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.     

Verbesserung der ambulanten Versorgung von Patienten mit chronischen Rückenschmerzen

BACKGROUND: Treatment for chronic low back pain in primary care has a poor-quality outcome. There is evidence that multimodal therapy is the most successful approach to its management. We tried to evaluate whether giving primary care physicians evidence-based recommendations on therapy of chronic back pain or directly implementing a multimodal program would improve the outcome of patients with low back pain treated in primary care. METHODS: In the first phase, physicians were asked to document the course of patients suffering from low back pain of at least 4 weeks' duration with no decrease in intensity, noting pain intensity before and after 6 months of conventional, nonsurgical treatments. In the present, second, phase of the study, recommendations issued by the Medicines Committee of the German Medical Profession and the U.S. Agency for Health Care Policy and Research for the management of back pain were presented to doctors in printed form and at conferences. In parallel with this, a multimodal program for the treatment of chronic low back pain (4 h/day for 20 days: medical training therapy, cognitive-behavioral therapy, physiotherapy, and patient education) was organized in a private health-oriented sports center in cooperation with three private physiotherapy practices, and a psychologist and a pain specialist from the outpatient pain clinic at the University Hospital in Erlangen. We examined how physicians changed the therapy and how effective it was, the latter as reflected in the mean sum value of the percent pre- to posttreatment changes in pain intensity, how much pain interfered with daily living, depressivity, and quality of life. Data after interventions were compared with baseline data from the first phase. RESULTS: Data relating to 36 patients following treatment by 14 primary care physicians who had been given information about therapy recommendations and to 51 patients who had participated in the multimodal therapy program were compared with baseline data recorded in 157 patients. Recommendations changed neither the therapy preferred by primary care physicians nor the quality of outcome of conventional treatment. In contrast, the multimodal program of therapy for chronic low back pain improved the outcome significantly more than conventional therapy (mean improvement in general outcome score 22 vs. 7%, respectively, compared with baseline data; P<0.001). CONCLUSIONS: Giving primary care physicians information on the therapy recommended for treatment of low back pain does not lead to any change in physicians' preferred therapy. Multimodal programs for treatment of chronic low back pain should be organized locally, with existing health care providers joining forces to improve the quality of outcome in chronic low back pain managed in primary care.     

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.     

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.     

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.     

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.      

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.     

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.     

Schmerzverarbeitungspattern bei chronischen R��ckenschmerzen Pilotstudie

Background

The variables pain intensity (SI), disability (DS) and quality of life (QoL) belong to a set of primary patient-based outcomes in chronic low back pain (CLBP). The avoidance-endurance model (AEM) assumes three maladaptive and one adaptive pain response pattern. The purpose of this study was to study the level and course of the outcomes with regard to the four AEM patterns.

Patients and methods

A total of 52?CLBP inpatients were investigated at 2?points in time: during the first days after admission and 6?months after the acute exacerbation of pain. Differences between AEM patterns were analyzed with repeated measurement analyses of variance.

Results

Groups differences were found for SI (F_{(3, 48)}=2.82, p<0.05), general (F_{(3, 48)}=6.78, p<0.05) and health-related QoL (F_{(3, 48)}=5.99, p <0.05). In contrast, for the variable disability only a significant time effect was found.

Conclusion

The results show differences in the level and process of SI, DS and QoL between the subgroups. An AEM-based classification of subgroups is also reasonable for CLPB patients.     

Die Muskulatur als Ursache für Rückenschmerzen

Zusammenfassung Die Funktion der Muskulatur scheint eine wichtige Rolle bei der Entstehung und Aufrechterhaltung chronischer Rückenschmerzen zu spielen. Eine muskuläre Insuffizienz, wie sie bei Rückenpatienten in vielen Untersuchungen nachgewiesen werden konnte, belastet die passiven, schmerzauslösenden Anteile der Wirbelsäule. Dabei spielt die funktionelle Instabilität der Wirbelsäule eine große Rolle. In den letzten Jahren konnten diese Veränderungen durch Oberflächen-EMG mittels Spektralanalyse, Untersuchung von Muskelfasertyp und -größe sowie durch Analyse der Körperkoordination nachgewiesen werden. Da viele Patienten mit chronischen Rückenschmerzen neben muskulärer Insuffizienz auch psychosoziale Probleme haben und ein ausgeprägtes Schon- und Vermeidungsverhalten zeigen, sind therapeutisch neben einem muskulären Training auch psychotherapeutische Maßnahmen notwendig.     

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.     

Akupunktur bei Rückenschmerzen

BACKGROUND: Acupuncture is commonly used to treat back pain. A meta-analysis of clinical trials of acupuncture for this condition came to a positive conclusion whilst a qualitative review was negative. AIM: To compare our meta-analysis of trials of acupuncture for the treatment of back pain with a qualitative review and the most recent studies on the subject. METHODS: A systematic literature search was conducted to retrieve all randomised controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture was assessed by consulting six experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of subjects who where improved at the end of treatment. These data are discussed in relation to the qualitative review and the most recent studies. RESULTS: Twelve studies were included of which nine presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval 1.28 to 4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25). The results from the majority of the most recent studies also support the effectiveness of acupuncture in the treatment of back pain. CONCLUSIONS: Collectively, these data imply that acupuncture is superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.     

Vergleich zweier Screening-Fragebogen für Patienten mit Rückenschmerzen

Background

Screening for risk factors for chronic low back pain (LBP) (yellow flags) is recommended by clinical guidelines. Various questionnaires to assess yellow flags have been proposed.

Objectives

The aim of this study was to compare the prognostic validity of two screening questionnaires.

Material and methods

This was a prospective observational study with 241 LBP patients from 9 general practitioners, 4 orthopedic surgeons and 2 pain clinics. We compared the Örebro musculoskeletal pain questionnaire (ÖMSPQ) and the Heidelberg short questionnaire (HKF-R10) which were completed by all patients at inclusion before the consultation. Primary outcomes were assessed after 3 months by mail. Clinical endpoints were pain intensity, disability and more than two follow-up consultations.

Results

The sensitivity of the HKF-R10 to predict the primary outcome ranged from 81 % to 88?%, while the specificity was much lower (37–47?%). The ÖMSPQ showed an opposite pattern with a low sensitivity ranging from 50 % to 58?% but a higher specificity (77–80?%). In patients initially classified as having chronic LBP (n?=?81), using the questionnaires as a diagnostic tool, the sensitivity of both questionnaires increased but specificity decreased. Single items may perform better with regard to primary outcome than the sum scores.

Conclusion

Both screening questionnaires for chronic LBP have insufficient diagnostic and prognostic validity for routine use in ambulatory care. Further studies are needed to improve diagnostic and prognostic validity and to elaborate criteria for a targeted use of screening questionnaires to guide therapeutic interventions.     

Psychosoziale Risikofaktoren für chronischen Rückenschmerz in der Allgemeingesellschaft und im Leistungssport

Background

Lumbar back pain and the high risk of chronic complaints is not only an important health concern in the general population but also in high performance athletes. In contrast to non-athletes, there is a lack of research into psychosocial risk factors in athletes. Moreover, the development of psychosocial screening questionnaires that would be qualified to detect athletes with a high risk of chronicity is in the early stages. The purpose of this review is to give an overview of research into psychosocial risk factors in both populations and to evaluate the performance of screening instruments in non-athletes.

Methods

The databases MEDLINE, PubMed, and PsycINFO were searched from March to June 2016 using the keywords “psychosocial screening”, “low back pain”, “sciatica” and “prognosis”, “athletes”. We included prospective studies conducted in patients with low back pain with and without radiation to the legs, aged ≥18 years and a follow-up of at least 3 months.

Results

We identified 16 eligible studies, all of them conducted in samples of non-athletes. Among the most frequently published screening questionnaires, the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) demonstrated a sufficient early prediction of return to work and the STarT Back Screening Tool (SBT) revealed acceptable performance predicting pain-related impairment. The prediction of future pain was sufficient with the Risk Analysis of Back Pain Chronification (RISC-BP) and the Heidelberg Short Questionnaire (HKF).

Conclusion

Psychosocial risk factors of chronic back pain, such as chronic stress, depressive mood, and maladaptive pain processing are becoming increasingly more recognized in competitive sports. Screening instruments that have been shown to be predictive in the general population are currently being tested for suitability in the German MiSpEx research consortium.

     

Welcher Weg führt von chronischen Rückenschmerzen zur Depressivit?t?

Background

Chronic pain and depression are highly comorbid; however, the longitudinal link is only partially understood. This study examined direct and indirect effects of chronic back pain on depression using path analysis in a general population sample, focussing on cognitive mediator variables.

Methods

Analyses are based on 413 participants (aged 18?C75 years) in a population-based postal survey on back pain who reported chronic back pain at baseline. Follow-up data were collected after 1 year. Depression was measured with the Center for Epidemiologic Studies Depression Scale (CES-D). Fear-avoidance-beliefs (FABQ), catastrophizing and helplessness/hopelessness (KRSS) were considered as cognitive mediators. Data were analyzed using path analysis.

Results

Chronic back pain had no direct effect on depression at follow-up when controlling for cognitive mediators. A mediating effect emerged for helplessness/hopelessness but not for catastrophizing or fear-avoidance beliefs.

Conclusions

These results support the cognitive mediation hypothesis which assumes that psychological variables mediate the association between pain and depression. The importance of helplessness/hopelessness is of relevance for the treatment of patients with chronic back pain.     

Wirksamkeit klassischer Massagetherapie bei chronischen Rückenschmerzen und Funktionsstörungen im Bewegungssystem

Manuelle Medizin - Klassische Massagetherapie (KMT) ist laut Physiotherapie-Ausbildungs- und Prüfungsverordnung Basis diagnostischer Tastfähigkeit zur Beurteilung von...     

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.     

Qualitätsindikatoren für die Versorgung von Patienten mit Rückenschmerzen

Introduction

Low back pain (LBP) is an epidemiologically and economically relevant health care problem appropriate for quality assurance approaches. Therefore an expert panel (AQUIK) of the National Association of Statutory Health Insurance Physicians has proposed three quality indicators (QI) for monitoring the quality of ambulatory care for LBP. The aim of this article is to present and evaluate the proposed QIs.

Material and methods

The three proposed QIs relating to red flags, imaging and sick leave certificates were evaluated with regard to the underpinning evidence, epidemiology and feasibility. Guidelines and original research as well results from surveys and observational studies evaluating adherence to LBP guidelines were used for assessment.

Results

The expert panel concluded that only the recording of red flags is a relevant and feasible QI. Despite a two-stage expert method the epidemiology of LBP, feasibility and existing routine health care data were not sufficiently taken into account. The author’s conclusion differs in two instances. The red flag concept is not sufficiently clinically validated and recordable to be used as a QI. Otherwise imaging is considered a suitable QI given the observed overuse and the availability of billing data.

Conclusion

Deriving valid and pragmatic QI from LBP guidelines for evaluating care for LBP is difficult. The core messages of guidelines are only recommendations with limited precision and transferability to individual patients. For pragmatic reasons definition of an upper or lower proportion of patients receiving a given health care service is recommended instead of tedious individual evaluation. Reasonable estimates can be based on data from research on health care services. Because of this uncertainty QIs should be evaluated before they are used as a steering instrument.