Laserakupunktur bei chronischen Rückenschmerzen

Background

The goal of this study was to evaluate the efficacy of laser acupuncture for the clinical picture of chronic back pain under everyday conditions using a randomized, double-blind, placebo-controlled study design. A further aim was to analyze to what extent placebo effects also influence the outcome of acupuncture under these conditions.

Patients and methods

The study included male and female patients with chronic back pain (lasting longer than 6 months) aged between 30 and 77 years with a pain score of at least 5 on a visual analog scale. The main criterion was achieving alleviation of pain by at least 50% 3 months after the start of treatment. The assessment tools used were the Von Korff questionnaire supplemented by the FFbH, FABQ, and SF-12. In addition, the participants were questioned about whether they perceived anything during the treatment and how certain they were that they had received treatment with active or inactive lasers.

Results

A total of 111 patients were included in the study and were treated according to the randomization list in two groups each consisting of 51 subjects. The study was completed as scheduled by 102 participants. Analysis of the primary outcome measure, improvement of the pain score by more than 50% over baseline, revealed improvements in both treatment groups between the time points used for measurement. The placebo group exhibited better levels than the group that received laser treatment. No efficacy advantage of laser acupuncture over placebo treatment could be determined.

Conclusion

It was possible to completely blind the acupuncture forms with the study design employed. Perhaps the consistent exclusion of nonspecific treatment effects contributed to this result. It cannot be ruled out that the effects of acupuncture are based on a strong placebo effect.     

Analyse der Krankheitskosten bei Rückenschmerzen

Zusammenfassung □ Hintergrund  Rückenschmerzen sind in modernen Industriestaaten ein Gesundheitsproblem betr?chtlichen Ausma?es. Obwohl eine gute ?rztliche Versorgung und ein gro?es Spektrum von effizienten Behandlungsm?glichkeiten zur Verfügung stehen und der weit überwiegende Teil der Patienten mit wenigen Konsultationen auskommt, sind Rückenschmerzen eine h?ufige Ursache für Krankheit und Arbeitsunf?higkeit. Sie verursachen neben einer mitunter erheblichen Einschr?nkung der Lebensqualit?t der Betroffenen auch eine hohe ?konomische Belastung der Volkswirtschaft und der Solidargemeinschaft der Versicherten. □ Kostenanalyse  Die Gesamtkosten, die durch Rückenschmerzen verursacht werden, betragen nach der vorliegenden Studie etwa 34 Milliarden DM pro Jahr. Davon entstehen ca. 10 Milliarden DM direkte Kosten, wobei Arztkonsultationen (einschlie?lich Diagnostik) einen Anteil von durchschnittlich 35%, Krankenhausbehandlungen von durchschnittlich 22%, Rehabilitationen durchschnittlich von 21%, physikalische Therapien durchschnittlich von 17% und Arzneimittel von durchschnittlich 5% ausmachen. Bei Betrachtung der Gesamtkosten, die zu rund 70% durch die indirekten Kosten verursacht werden, relativieren sich die direkten Kosten erheblich. □ Schlu?folgerung  Einsparungen durch restriktiveres Verordnungsverhalten im Bereich der medikament?sen Therapie beeinflussen die Gesamtkosten nicht wesentlich. Nur eine effektivere Therapie, die die Arbeitsunf?higkeitstage, die Zahl der Rezidive und die Gefahr einer Chronifizierung vermindert, sowie eine effektivere Pr?vention, die das Auftreten von Rückenschmerzen reduziert, kann auf lange Sicht die Kosten der Dorsopathien begrenzen. Eine weitere Forschung auf breiter Basis kann daher in diesem Bereich von gro?em Nutzen sein.      

Angstvermeidungs-Überzeugungen bei Rückenschmerzen

OBJECTIVE: This study investigated the quality criteria of a screening procedure used to identify fear-avoidance beliefs. METHODS: The translated version of the original FABQ was submitted to 302 patients with chronic back pain. Additionally, self-assessment protocols were used to document information on disease history, pain-specific parameters, extent of subjectively experienced impairment, and depressive symptoms. RESULTS: Correlation statistical analysis confirmed the relevance of fear-avoidance beliefs for the impairment as experienced by the patients with back pain. The FABQ proved to be a better predictor of subjectively experienced impairment than pain intensity or affective/emotional orientation. CONCLUSIONS: Fear-avoidance beliefs represent significant cognitive factors for chronification of back pain. The results demonstrated the practicability, reliability, and validity of the questionnaire to assess fear-avoidance beliefs.     

Triggerpunkttherapie und Bewegungskontrolle bei Rückenschmerzen

Background

This case series study assessed whether manual trigger point therapy supplemented by an exercise program for movement control could improve disability, pain and movement control in patients suffering from chronic low back pain (CLBP).

Patients and methods

In this study ten patients were treated four times using manual trigger point therapy followed by four exercise sequences aimed at improving movement control. Myofascial trigger points (mTrP) located in the erector spinal muscles between Th10 and S3 and in the quadratus lumbar muscle were treated. Testing was conducted using the Roland Morris disability questionnaire (RMDQ), the patient-specific functional scale (PSFS), the numeric rating scale (NRS) and six movement control tests (MCT).

Results

After four therapeutic trigger point interventions disability decreased significantly (RMDQ from 7.7 to 4.5 and PSFS from 6.5 to 3.8) while the pain was moderately reduced (NRS from 4.9 to 3.1) and movement control improved slightly from 3.0 to 2.4. The mean score of RMDQ and PSFS dropped further (3.3 and 3.2, respectively) following the movement control exercises. This also led to a strong improvement in MCT values (1.5). After 6 months a follow-up intervention showed further improvements in the RMDQ (2.3) and NRS (3.0) scores while the PSFS value stayed constant at 3.2.

Conclusion

A combination therapy of trigger point interventions and movement control exercises may reduce dysfunction in patients with CLBP.     

Messung von Behandlungserfolg bei chronischen Rückenschmerzen

Background

The multimodal therapy has proved to be useful for the treatment of patients with chronic back pain. The aim of this methodical study was to test whether specific effects for the individual can be inferred from general effects of the entire sample, in order to define criteria for the success of treatment. These could be helpful when deciding to which patients the multimodal therapy can best be applied.

Patients and methods

A total of 408 patients with chronic back pain took part in a 3-week multimodal therapy program in a day hospital. The patients were questioned regarding parameters such as pain intensity, depression, functional back capacity and quality of life before therapy as well as 6 months after therapy.

Results

On average, a significant improvement of all parameters could be shown after 6 months. However, scatterplots and correlations showed that general results of the entire sample should not be transferred to the individual patient

Conclusion

Taking into account principles of classical test theory this study showed that sufficient systematic coherence of the data must be proven before changes can be calculated. As long as neither an adequate systematic nor useful criteria can be found, there seems to be no reason to exclude any patient from multimodal therapy using pre-selection criteria.     

Medikamentöse Therapie bei Rückenschmerzen

Today, a wide range of efficient analgesic and non-analgesic drugs for the treatment of back pain are available. However, drugs should never be the only mainstay of a back pain treatment program. Non-steroidal antiinflammatory drugs (NSAID) are widely used in acute back pain. NSAIDs prescribed at regular intervals are effective to reduce simple back pain. The different NSAIDs are effective for the reduction of this pain. They have serious adverse effects, particularly at high doses, in the elderly, and on long-term administration. The new cyclooxygenase II-inhibitors have less gastrointestinal complications. But the long-term experiences are limited up to now. Considerable controversy exists about the use of opioid analgesics in chronic noncancer pain. Many physicians are concerned about the effectiveness and adverse effects of opioids. Other clinicians argue that there is a role for opioid therapy in chronic noncancer pain, e. g. especially in chronic low back pain. There is a low incidence of organ toxicity in patients who respond to opioids. The incidence of abuse and addiction is likewise relatively low. The potential for increased function and improved quality of life seems to outweigh the risks. However, there is a lack of randomised controlled trials (RCT) on opioid therapy in a multimodal pain treatment approach. Clinical experience and some studies suggest administration of sustained release opioids because of better comfort for the patient and less risks for addiction. The opioids should be selected due to the specific side effects of the different drugs. For patients with pre-existing constipation transdermal fentanyl should be preferred. Antidepressant medications have been used for the treatment of chronic back pain, though there is only little scientific evidence for their effectiveness. There is no evidence for the use of antidepressants in acute low back pain. Trials of muscle relaxants for patients with acute back pain have used a wide range of agents, e. g. benzodiazepines. They mostly reduce acute back pain, but they have significant adverse effects including drowsiness and psychological and physical dependence even after relatively short treatment. Benzodiazepines are not indicated in the treatment of chronic back pain. Drugs are sometimes necessary for the patients to begin and persevere a multimodal treatment program. Drug therapy should be terminated as soon as other treatment strategies succeed. Unfortunately, no studies exist evaluating the place of analgesics within a multimodal treatment program.     

Fragebogen zu Bewältigungsressourcen bei Rückenschmerzen

Background

The coping resources questionnaire for back pain (FBR) uses 12 items to measure the perceived helpfulness of different coping resources (CRs, social emotional support, practical help, knowledge, movement and relaxation, leisure and pleasure, spirituality and cognitive strategies). The aim of the study was to evaluate the instrument in a clinical patient sample assessed in a primary care setting.

Sample and methods

The study was a secondary evaluation of empirical data from a large cohort study in general practices. The 58 participating primary care practices recruited patients who reported chronic back pain in the consultation. Besides the FBR and a pain sketch, the patients completed scales measuring depression, anxiety, resilience, sociodemographic factors and pain characteristics. To allow computing of retested parameters the FBR was sent to some of the original participants again after 6 months (90% response rate). We calculated consistency and retest reliability coefficients as well as correlations between the FBR subscales and depression, anxiety and resilience scores to account for validity. By means of a cluster analysis groups with different resource profiles were formed. Results.

Results

For the study 609 complete FBR baseline data sets could be used for statistical analysis. The internal consistency scores ranged fromα=0.58 to α=0.78 and retest reliability scores were between rTT=0.41 and rTT=0.63. Correlation with depression, fear and resilience ranged from r=-0.38 to r=0.42. The cluster analysis resulted in four groups with relatively homogenous intragroup profiles (high CRs, low spirituality, medium CRs, low CRs). The four groups differed significantly in fear and depression (the more inefficient the resources the higher the difference) as well as in resilience (the more inefficient the lower the difference). The group with low CRs also reported permanent pain with no relief. The groups did not otherwise differ.

Conclusions

The FBR is an economic instrument that is suitable for practical use e.g. in primary care practices to identify strengths and deficits in the CRs of chronic pain patients that can then be specified in face to face consultation. However, due to the rather low reliability, the use of subscales for profile differentiation and follow-up measurement in individual diagnoses is limited.     

Multimodale Schmerztherapie bei chronischen und chronifizierenden Rückenschmerzen

Objectives

In recent years, multimodal treatment programs for chronic lower back pain (LBP) have been successfully established, however, the availability of such programs is limited. The aim of this study was to determine the predictors of success in a multimodal pain treatment program.

Methods

The study included 408 patients with chronic lower back or neck pain, who were admitted to a multimodal treatment program over 3 weeks. The German pain questionnaire was used for initial evaluation. Pain intensity was measured via VAS at the beginning of treatment and 6 months after therapy. The items on the pain questionnaire were tested by studying variance and regression analyses for their ability to predict treatment outcome (change of pain intensity).

Results

The following items could predict treatment outcome: duration of current pain episode, application for pension, pain intensity and job satisfaction. Age, sex, pain location (neck pain versus LBP) and chronicity stage according to MPSS were not found to be significant predictors.

Conclusions

According to our data, patients suffering from LBP or neck pain for less than 3 years, regardless of the stage of chronicity, can be expected to have a good outcome (pain reduction) after admission to a multimodal treatment program. Job satisfaction is a further predictor of good outcome. Predictors for a bad treatment outcome are: pain intensity less than 30/100 (VAS), pain duration longer than 3 years, and application for pension.     

Psychologische und psychotherapeutische Interventionen bei Patienten mit Rückenschmerzen

Contingent to the successful treatment of patients with low back pain by psychological interventions is that the specific therapy and methods are the correct fit for the patient’s needs. A patient’s needs can be examined through either an anamnestic interview or with the help of screening questionnaires. Psychosocial risks for chronic pain include depression, fear-avoidance and endurance behavior patterns and work- or family-related stressors, among others. Cognitive behavioral therapy, acceptance and commitment therapy and combinations of physiotherapeutic and psychological interventions have proved to be effective in the rehabilitation of patients with low back pain.     

Komorbidität bei Patienten mit chronischen Rückenschmerzen

BACKGROUND: Studies concerning comorbidity in patients with chronic low back pain and its correlation to the stage of chronification are rare. METHODS: This case-control study (matched-pair analysis) examines the number and specificity of comorbidity as well as the extent of disability due to comorbidity in 51 patients with chronic low back pain compared to age- and sex-matched control persons. Moreover, the correlation of comorbidity and the stage of chronification was analysed in these patients. RESULTS: Patients with chronic low back pain had significantly more comorbidities and a higher disability due to comorbidity compared to the control persons. The higher the stage of chronification according to the Mainz Pain Staging System (MPSS) the higher was the number of comorbidities. CONCLUSION: Comorbidity should be given due consideration when evaluating diagnosis, therapy, prognosis and therapy outcome in patients with chronic low back pain.     

Differenzialtherapie lumbaler Rückenschmerzen

Background

Back pain patients present with complex symptomatology. To demonstrate the possibilities of primary treatment viewed from the perspective of manual medicine, treatment data covering a period of 2.5 years of patients consulting a general practitioner for complaints of “lumbar back pain” were analyzed.

Results

In more than 90% of these patients, manual medical examination was able to detect conditions such as segment obstruction, myofascial trigger points, static imbalance, and psychosomatic disorders. Further paraclinical tests and imaging diagnostics were only needed in exceptional cases to distinguish potentially dangerous processes. It was not possible to prevent a decline in social status in only 1% of the cases due to lumbar back pain that was considerably influenced by psychosomatic factors.

Conclusion

Differential therapy of the findings based on aspects of manual medicine including psychosomatic interventions proved to be extraordinarily effective, long-lasting, and without side effects when applied for primary treatment in the family practice setting.     

Risikofaktoren für Rückenschmerzen bei Kindern und Jugendlichen in Industrienationen

Factors that have led to the increasing prevalence of back pain amongst children and adolescents living in industrialized nations are mostly unknown. The following literature review was aimed at determining the risk factors for back pain amongst children and adolescents. We searched both PUBMED and MEDLINE between the years 1985 and 2003 for the keywords "children or adolescents" and "back pain". Only data published in original articles were used. The risk for suffering back pain is influenced by physical, behavioural, emotional and social factors. The effects of physical activity, sitting, muscle status, weight of schoolbags, exercise, television and computer use, as well as age and gender on the development of back pain in children and adolescents were examined. Associations between continuous or recurring back pain and psychosocial factors (lifestyle, emotional factors, social relationships) could be demonstrated. There was no relationship between changes of the spine seen by radiological tests and the development of chronic back pain. Longitudinal epidemiological studies are urgently needed to delineate the risk factors for the development as well as the natural history of chronic back pain in the young.     

Die Cortisol-Aufwachreaktion bei Patienten mit akuten und chronischen Rückenschmerzen

Background

Peculiarities of the hypothalamic-pituitary-adrenal axis activity in stress-related pain-disorders and potential relations with psychological risk factors of pain chronicity have been discussed controversially.

Material and methods

The cortisol awakening responses of 31 low back pain patients (14 acute, 17 chronic) and 14 healthy controls were compared. In addition the interrelations between awakening response and chronic stress as well as depressive mood and – for the first time – maladaptive painprocessing and -copingstrategies were investigated.

Results

The groups did not differ in their cortisol awakening responses. Chronic stress, depressive mood and maladaptive cognitive painprocessing did not correlate with the awakening response. There were, however, significant interrelations between awakening responses and the behavioral paincoping-strategies.

Conclusions

Behavioral paincoping-strategies should be considered as a potentially important contributing psychological factor in the relation between the activity of the hypothalamic-pituitary-adrenal axis and stress-related pain disorders.     

Manualmedizinische Syndrome bei unteren Rückenschmerzen: Teil II

The differential diagnostic evaluation of painful functional disorders of the lumbosacral and lumbopelvic region, e.g. so-called low back pain, is very extensive but is often reduced to the question of chronicity. The manual medical diagnosis can make a valuable contribution in the determination of structural and functional pathologies. Early application of manual medical therapies seems to be effective for peracute complaints. The mobilization of restrictions of the pelvic visceral attachments should be included. A first article dealt in particular with the dorsal lumbosacral syndrome. The current part II deals with further syndromes in manual medicine, in particular with the lumbopelvic syndrome. This facilitates the primary differential diagnostic evaluation as well as treatment planning. The combination with osteopathic methods is very profitable. A necessary specialist differential diagnosis remains essential.     

Manualmedizinische Syndrome bei unteren Rückenschmerzen: Teil?I

The differential diagnostic evaluation of painful functional disorders of the lumbosacral and lumbopelvic region, i.e. so-called low back pain, is very extensive but is often reduced to the question of chronicity. The manual medical diagnosis can make a valuable contribution in the determination of structural and functional pathology. Early application of manual medical therapies seems to be effective for peracute complaints. The mobilization of restrictions of the pelvic visceral attachments should be included. In this review and in a following issue manual medical syndromes are presented that summarize the findings from the musculoskeletal and visceral systems. This alleviates the primary differential diagnostic evaluation as well as treatment planning. The combination with osteopathic methods is very profitable. A necessary specialist differential diagnosis remains essential.     

Selbstmanagement in der Manualtherapie bei Patienten mit chronischen Rückenschmerzen

Chronic non-specific back pain usually has no direct association with a measurable pathology. Nevertheless, affected patients can experience significant functional impairment in their everyday lives and work. As such, several individual findings, particularly on a psychosocial level, go to make up the overall clinical presentation. If acute symptoms persist despite the sound application of effective techniques or if pain has already become chronic, an interdisciplinary assessment should be considered. Guideline-compliant multimodal interdisciplinary treatment comprises various components: intensive education that takes a biopsychosocial disease model into account, medicinal pain therapy, physiotherapy, everyday training, stress management and sports therapy. To guarantee long-term success, it is essential to integrate an appropriate self-management program into everyday life in order to cope with back pain. This article discusses the aim, content, and implementation of a self-management program of this type.     

Geschlechtsspezifische Risikofaktoren akuter Rückenschmerzen

Background

Women complain about back pain more often than men, giving rise to the question of whether gender-specific risk profiles could be identified.

Methods

Secondary data analysis was done of the telephone health survey conducted by the Robert Koch Institute in 2003 (n=7,829). Bivariate (χ²) and gender-stratified multivariate tests were conducted (odds ratio, 95% confidence intervals).

Results

Women (28.5%) complained about acute low back pain significantly more often than men did (18%; p<0.001). The multivariate analysis found gender-specific risk estimates for the following factors: age, degenerative diseases of the joints, osteoporosis, depression, smoking, employment, municipality size, and impairment of daily work because of physical impairment.

Conclusion

The present examination is an attempt to deduce factors to be taken into account for gender-specific care of patients with acute low back pain. Preventive measures and therapy approaches could be influenced by these findings. To adequately address the problem, future analyses should specifically include psychosocial factors.