Outcome of low back pain in general practice: a prospective study

Objectives: To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Design: Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Setting: Two general practices in south Manchester. Subjects: 490 subjects (203 men, 287 women) aged 18-75 years. Main outcome measures: Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Results: Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. Conclusions: The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.

Key messages

• It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month
• In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behaviour and self reported pain and disability
• While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability
• Only 25% of the patients who consulted about low back pain had fully recovered 12 months later
• Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

     

Trunk muscle onset and cessation in golfers with and without low back pain

The knowledge of the onset and cessation timing of the paraspinal muscles that surround the lumbar spine is an important area of research for the understanding of low back pain. This study examined the timing of the erector spinae and external oblique muscle activity in a group of golfers with and without low back pain. The study compared the results of surface electromyography measurements for two groups of golfers. Twelve male golfers who had reported a mild or greater level of pain in the lower back that was experienced while playing golf were examined. A further fifteen male golfers who had reported no history of lower back pain in the previous 12 months were recruited as controls. The results showed that the low-back-pain golfers switched on their erector spinae muscle significantly in advance of the start of the backswing. This finding was not evident in the group who did not have low back pain symptoms. Low-back-pain golfers, therefore, may use the erector spinae muscle as a primary spinal stabiliser instead of the stronger deeper muscles such as transversus abdominis and multifidus. These results may have important implications for conditioning programmes for golfers with low back pain.     

Native Healing in Alaska—Report From Serpentine Hot Springs

Traditional Alaskan Native healing practices, specifically sweat bathing and hot springs bathing, have medical connotations in that they involve sociocultural factors important to practicing medicine among Alaskan Native people. At Serpentine Hot Springs in northwest Alaska, relief for arthritis, back pain, hip pain, headaches, skin rashes and other disorders was sought. The “treatment setting” was an informal bathhouse and bunkhouse and Eskimo tribal doctors and patients were assigned tasks related to healing. Continuity with traditional cultural patterns was achieved in several ways: meals tended to be traditional Eskimo fare, the predominant language spoken was Inupiaq and styles of interaction were Inupiat in character. All patients showed improvement. The experience reported herein is instructive for those seeking innovative approaches treating Native American groups.     

Is muscle co-activation a predisposing factor for low back pain development during standing? A multifactorial approach for early identification of at-risk individuals

Purpose and scopeLow back pain development has been associated with static standing postures in occupational settings. Previous work has demonstrated gluteus muscle co-activation as a predominant pattern in previously asymptomatic individuals who develop low back pain when exposed to 2-h of standing. The purpose of this work was to investigate muscle co-activation as a predisposing factor in low back pain development while including a multifactorial approach of clinical assessment tools and psychosocial assessments to identify individuals who are at risk for pain development during standing.ResultsForty percent of participants developed low back pain during the 2-h of standing. Pain developers demonstrated bilateral gluteus medius and trunk flexor–extensor muscle co-activation prior to reports of pain development. Pain developers and non-pain developers demonstrated markedly different patterns of muscle activation during the 2-h of standing. A novel screening test of active hip abduction was the only clinical assessment tool that predicted pain development.ConclusionsGluteus medius and trunk muscle co-activation appears to be a predisposing rather than adaptive factor in low back pain development during standing. A combination of a positive active hip abduction test and presence of muscle co-activation during standing may be useful for early identification of at-risk individuals.     

Stretching of the back improves gait, mechanical sensitivity and connective tissue inflammation in a rodent model

The role played by nonspecialized connective tissues in chronic non-specific low back pain is not well understood. In a recent ultrasound study, human subjects with chronic low back pain had altered connective tissue structure compared to human subjects without low back pain, suggesting the presence of inflammation and/or fibrosis in the low back pain subjects. Mechanical input in the form of static tissue stretch has been shown in vitro and in vivo to have anti-inflammatory and anti-fibrotic effects. To better understand the pathophysiology of lumbar nonspecialized connective tissue as well as potential mechanisms underlying therapeutic effects of tissue stretch, we developed a carrageenan-induced inflammation model in the low back of a rodent. Induction of inflammation in the lumbar connective tissues resulted in altered gait, increased mechanical sensitivity of the tissues of the low back, and local macrophage infiltration. Mechanical input was then applied to this model as in vivo tissue stretch for 10 minutes twice a day for 12 days. In vivo tissue stretch mitigated the inflammation-induced changes leading to restored stride length and intrastep distance, decreased mechanical sensitivity of the back and reduced macrophage expression in the nonspecialized connective tissues of the low back. This study highlights the need for further investigation into the contribution of connective tissue to low back pain and the need for a better understanding of how interventions involving mechanical stretch could provide maximal therapeutic benefit. This tissue stretch research is relevant to body-based treatments such as yoga or massage, and to some stretch techniques used with physical therapy.     

Limited Health Knowledge as a Reason for Non-Use of Four Common Complementary Health Practices

Background

Complementary health practices are an important element of health/healthcare seeking behavior among adults in the United States. Reasons for use include medical need, prevention and wellness promotion, and cultural relevance. Survey studies published over the past several decades have provided important information on the use of complementary health practices, such as acupuncture and yoga. A review of the literature, however, reveals an absence of studies looking specifically at who does not use these approaches, and why not.

Methods

To explore this issue two samples were created using data from the 2007 National Health Interview Survey Complementary and Alternative Medicine supplement. Of particular interest was the relationship between lack of health knowledge, as a reason for non-use, and key independent variables. The first sample was comprised of individuals who had never used any of four common complementary health practices -- acupuncture, chiropractic, natural products, and yoga. The second was a subset of those same non-users who had also reported low back pain, the most frequently cited health concern related to use of complementary therapies.

Results

A hypothesized association between lack of health knowledge, lower educational attainment, and other key socioeconomic indicators was supported in the findings. Although it was hypothesized that low back pain would be associated with greater information seeking, regardless of level of education, that hypothesis was not supported.

Conclusion

Lack of knowledge was found to affect utilization of common complementary health practices, regardless of the potentially motivating presence of back pain. Disparities in the utilization of complementary medicine, related to educational attainment and other socioeconomic factors, may negatively affect quality of care for many Americans. Creative approaches are needed to help reduce inequities in understanding and improve access to care for underserved populations.     

Osteopathic manipulative treatment and its relationship to autonomic nervous system activity as demonstrated by heart rate variability: a repeated measures study

Background

Osteopathic manipulative treatment (OMT) and ultrasound physical therapy (UPT) are commonly used for chronic low back pain. Although there is evidence from a systematic review and meta-analysis that OMT generally reduces low back pain, there are no large clinical trials that specifically assess OMT efficacy in chronic low back pain. Similarly, there is a lack of evidence involving UPT for chronic low back pain.

Methods

The OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial is a Phase III randomized controlled trial that seeks to study 488 subjects between August 2006 and June 2010. It uses a 2 × 2 factorial design to independently assess the efficacy of OMT and UPT for chronic low back pain. The primary outcome is a visual analogue scale score for pain. Secondary outcomes include back-specific functioning, generic health, work disability, and satisfaction with back care.

Conclusion

This randomized controlled trial will potentially be the largest involving OMT. It will provide long awaited data on the efficacy of OMT and UPT for chronic low back pain.

Trial registration

http://www.clinicaltrials.gov, NCT00315120     

Degenerative Pathways of Lumbar Motion Segments - A Comparison in Two Samples of Patients with Persistent Low Back Pain

Background

Magnetic resonance imaging (MRI) is used to identify spinal pathoanatomy in people with persistent low back pain. However, the clinical relevance of spinal degenerative MRI findings remains uncertain. Although multiple MRI findings are almost always present at the same time, research into the association with clinical outcomes (such as pain) has predominantly focused on individual MRI findings. This study aimed to: (i) investigate how multiple MRI lumbar spine findings cluster together within two different samples of patients with low back pain, (ii) classify these clusters into hypothetical pathways of degeneration based on scientific knowledge of disco-vertebral degeneration, and (iii) compare these clusters and degenerative pathways between samples.

Methods

We performed a secondary cross-sectional analysis on two dissimilar MRI samples collected in a hospital department: (1) data from the spinal MRI reports of 4,162 low back pain patients and (2) data from an MRI research protocol of 631 low back pain patients. Latent Class Analysis was used in both samples to cluster MRI findings from lumbar motion segments. Using content analysis, each cluster was then categorised into hypothetical pathways of degeneration.

Results

Six clusters of MRI findings were identified in each of the two samples. The content of the clusters in the two samples displayed some differences but had the same overall pattern of MRI findings. Although the hypothetical degenerative pathways identified in the two samples were not identical, the overall pattern of increasing degeneration within the pathways was the same.

Conclusions

It was expected that different clusters could emerge from different samples, however, when organised into hypothetical pathways of degeneration, the overall pattern of increasing degeneration was similar and biologically plausible. This evidence of reproducibility suggests that Latent Class Analysis may provide a new approach to investigating the relationship between MRI findings and clinically important characteristics such as pain and activity limitation.     

Work-related low back pain: secondary intervention.

A review of the literature indicates that non-specific low back pain is basically an age-related disorder that is affected by differences in occupation, genetics and personal behavior. The cause of low back pain is unknown in most cases, and most of the treatments in routine use are ineffective. There is no evidence that low back pain has decreased in recent years. Consequently, there are a growing number of investigators who believe that efforts at preventing low back pain are futile; that low back pain is an unavoidable consequence of life that will afflict two thirds of the adult population at some point in their lives. These investigators believe that programs aimed at reducing low back disability are likely to be more effective and less costly. Only a small percentage of people with low back pain become disabled, but this small percentage consumes most of the cost. The literature pertaining to the reduction of low back disability is reviewed and discussed. It is concluded that low back disability can be reduced, and that management (not the health care provider) has the primary responsibility for reducing disability.     

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.

OBJECTIVE--To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes. DESIGN--Inception cohort study. SETTING--Primary care. PATIENTS--103 patients with acute localised non-specific back pain lasting less than 72 hours. MAIN OUTCOME MEASURES--Complete recovery (disappearance of both pain and disability) and return to work. RESULTS--90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender. CONCLUSIONS--The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.     

Fibre type characteristics and function of the human paraspinal muscles: normal values and changes in association with low back pain

This review focuses on the role of the paraspinal muscles in relation to the development and existence of low back pain. It begins with a discussion of the deficits in paraspinal muscle strength and fatigue-resistance observed in low back pain patients and addresses the issue of ‘cause or effect’ with respect to muscle dysfunction and back pain. Our current knowledge regarding the ‘normal’ fibre type characteristics of the human erector spinae is then presented and the influence of these fibre type characteristics on the muscle's performance capacity is discussed. Alterations in the ‘microanatomy’ of the musculature in connection with low back pain, and the associated implications for the performance capacity of the patient, are then considered. Finally, a number of outstanding issues in relation to the clinical significance of back muscle dysfunction are identified, leading to the proposal of areas for future research.     

An investigation of the flexion relaxation ratio in adults with and without a history of self-reported low back pain and transient sitting-induced pain

It is unknown whether the presence of sitting-induced pain or a clinical history of low back pain (LBP) changes spine function outcomes such as the flexion relaxation ratio (FRR). The purpose of this investigation was to determine whether sitting-induced pain or a history of non-specific LBP results in a different FRR. Forty-seven participants were instrumented with surface electromyography over erector spinae at L1, and accelerometers at L1 and S2. Standing maximum lumbar flexion trials were taken preceding and following a 1-hour sitting trial. Pain ratings during sitting and history of LBP were used to group participants for analysis. FRR values taken after the sitting exposures were compared between those that did and did not develop pain during sitting. Baseline FRR values were compared participants with and without a history of LBP. No significant differences in FRR were found for either pain groups (p = 0.11) or clinical history (p = 0.85). Lack of differences may be due to participants not currently experiencing a clinical episode of pain when the ratio was measured and/or because 1-hour sitting exposure was not long enough to induce pain modulation. The findings suggest that neither sitting-induced pain development or clinical history need to be controlled to prevent confounding of FRR.     

Trial of an Anti-inflammatory Agent (Indomethacin) in Low Back Pain with and without Radicular Involvement

A short-term double-blind sequential trial of indomethacin against placebo in the treatment of low back pain, with and without nerve root pain such as sciatica, showed that indomethacin was significantly more effective than placebo in the group with nerve root pain. On the other hand, no difference was found between the treatments in the patients with uncomplicated low back pain. This difference may result from an effect of indomethacin on the inflammatory process around the nerve root which has been shown to be present when this is compressed.     

Prospective cohort study of predictors of incident low back pain in nurses.

OBJECTIVE: To assess the impact of handling patients and indicators of individual susceptibility on risk of low back pain in nurses. DESIGN: Prospective cohort study with follow up by repeated self administered every three months over two years. SETTING: NHS university hospital trust. SUBJECTS: 961 female nurses who had been free from low back pain for at least one month at the time of completing a baseline questionnaire. MAIN OUTCOME MEASURES: Incidence of new low back pain during follow up and of pain leading to absence from work. RESULTS: Of 838 women who provided data suitable for analysis, 322 (38%) developed low back pain during follow up (mean 18.6 months), including 93 (11%) whose pain led to absence from work. The strongest predictor of new low back pain was earlier history of the symptom, and risk was particularly high if previous pain had lasted for over a month in total and had occurred within the 12 months before entry to the study (incidence during follow up 66%). Frequent low mood at baseline was strongly associated with subsequent absence from work for back pain (odds ratio 3.4; 95% confidence interval 1.4 to 8.2). After adjustment for earlier history of back pain and other potential confounders, risk was higher in nurses who reported frequent manual transfer of patients between bed and chair, manual repositioning of patients on the bed, and lifting patients in or out of the bath with a hoist. CONCLUSIONS: Of the indicators of individual susceptibility that were examined, only history of back trouble was sufficiently predictive to justify selective exclusion of some applicants for nursing posts. The main route to prevention of back disorders among nurses is likely to lie in improved ergonomics.     

Knee Pain and Low Back Pain Additively Disturb Sleep in the General Population: A Cross-Sectional Analysis of the Nagahama Study

Introduction

Association of knee and low back pain with sleep disturbance is poorly understood. We aimed to clarify the independent and combined effects of these orthopedic symptoms on sleep in a large-scale general population.

Methods

Cross-sectional data about sleep and knee/low back pain were collected for 9,611 community residents (53±14 years old) by a structured questionnaire. Sleep duration less than 6 h/d was defined as short sleep. Sleep quality and the presence of knee and low back pain were evaluated by dichotomous questions. Subjects who complained about knee or low back pains were graded by tertiles of a numerical response scale (NRS) score and a Roland-Morris disability questionnaire (RDQ) score respectively. Multivariate regression analyses were performed to determine the correlates of short sleep duration and poor sleep quality.

Results

Frequency of participants who complained of the orthopedic symptoms was as follows; knee pain, 29.0%; low back pain, 42.0% and both knee and low back pain 17.6%. Both knee and low back pain were significantly and independently associated with short sleep duration (knee pain: odds ratio (OR) = 1.19, p<0.01; low back pain: OR = 1.13, p = 0.01) and poor sleep quality (knee pain: OR = 1.22, p<0.01; low back pain; OR = 1.57, p<0.01). The group in the highest tertile of the NRS or RDQ score had the highest risk for short sleep duration and poor sleep quality except for the relationship between the highest tertile of the RDQ score and short sleep duration.(the highest tertile of the NRS: OR for short sleep duration = 1.31, p<0.01; OR for poor sleep quality = 1.47, p<0.01; the highest tertile of the RDQ: OR for short sleep duration = 1.11, p = 0.12; OR for poor sleep quality = 1.81, p<0.01) Further, coincident knee and low back pain raised the odds ratios for short sleep duration (either of knee or low back pain: OR = 1.10, p = 0.06; both knee and low back pain: OR = 1.40, p<0.01) and poor sleep quality (either of knee or low back pain: OR = 1.61, p<0.01; both knee and low back pain: OR = 2.17, p<0.01).

Conclusion

Knee and low back pains were independently associated with short sleep duration and poor sleep quality. Further, they additively increased the correlation with these sleep problems in the general population.     

Visualization of painful experiences believed to trigger the activation of affective and emotional brain regions in subjects with low back pain

In the management of clinical low back pain (LBP), actual damage to lower back areas such as muscles, intervertebral discs etc. are normally targeted for therapy. However, LBP may involve not only sensory pain, but also underlying affective pain which may also play an important role overall in painful events. Therefore we hypothesized that visualization of a painful event may trigger painful memories, thus provoking the affective dimension of pain. The present study investigated neural correlates of affect processing in subjects with LBP (n = 11) and subjects without LBP (n = 11) through the use of virtual LBP stimuli. Whole brain functional magnetic resonance imaging (MRI) was performed for all subjects while they were shown a picture of a man carrying luggage in a half-crouching position. All subjects with LBP reported experiencing discomfort and 7 LBP subjects reported experiencing pain. In contrast to subjects without LBP, subjects with LBP displayed activation of the cortical area related to pain and emotions: the insula, supplementary motor area, premotor area, thalamus, pulvinar, posterior cingulate cortex, hippocampus, fusiform, gyrus, and cerebellum. These results suggest that the virtual LBP stimuli caused memory retrieval of unpleasant experiences and therefore may be associated with prolonged chronic LBP conditions.     

Effect of chronic idiopathic low back pain on the kinetic gait characteristics in different foot masks

Identification of kinetic variables in different masks of foot is important for the evaluation and treatment of chronic low back pain. The aim of this study was to investigate the effect of chronic idiopathic low back pain on kinetic variables of gait in different foot masks. 11 idiopathic chronic low back pain patients and 13 healthy matched controls participated in this study. Using Emed foot-scanner system, the ground reaction force and impulse were measured during barefoot normal walking. Then, the average footprints were divided into 10 masks using the Automask program and the data were extracted using Multimask Evaluation programs. The low back pain disability was measured by Quebec questionnaire. Our results revealed that the ground reaction force and impulse in medial and lateral midfoot and hallux masks of patients were significantly lower than controls. Furthermore, these patients demonstrated greater ground reaction force and impulse in 3–5th metatarsals mask than control group. There was a significant interaction between the low back pain and the foot masks factors. In conclusion, the ground reaction forces and impulses in different areas of foot are affected by low back pain. Therefore, the kinetic gait analysis should be considered as an appropriate tool in evaluation and prescribing proper treatment program in low back pain patients.     

EMG scanning in the diagnosis of chronic pain

A surface EMG diagnostic protocol was developed to assess the neuromuscular/postural contributions to pain states. The EMG activity of the right and left aspects of 11 muscle groups were monitored while the patient was in the sitting and standing positions. The diagnostic protocol was evaluated by comparing the patterns of EMG activity in four diagnostic groups: headache only, neck/shoulder/upper back pain only, low back pain only, and mixed pain states. The results suggest that (1) bilateral levels of EMG activity in the frontalis and masseter groups are of primary importance for the headache patients, (2) the discrepancy between the right and left EMG activity in the lumbar and cervical paraspinal muscle groups are of primary importance for low back pain patients, (3) position (sit/stand) may provide important diagnostic information, and (4) the data appear to support the notion of a postural disturbance as a contributing factor in low back pain.     

Clinical diagnosis for discogenic low back pain

Discogenic lower back pain (DLBP) is the most common type of chronic lower back pain (LBP), accounting for 39% of cases, compared to 30% of cases due to disc herniation, and even lower prevalence rates for other causes, such as zygapophysial joint pain. Only a small proportion (approximately 20%) of LBP cases can be attributed with reasonable certainty to a pathologic or anatomical entity. Thus, diagnosing the cause of LBP represents the biggest challenge for doctors in this field. In this review, we summarize the process of obtaining a clinical diagnosis of DLBP and discuss the potential for serum-based diagnosis in the near future. The use of serum biomarkers to diagnose DLBP is likely to increase the ease of diagnosis as well as produce more accurate and reproducible results.