Depression, mood state, and back pain during microgravity simulated by bed rest.

OBJECTIVE: The objective of this study was to develop a ground-based model for spinal adaptation to microgravity and to study the effects of spinal adaptation on depression, mood state, and pain intensity. METHODS: We investigated back pain, mood state, and depression in six subjects, all of whom were exposed to microgravity, simulated by two forms of bed rest, for 3 days. One form consisted of bed rest with 6 degrees of head-down tilt and balanced traction, and the other consisted of horizontal bed rest. Subjects had a 2-week period of recovery between the studies. The effects of bed rest on pain intensity in the lower back, depression, and mood state were investigated. RESULTS: Subjects experienced significantly more intense lower back pain, lower hemisphere abdominal pain, headache, and leg pain during head-down tilt bed rest. They had higher scores on the Beck Depression Inventory (ie, were more depressed) and significantly lower scores on the activity scale of the Bond-Lader questionnaire. CONCLUSIONS: Bed rest with 6 degrees of head-down tilt may be a better experimental model than horizontal bed rest for inducing the pain and psychosomatic reactions experienced in microgravity. Head-down tilt with balanced traction may be a useful method to induce low back pain, mood changes, and altered self-rated activity level in bed rest studies.     

Availability of services to treat patients with acute low back pain.

Guidelines for the management of acute low back pain were published in 1994. This national survey, conducted soon after, showed that the availability of services for general practitioners (GPs) to treat acute back pain fell short of the guideline recommendations. A repeat survey will be performed to measure the impact of guideline publication and dissemination.     

Psychological aspects of acute low back pain in general practice

A prospective controlled study of acute low back pain in general practice was carried out. The presence of psychiatric illness was measured by use of the general health questionnaire (GHQ), by clinical assessment, and personality factors by use of the Eysenck personality inventory (EPI). It was found that overall the amount of psychiatric illness did not differ between patients with back pain and their controls at the time of presentation, although there was a higher prevalence of previous psychiatric illness in the back-pain group. The only difference in the personality factors measured was a higher degree of extraversion in the back-pain patients.     

Screening of lower back pain, low back pain clinic. The clinical experience

Acute low back pain is a common complaint with high prevalence in society. Orthopaedic and specialist spinal services may be overwhelmed by large numbers of patients with low back pain who do not require investigation or surgical intervention. This phenomenon has led to the establishment of back pain screening clinics as a system of triage for those with acute low back pain. In March 2001, a back pain screening clinic was established in the Adelaide and Meath Hospitals incorporating the National Children's hospital. Six hundred and sixty-five patients were seen in the first year of this clinic. Of these, only ninety-six required referral to the orthopaedic spinal clinic. Just twenty-nine of these patients required surgical intervention. The introduction of this service resulted in a reduction in the waiting periods for the specialised spine clinic. We conclude that back pain screening clinics result in a clinical and economical improvement in the care of those suffering from acute low back pain. This is achieved by the systematic and efficient assessment, treatment and referral of patients afflicted with acute low back pain.     

Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

BACKGROUND: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care. AIM: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs). DESIGN OF STUDY: Group randomised controlled trial, using the health centre as the unit of randomisation. SETTING: Primary care teams in north-west England. METHOD: Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms. RESULTS: Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%). CONCLUSION: The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.     

Transdermal fentanyl for chronic low back pain

Purpose

Chronic low back pain is a common clinical problem. As medication, non-steroidal anti-inflammatory drugs are generally used; however, they are sometimes non-effective. Recently, opioids have been used for the treatment of chronic low back pain, and since 2010, transdermal fentanyl has been used to treat chronic non-cancer pain in Japan. The purpose of the current study was to examine the efficacy of transdermal fentanyl in the treatment of chronic low back pain.

Materials and Methods

This study included patients (n=62) that suffered from chronic low back pain and were non-responsive to non-steroidal anti-inflammatory drugs. Their conditions consisted of non-specific low back pain, multiple back operations, and specific low back pain awaiting surgery. Patients were given transdermal fentanyl for chronic low back pain. Scores of the visual analogue scale and the Oswestry Disability Index, as well as adverse events were evaluated before and after therapy.

Results

Overall, visual analogue scale scores and Oswestry Disability Index scores improved significantly after treatment. Transdermal fentanyl (12.5 to 50 µg/h) was effective in reducing low back pain in 45 of 62 patients; however, it was not effective in 17 patients. Patients who experienced the most improvement were those with specific low back pain awaiting surgery. Adverse events were seen in 40% of patients (constipation, 29%; nausea, 24%; itching, 24%).

Conclusion

Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery; however, it did not decrease pain in 27% of patients, including patients with non-specific low back pain or multiple back operations.     

Research methods for subgrouping low back pain

Background  

There is considerable clinician and researcher interest in whether the outcomes for patients with low back pain, and the efficiency of the health systems that treat them, can be improved by 'subgrouping research'. Subgrouping research seeks to identify subgroups of people who have clinically important distinctions in their treatment needs or prognoses. Due to a proliferation of research methods and variability in how subgrouping results are interpreted, it is timely to open discussion regarding a conceptual framework for the research designs and statistical methods available for subgrouping studies (a method framework). The aims of this debate article are: (1) to present a method framework to inform the design and evaluation of subgrouping research in low back pain, (2) to describe method options when investigating prognostic effects or subgroup treatment effects, and (3) to discuss the strengths and limitations of research methods suitable for the hypothesis-setting phase of subgroup studies.     

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.     

Chronic low back pain and depression

In an attempt to clarify the relationship between chronic low back pain and depression, the authors studied the incidence of depression, alcoholism, and chronic back pain in first-degree relatives of chronic pain patients with and without depression. A higher incidence of recurrent unipolar depression was found in those relatives of patients with depression than without depression. These findings raise questions about the concept of chronic low back pain simply as a variant of depression and they suggest that the occurrence of major depression together with chronic back pain might relate to genetic vulnerability to depression.     

Development of a diagnostic checklist for low back pain patients.

The study of psychosomatic disorders implies that environmental variables, as well as attitudes and personality, can influence an individual's physical health. The present study developed a checklist composed of demographic and psychological variables to help to make diagnostic decisions related to chronic low-back pain. The need for the checklist stems from the situation that medical clinical evidence is often inconclusive to identify the etiology of patient complaints of low back pain. Cut-off scores on the checklist were able to discriminate with greater than 80% accuracy patients who received a specific medical diagnosis from patients who received a non-specific medical diagnosis. The findings provide additional support for procedures used to make difficult diagnoses of low back pain.