Low back pain

Many people suffer from low back pain in the course of their life, of whom not all seek health care. In the majority of patients who seek care and refrain from work, the problem of pain resolves within a few weeks. It is reason that chronic pain syndromes such as chronic back pain are responsible for enormous costs for health care and society. Also, many diagnostics procedures and durability of rehabilitation makes low back pain as a very expensive disease. All of that are good reasons to make algorithm for diagnostic and treatment of low back pain in Croatian Society for Rheumatology.     

Low back pain: how does your physical therapist treat low back pain?

Low back pain is so common that 8 of 10 people experience it at some time in their lives. Although the pain in your back may be severe, most low back pain is not due to a serious problem. There are many risk factors that increase the chances of getting low back pain. As we get older, we often feel more back pain due to weakened muscles and stiffening joints. New clinical practice guidelines for the treatment of low back pain were published in the April 2012 issue of JOSPT. The guidelines describe ways to treat back pain based on best research evidence.     

Epidemiology of low back pain.

The science of epidemiology is difficult to apply to the problem of low back pain. This article discusses the problems associated with the study of low back pain, population surveys, risk factors for low back pain, and disability because of low back pain.     

Assessment of sexual activity in patients with back pain compared with patients with neck pain

Recent research has shown significant adverse effects of chronic low back pain on sexual activity in 46% of patients. To establish whether and how chronic low back pain adversely affects sexual activity, a questionnaire-based study was conducted on a patient group (low back pain) and a comparison group (neck pain). Patients were administered a visual analog scale, a series of conventional questionnaires, and a specifically designed sexual activity questionnaire covering frequency of intercourse before and since onset of pain, discomfort during intercourse, satisfaction with sexual life, and comfortable and uncomfortable basic coital positions. Patients with low back pain reported more interference than did patients with neck pain, and women with low back pain were more affected than men. Compared with the other groups, women with low back pain had greater reduction in frequency of intercourse, more marked discomfort during intercourse, and more interference with their sexual lives. The most pain generating position was prone for both genders, and the most comfortable one was supine. Sexual impairment, more marked in women, seems to be related to the triggering of pain by intercourse and to psychologic factors.     

椎间盘源性腰痛的分型

目的 介绍一种新的椎间盘源性腰痛的分型方法 ,以更好地指导临床诊断和治疗.方法通过回顾性分析386例慢性腰痛患者的椎间盘造影术中X线荧光影像和术后CT扫描片,结合术中患者有无一致性疼痛复制反应,将椎间盘源性腰痛进行分型.结果386例腰痛患者共行1056个椎间盘的腰椎间盘造影术,共有192例患者(49.7%)的226个椎间盘(21.4%)出现疼痛复制反应.192例出现疼痛复制反应的患者中,由于纤维环破裂(internal disc disruption,IDD)160例,由于终板破裂(internal end-plate disruption,IED)32例,分别占83.3%和16.7%.应用修正的Dallas CT椎间盘造影分级方法评估IDD患者纤维环放射状撕裂程度,应用术中荧光X线影像结合术后CT扫描评估IED患者终板放射状破裂程度.IDD患者纤维环破裂分级越高,椎间盘造影时一致性疼痛比例越大(r=-0.604,P=0.000).IED患者终板破裂程度越大,椎间盘造影时一致性疼痛比例越大(r=0.683,P=0.000).结论 根据临床研究结果,我们将椎间盘源性腰痛分为两种类型,由IDD引起的腰痛和由IED引起的腰痛.临床上这两种类型的椎间盘源性腰痛都要通过腰椎间盘造影术确诊,诊断过程、放射状撕裂方式和疼痛反应方式完全一致,表明其为一种科学、合理的分型方法.     

Correlation of nerve root pain with dermatomal sensory threshold and back pain with spinal movement in single level lumbar spondylosis

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain.     

Low back pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.     

An analysis of the relationship between activity and pain in chronic and acute low back pain

We studied the temporal relationship between pain and activity in patients with acute or chronic low back pain. We studied 15 patients with acute low back pain and 15 patients with chronic low back pain over 3 wk. The activity levels were collected automatically using a wrist accelerometer and were sampled every minute. The pain levels were recorded at least every 90 min using a pocket-sized electronic diary. The time series from each patient were then analyzed using the cross-correlation function at various time offsets. We found that during the first 7 days of acute low back pain, there was a significant (P < 0.01) degree of cross-correlation between activity and pain. On average, pain followed activity by approximately 30 min. As these patients improved and reported less pain, the relationship between activity and pain disappeared. There was no such relationship at any point among the patients with chronic low back pain.     

A prospective follow-up study of low back pain in the community

STUDY DESIGN: Opportunistic prospective follow-up study. OBJECTIVE: To describe the natural history of low back pain in the community and to model the factors predictive of recovered versus persistent low back pain. SUMMARY OF BACKGROUND DATA: A two-phase questionnaire was mailed to adults in the Bradford Metropolitan Health District in 1994. Valid respondents were surveyed again in 1997. Analysis is based on the combined results of these two surveys. METHODS: Unifactorial and multifactorial statistics were analyzed based on 1455 adults, with and without low back pain. RESULTS: One third of respondents reported no lifetime low back pain. Average lifetime prevalence was 59% and average annual prevalence 41%. Of those who reported lifetime low back pain, 42% reported persistent annual low back pain, 18% reported a first episode in 1997, resulting in a 4% population incidence rate, and 40% reported intermittent low back pain. The likelihood of having had low back pain increased significantly with age. Those who reported a new case of low back pain in 1997 were significantly more likely to be 25-34 years of age, and these persons were most likely to report acute low back pain with very little disability. Those with persistent low back pain were significantly more likely to report chronic low back pain with some disability. Logistic regression modeling was unable to predict recovered versus persistent low back pain, given the person, pain, and treatment factors available. CONCLUSIONS: Results showed that low back pain is a mutable problem with acute episodes blending into longer periods resulting in more disability as time progresses. A wide range of demographic, pain, consultation, and treatment factors were not predictive of low back pain recovery.     

Spine loading characteristics of patients with low back pain compared with asymptomatic individuals.

STUDY DESIGN: Patients with low back pain and asymptomatic individuals were evaluated while performing controlled and free-dynamic lifting tasks in a laboratory setting. OBJECTIVE: To evaluate how low back pain influences spine loading during lifting tasks. SUMMARY OF BACKGROUND DATA: An important, yet unresolved, issue associated with low back pain is whether patients with low back pain experience spine loading that differs from that of individuals who are asymptomatic for low back pain. This is important to understand because excessive spine loading is suspected of accelerating disc degeneration in those whose spines are damaged already. METHODS: In this study, 22 patients with low back pain and 22 asymptomatic individuals performed controlled and free-dynamic exertions. Trunk muscle activity, trunk kinematics, and trunk kinetics were used to evaluate three- dimensional spine loading using an electromyography- assisted model in conjunction with a new electromyographic calibration procedure. RESULTS: Patients with low back pain experienced 26% greater spine compression and 75% greater lateral shear (normalized to moment) than the asymptomatic group during the controlled exertions. The increased spine loading resulted from muscle coactivation. When permitted to move freely, the patients with low back pain compensated kinematically in an attempt to minimize external moment exposure. Increased muscle coactivation and greater body mass resulted in significantly increased absolute spine loading for the patients with low back pain, especially when lifting from low vertical heights. CONCLUSIONS: The findings suggest a significant mechanical spine loading cost is associated with low back pain resulting from trunk muscle coactivation. This loading is further exacerbated by the increases in body weight that often accompany low back pain. Patient weight control and proper workplace design can minimize the additional spine loading associated with low back pain.     

Post-surgical back pain

The incidence of post-surgical low back pain in patients who have been subjected to general anæsthesia or epidural has been found to be about 20%. The aim of this paper is to raise awareness about the ætiology, clinical recognition and prevention of post-surgical low back pain. The case of a 51 year old male is detailed. He had a 5-year history of severe low back pain following surgery to his right wrist for DeQuervain's syndrome. He also reported lower extremity pain, greater on the right, and stomach cramps. The patient's ability to walk was limited and pain was aggravated by sitting, standing still, lying down and walking. Little seemed to relieve the pain. Referral to various orthopædic surgeons and neurologists had proved fruitless, and no diagnosis for his symptoms had been established. After conservative, non-manipulative care by chiropractors, an MRI Scan and referral to another orthopædic surgeon, a diagnosis of central disc protrusion was established. It has been noted that patients who are anæsthetised for 40 minutes or longer, seem to be at a greater risk of subsequent low back pain. It is this factor and a combination of muscle relaxants and poor patient support that appear to contribute to the outcome of post surgical low back pain.     

Intertester reliability of a low back pain classification system

STUDY DESIGN: This prospective study of intertester reliability examined pairs of therapists' ability to agree independently on a patient's low back pain diagnosis. OBJECTIVE: To determine the intertester reliability of a low back pain classification system among experienced and novice clinicians. BACKGROUND: Many of the disparate categorization schemes for patients with low back pain are purely nominal, assigning designations based on the presumptive source of the problem without providing any practical guide for rehabilitation. A useful classification scheme reliably groups patients into treatment-directing categories. METHODS: The study included 204 patients with low back pain referred to 10 clinics across Canada. Paired physiotherapists performed separate physical examinations on each patient. Both examiners then completed a simple ballot choosing one of five pain patterns. RESULTS: Agreement on patient classification by independent examiners was 78.9% (kappa = 0.61). CONCLUSION: This clinically relevant and clearly defined pain pattern system uses key elements of the history and examination to classify patients with low back pain. The pattern provides a framework for initiating active rehabilitation strategy. Using this approach, clinicians agreed on the categorization of 78.9% of mechanical low back pain cases.     

Prognosis of chronic low back pain: design of an inception cohort study

Background

Although clinical guidelines generally portray chronic low back pain as a condition with a poor prognosis this portrayal is based on studies of potentially unrepresentative survival cohorts. The aim of this study is to describe the prognosis of an inception cohort of people with chronic low back pain presenting for primary care.

Methods/Design

The study will be an inception cohort study with one year follow-up. Participants are drawn from a cohort of consecutive patients presenting with acute low back pain (less than 2 weeks duration) to primary care clinics in Sydney, Australia. Those patients who continue to experience pain at three months, and are therefore classified as having chronic back pain, are invited to participate in the current study. The cohort will be followed up by telephone at baseline, 9 months and 12 months after being diagnosed with chronic low back pain. Recovery from low back pain will be measured by sampling three different outcomes: pain intensity, interference with function due to pain, and work status. Life tables will be generated to determine the one year prognosis of chronic low back pain. Prognostic factors will be assessed using Cox regression.

Discussion

This study will determine the prognosis of chronic non-specific low back pain in a representative cohort of patients sourced from primary care. The results of this study will improve understanding of chronic low back pain, allowing clinicians to provide more accurate prognostic information to their patients.     

Industrial back pain and recovery time

A retrospective longitudinal non randomized pilot study of 79 selected patient files was analysed in regards to industrial low back pain and recovery time. The files are from a multidisciplinary industrial clinic dealing with occupationally injured workers. The patients in the study were all males, between the ages of 17 and 63 years and all presented with post-traumatic low back pain. An attempt was made to see if the return of the injured worker to the workplace could be predicted. Manipulation was the main approach in the treatment of low back pain. Results of the study show that approximately 10 treatments were required to return the patient to work, within the parameters of industrially related post-traumatic low back pain, without radiation and without psychological overlay. This retrospective study serves to identify the lack of guidelines in selecting appropriate therapy modes and calls for a subsequent prospective evaluation.     

Myofascial aspects of low back pain.

Myofascial TrPs are an often overlooked but treatable source of pain and discomfort in the low back. They often complicate or coexist with other causes of low back pain, and they can mimic other neuromuscular or back musculoskeletal problems. Successful treatment of myofascial pain requires the identification of TrPs by manual examination, identification of mechanical or systemic perpetuating factors, treatment of the specific TrPs, and corrective action to prevent their recurrence.     

Theories of back pain and health care utilization.

Because most people in the United States have occasional back pain, demand for the treatment of back pain is widespread. Yet, few treatments have proven to be more effective than placebo therapy. We examine patterns of treatment that have emerged in the absence of definitive treatment. We concentrate on high-cost users of back pain treatment (i.e., chronic pain patients) and high-cost treatments (i.e., surgical and non-surgical hospitalization for low back pain). The small minority of back pain patients whose disability persists into chronicity (90 days or more) accounts for a disproportionate amount of all back pain costs. Interventions have been developed to prevent back pain but, once back pain has already occurred, little is done to prevent it from becoming chronic. Drug therapy may be used to treat the symptom of chronic pain, the cause of which may not be thereby affected. Regarding high-cost treatments, surgical and nonsurgical hospitalizations for low back pain are common practices in the United States. Pain specialists for the past 15 years have advocated a conservative approach to back pain, but the rate of surgery for low back pain increased during this time. Average lengths of stay for surgical and nonsurgical low back pain hospitalizations decreased. We explore why, in the instance of low back pain surgery, change was resisted, whereas, in the instance of average lengths of stay, change was accepted. In view of why change may be resisted or accepted, we discuss interventions designed to change physicians' practice style.     

Association between brain and low back pain

Most chronic low back pain includes elements of nociceptive pain, neuropathic pain, and nonorganic pain. We conducted screening for nonorganic pain with use of the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP), which is simple and can be used for multidimensional assessment. Research on pain areas using functional magnetic resonance imaging (fMRI) and positron emission tomography has shown that the dopamine system contributes to the pathology of chronic low back pain. Chronic low back pain patients show decreased activation of the anterior cingulate cortex, prefrontal cortex, and nucleus accumbens. Given that both the anterior cingulate cortex and prefrontal cortex belong to the descending inhibitory system, and that the nucleus accumbens, which is involved in the dopamine system, releases μ-opioids that act to relieve pain, decreased activation in these three brain regions may be related to decreased function of the descending inhibitory system. A pathological condition that can be explained at the molecular biological level clearly exists between chronic low back pain and psychosocial factors, and investigations of a pathological condition of chronic low back pain including brain function are needed.     

Psychological and functional profiles in select subjects with low back pain.

BACKGROUND CONTEXT: Some researchers have found a correlation of poor treatment outcomes in patients with low back pain and abnormal psychological profiles, whereas others have failed to confirm this correlation. A critical feature of this debate has been whether abnormal psychological profiles seen in patients with back pain are the result of the ongoing back pain or whether pre-existing psychological features predispose to a poor clinical outcome. PURPOSE: To determine the relationship of psychometric testing scores to the presence and duration of back pain of differing causes. STUDY DESIGN/SETTING: This was a prospective observational study of the psychological profiles of groups of patients with low back pain and controls. PATIENT SAMPLE: Subjects having a variety of painful back conditions (n=310) were compared with a control group of subjects without low back complaints who had undergone cervical spine surgery (n=73). OUTCOMES MEASURES: Psychometric testing (Modified Zung and Modified Somatic Pain Questionnaire) was performed along with pain scores (visual analog scale [VAS]), a standardized Low Back Pain Questionnaire, and the Oswestry Low Back Pain Disability Questionnaire in the evaluation of back pain and control subjects. METHODS: The subjects with painful back conditions included patients with presumed discogenic pain undergoing discography (n=95); patients with symptomatic isthmic spondylolisthesis coming to fusion (n=61); patients with chronic vertebral osteomyelitis before diagnosis and treatment (n=39). There was also a nonpatient group of soldiers with chronic low back pain not seeking medical care (n=115). The control subjects without low back pain consisted of a group who had undergone cervical spine surgery (n=73). Psychometric testing was performed and compared in the evaluation of subjects having these different painful back conditions. Analysis was done comparing pain scores, function scores, and psychological testing scores between the symptomatic and asymptomatic groups. RESULTS: The VAS maximum in last week score for the entire group was 7.1, and scores were not significantly different in all low back pain groups. The Oswestry scores were poorest in the discography group compared to spondylolisthesis and osteomyelitis. Functional scores were similar in the soldiers with low back pain and controls without low back pain. Both Depression and Somatic Pain scores were most abnormal in the discogenic low back pain group. Only 21% of this group had normal scores, compared with 71% of the spondylolisthesis group, 79% of osteomyelitis group, and 88% of the group with chronic low back pain not seeking treatment (p<.001 in all groups). The asymptomatic control group had 85% normal scores. CONCLUSIONS: Despite similar pain levels and pain duration, patients with the discographic diagnosis of discogenic back pain have poorer functional scores and very abnormal psychological scores compared with other subjects with chronic low back pain resulting from spondylolisthesis requiring surgery or chronic pyogenic osteomyelitis. Chronic moderately severe mechanical low back pain in healthy subjects was not associated with abnormal psychological scores or functional disability.