations has been widely assessed. In acute and subacute LBP, exercise did not reduce pain compared to no exercise. In chronic low back pain (CLBP), exercise reduced pain at the earliest follow-up compared with no exercise. In a recent systematic review, exercise improved function both at the end of treatment and in the long-term compared with usual care. Exercice also reduced work disability in the long-term. We were unable to establish a clear hierarchy between different exercise modalities. Multidisciplinary functional programs consistently improved pain and function in the short- and long-term compared with usual care and physiotherapy and improved the long-term likelihood of returning to work compared to non-multidisciplinary programs.ConclusionPhysical activity of all types is an effective treatment for CLBP.     

Medically incongruent chronic back pain: physical limitations, suffering, and ineffective coping

Chronic low back pain (CLBP) patients with pain and symptomatology incongruent with physical pathology have been found to have a poorer outcome to medical treatment and rehabilitation, and to use health care resources excessively. To examine possible psychological and behavioral bases for this pattern, this investigation contrasted 40 CLBP patients who displayed non-organic physical signs, inappropriate symptoms, and/or anatomically incongruent pain drawings with 40 'control' CLBP patients without incongruent pain criteria. Multivariate analyses revealed that the incongruent CLBP group reported greater pain intensity and depression, received higher observer ratings of pain, displayed more ambulatory/postural pain behavior, and reported more dysfunctional cognitions during pain. Incongruent CLBP patients also were found to have greater physical impairment and disability. When group differences on physical impairment/disability were controlled statistically, all the afore-mentioned differences disappeared, with one exception. Incongruent CLBP patients still displayed more maladaptive and dysfunctional cognitions. These findings indicate that incongruent CLBP patients may be conceptualized as ineffective and overwhelmed in their attempts to cope and as more physically disabled as a result of their pain. The role of cognitive factors, reasons for failure of physically based interventions, and implications for patient management are discussed.     

Low back pain: state of art

Diagnosis of low back pain (LBP) is made by exclusion of secondary spinal diseases, identifiable in the first month of pain (acute LBP – ALBP) through the so-called “reds flags”, and only if pain persists over 4 weeks (sub-acute LBP – SALBP) using diagnostic exams. LBP classification is actually based on the localization (LBP and sciatica) and duration of pain: ALBP, SALBP, and chronic (CLBP) when it lasts over 6 months. ALBP prognosis is very good because it is auto-resolving in most of the cases; on the contrary, CLBP has a bad prognosis (very low rate of resolution even with treatment). The stage of most interest is SALBP, in which it is possible to identify risk factors (“yellow flags”) of chronicity and to avoid the development of a series of vicious cycles that, according to a bio-psycho-social model of illness, can lead the patient to CLBP. In CLBP it's mandatory to make the patient able to manage his problem, so to increase his quality of life and decrease disability and pain. Treatment approach to ALBP consist of reassuring the patient and providing accurate preventive information, recommendations to remain as active as possible, to avoid bed rest. In SALBP and CLBP, a multidisciplinary team rehabilitation approach is the most important one, combining educational, cognitive-behavioural and physical exercise treatments according to the individual needs. Pain killer therapies can be proposed, but bearing in mind their short-term effects.     

Physical and functional measures related to low back pain in individuals with lower-limb amputation: an exploratory pilot study

For this study, we compared the physical impairments and functional deficits of individuals with lower-limb amputation (LLA) for those with and without low back pain (LBP). Nineteen participants with LLA were placed into two groups based on visual analog scores of LBP. We assessed functional limitations, iliopsoas length, hamstring length, abdominal strength, back extensor strength, and back extensor endurance. Data analysis included correlations and t-tests. We found significant correlations between pain score and functional limitations, iliopsoas length, and back extensor endurance. We also detected significant differences in functional limitations, iliopsoas length, back extensor strength, and back extensor endurance between those with and without LBP. We saw significant differences in back extensor strength and back extensor endurance between those with transtibial and transfemoral amputations. Differences exist in physical measures of individuals with LLA with and without LBP. Clinicians should consider these impairments in individuals with amputation who experience LBP. Because of the participants' characteristics, these findings may be applicable to veterans with LLA.     

A Randomised Controlled Study of the Outcome of Hydrotherapy for Subjects with Low Back or Back and Leg Pain

Background and purpose:

Exercise is frequently selected by physiotherapists to treat patients with low back pain (LBP) or with back and leg pain. Anecdotally a particular form of exercise, group hydrotherapy, is widely accepted as a beneficial and cost-effective method of management. This study was designed to investigate the claimed benefits of group hydrotherapy for subjects with chronic low back pain (CLBP) and back and leg pain.

Subjects:

A total of 109 adults with LBP or back and leg pain of more than three months duration were randomly assigned to either a hydrotherapy (experimental) or control (delayed hydrotherapy) group; 95 subjects completed the study.

Methods:

Before and after the four-week‘intervention period’ the following measures were recorded for all subjects in both groups: the ranges of active lumbar flexion and extension and of passive straight leg raise; the levels of lower limb strength, reflex responses, light touch sensation, functional disability using the Oswestry Low Back Pain Disability Questionnaire, and pain using the McGill Pain Questionnaire. All measurements were made and recorded by an experienced physiotherapist unaware of the group assignment of subjects.

Results:

Analysis with chi-square showed a statistically significant greater number of subjects in the experimental group improved in their function and fewer deteriorated. Subjects whose condition improved on the other measures were typically in the experimental group, while those whose condition deteriorated were typically in the control group.

Conclusion and discussion:

The findings offer qualified support to anecdotal evidence that group hydrotherapy can benefit subjects with CLBP or back and leg pain.     

Diagnosis and classification of pelvic girdle pain disorders, Part 2: illustration of the utility of a classification system via case studies

Pelvic girdle pain (PGP) disorders are complex and multi-factorial and are likely to be represented by a series of sub-groups with different underlying pain drivers. Both the central and peripheral nervous systems have the potential to mediate PGP disorders. Even in the case of a peripheral pain disorder, the central nervous system can modulate (to promote or diminish) the pain via the forebrain (cognitive factors). It is hypothesised that the motor control system can become dysfunctional in different ways. A change in motor control may simply be a response to a pain disorder (adaptive), or it may in itself promote abnormal tissue strain and therefore be 'mal-adaptive' or provocative of a pain disorder. Where a deficit in motor control is 'mal-adaptive' it is proposed that it could result in reduced force closure (deficit in motor control) or excessive force closure (increased motor activation) resulting in a mechanism for ongoing peripheral pain sensitisation. Three cases are presented which highlight the multi-dimensional nature of PGP. These cases studies outline the practical clinical application of a classification model for PGP and the underlying clinical reasoning processes inherent to the application of this model. The case studies demonstrate the importance of appropriate classification of PGP disorders in determining targeted intervention directed at the underlying pain mechanism of the disorder.     

Investigating the effects of myofascial induction therapy techniques on pain,function and quality of life in patients with chronic low back pain

IntroductionLow back pain (LBP) is well documented as a common health problem; it is the leading cause of activity limitation and work absence throughout much of the world, and it causes an enormous economic burden on individuals, families, communities, industry, and governments. The aim of this study was to comparatively investigate the effects of myofascial induction therapy (MIT) against pain neuroscience education (PNE) on pain and function in patients with chronic low back pain (CLBP).MethodForty patients with CLBP were included and randomly divided into two groups according to the treatment program (40 min/session, 2 sessions/week during 8-week), as follows: the MIT and the PNE groups. The outcome measures were the fear-avoidance beliefs questionnaire (FABQ), Roland Morris disability questionnaire, McGill pain questionnaire, finger floor test, SF-36 quality-of-life questionnaire, and thoracolumbar fascia ultrasound imaging results. Patients were evaluated before and after treatment.ResultsWithin both groups, all outcome scores showed a significant improvement (p < 0.05). After 8-week, SF-36 physical function, physical role and mental health scores significantly improved in MIT group compared with PNE group, finger floor test score significantly decreased in MIT group compared with PNE group, and FABQ score significantly decreased in PNE group compared with MIT group (p < 0.05).ConclusionsAlthough both MIT and PNE were found to be effective on pain and function in patients with CLBP, MIT techniques were substantially better in improving the mobility of trunk flexion and quality of life in these patients.     

The relationship beween posture and back muscle endurance in industrial workers with flexion-related low back pain

This preliminary cross-sectional study was undertaken to determine if there were measurable relationships between posture, back muscle endurance and low back pain (LBP) in industrial workers with a reported history of flexion strain injury and flexion pain provocation. Clinical reports state that subjects with flexion pain disorders of the lumbar spine commonly adopt passive flexed postures such as slump sitting and present with associated dysfunction of the spinal postural stabilising musculature. However, to date there is little empirical evidence to support that patients with back pain, posture their spines differently than pain-free subjects. Subjects included 21 healthy industrial workers and 24 industrial workers with flexion-provoked LBP. Lifestyle information, lumbo-pelvic posture in sitting, standing and lifting, and back muscle endurance were measured. LBP subjects had significantly reduced back muscle endurance (P < 0.01). LBP subjects sat with less hip flexion, (P = 0.05), suggesting increased posterior pelvic tilt in sitting. LBP subjects postured their spines significantly closer to their end of range lumbar flexion in 'usual' sitting than the healthy controls (P < 0.05). Correlations between increased time spent sitting, physical inactivity and poorer back muscle endurance were also identified. There were no significant differences found between the groups for the standing and lifting posture measures. These preliminary results support that a relationship may exist between flexed spinal postures, reduced back muscle endurance, physical inactivity and LBP in subjects with a history of flexion injury and pain.     

Comprehensive assessment of chronic low back pain patients and controls: physical abilities, level of activity, psychological adjustment and pain perception

A comprehensive functional evaluation designed for patients with chronic low back pain (CLBP) is described. The evaluation includes measures from 4 domains of the CLBP syndrome; physical abilities, level of activity, psychological adjustment and pain perception. New measures for standardized assessment of physical abilities and employment of body mechanics are introduced. Evaluation data from 68 CLBP subjects and 35 age-matched, pain-free, controls is presented. Results indicate important deficits in physical abilities and psychological adjustment for the CLBP group compared to the controls. Factor analysis of the evaluation measures yielded a general conditioning factor and a general psychological adjustment factor but complicated factor structures for report of pain and time in activities. Further analysis demonstrated a strong relationship between objective disability and psychological and psychosocial adjustment but little relationship between level of pain and other disability measures.     

No association between level of vitamin D and chronic low back pain in Swedish primary care: a cross-sectional case-control study

Objective: Assessment of vitamin D levels and deficiency status in individuals with chronic low back pain (CLBP) in a Swedish general population, compared with controls matched for sex and age.

Design: Cross-sectional case-control study.

Setting: Primary care, southern Sweden.

Subjects: Participants (n?=?44) with self-reported low back pain for at least 3 months and individually sex- and age-matched controls without a chronic pain condition (n?=?44), recruited from the general population by random letter of invitation.

Main outcome measure: Association between vitamin D level and CLBP when adjusting for possible confounders in a multivariate forward conditional logistic regression model.

Results: Mean S-25-hydroxyvitamin D levels were 81 and 80?nmol/L in the CLBP and control group, respectively. The prevalence of vitamin D deficiency was low and similar in the CLBP group and the control group. Vitamin D level was not associated with CLBP when potential confounders were taken into account.

Conclusions: No difference in vitamin D levels between participants with CLBP and matched controls could be demonstrated in the present sample. Assessment of vitamin D level and deficiency status may be of questionable value in the management of CLBP in primary care settings at similar latitudes, unless there are additional risk factors for deficiency or specific indicators of osteomalacia.

• Key Points

• Vitamin D deficiency is common and reported in many chronic pain conditions, including chronic low back pain (CLBP), but evidence for an association and causality is insufficient.

• The present study found no association between vitamin D levels and CLBP in a case-control sample of 44?+?44 individuals from the Swedish general population.

• Prevalence of vitamin D deficiency was low and comparable in individuals with CLBP and controls without chronic pain, matched for sex and age.

• Assessment of vitamin D status, for the purpose of finding and treating an underlying cause of pain, may be of limited value in the management of CLBP in primary care settings at similar latitudes.