Back Pain Conditions Research Articles

Multicolumn Spinal Cord Stimulation Lead Implantation Using an Optic Transligamentar Minimally Invasive Technique

A new generation of neurostimulation surgical leads is used to increase the success of spinal cord stimulation in difficult-to-treat indications such as failed back surgery syndrome. Minimal access spinal technologies (MASTs) have previously been used for surgical lead implantation. However, only a unilateral approach was possible, causing difficulties for median lead placement, and not always preventing laminectomy. A recent MAST technique was used to implant spinal cord stimulation leads without these limitations. To describe the MAST technique used in a pilot study. Twenty-four consecutive patients were implanted with a multicolumn surgical lead for refractory chronic back and leg pain by using the optic transligamentar MAST technique. The MAST technique allowed median lead placement, facilitated visualization of the spine, and permitted transligamentar insertion that minimized scarring and muscle damage. No technique-related adverse events or lead revisions were reported. Use of a MAST approach could be useful in safe implantation of multicolumn surgical leads in difficult-to-treat, refractory lower back pain conditions such as failed back surgery syndrome.

Use of botulinum toxin in musculoskeletal pain

Chronic musculoskeletal pain is a common cause of chronic pain, which is associated with a total cost of $635 billion per year in the U.S. Emerging evidence suggests an anti-nociceptive action of botulinum toxin, independent of its muscle paralyzing action. This review provides a summary of data from both non-randomized and randomized clinical studies of botulinum toxin in back pain and various osteoarticular conditions, including osteoarthritis, tennis elbow, low back pain and hand pain. Three randomized controlled trials (RCTs) of small sizes provide evidence of short-term efficacy of a single intra-articular injection of 100 units of botulinum toxin A (BoNT/A) for the relief of pain and the improvement of both function and quality of life in patients with chronic joint pain due to arthritis. Three RCTs studied intramuscular BoNT/A for tennis elbow with one showing a significant improvement in pain relief compared with placebo, another one showing no difference from placebo, and the third finding that pain and function improvement with BoNT/A injection were similar to those obtained with surgical release. One RCT of intramuscular BoNT/A for low back pain found improvement in pain and function compared to placebo. Single RCTs using local injections of BoNT in patients with either temporomandibular joint (TMJ) pain or plantar fasciitis found superior efficacy compared to placebo. One RCT of intramuscular BoNT/B in patients with hand pain and carpal tunnel syndrome found improvement in pain in both BoNT/B and placebo groups, but no significant difference between groups. Most evidence is based on small studies, but the use of BoNT is supported by a single, and sometimes up to three, RCTs for several chronic musculoskeletal pain conditions. This indicates that botulinum toxin may be a promising potential new treatment for chronic refractory musculoskeletal pain. Well-designed large clinical trials are needed.

Use of botulinum toxin in musculoskeletal pain

Chronic musculoskeletal pain is a common cause of chronic pain, which is associated with a total cost of $635 billion per year in the U.S. Emerging evidence suggests an anti-nociceptive action of botulinum toxin, independent of its muscle paralyzing action. This review provides a summary of data from both non-randomized and randomized clinical studies of botulinum toxin in back pain and various osteoarticular conditions, including osteoarthritis, tennis elbow, low back pain and hand pain. Three randomized controlled trials (RCTs) of small sizes provide evidence of short-term efficacy of a single intra-articular injection of 100 units of botulinum toxin A (BoNT/A) for the relief of pain and the improvement of both function and quality of life in patients with chronic joint pain due to arthritis. Three RCTs studied intramuscular BoNT/A for tennis elbow with one showing a significant improvement in pain relief compared with placebo, another one showing no difference from placebo, and the third finding that pain and function improvement with BoNT/A injection were similar to those obtained with surgical release. One RCT of intramuscular BoNT/A for low back pain found improvement in pain and function compared to placebo. Single RCTs using local injections of BoNT in patients with either temporomandibular joint (TMJ) pain or plantar fasciitis found superior efficacy compared to placebo. One RCT of intramuscular BoNT/B in patients with hand pain and carpal tunnel syndrome found improvement in pain in both BoNT/B and placebo groups, but no significant difference between groups. Most evidence is based on small studies, but the use of BoNT is supported by a single, and sometimes up to three, RCTs for several chronic musculoskeletal pain conditions. This indicates that botulinum toxin may be a promising potential new treatment for chronic refractory musculoskeletal pain. Well-designed large clinical trials are needed.

Relationship Between Self-reported Low-back Pain Severity and Other Patient-reported Outcomes

A cross-sectional observational study of physicians and patients with chronic low-back pain (CLBP) in the United States. To evaluate the association of patient-reported CLBP severity with other patient-reported outcomes. Appropriate management of patients with CLBP can be enhanced by understanding how patients perceive the severity of their CLBP. Data were from the 2009 Adelphi Disease Specific Programme. Patients reported the severity of their CLBP condition by answering the question Please rate how your chronic lower back pain condition is today with responses of mild, moderate, and severe. Patient-reported severity was evaluated with respect to scores on standard patient self-report measures of pain, pain interference, health status, functional disability, work productivity, and questions addressing satisfaction with medications for treating CLBP. Of 1860 subjects in the CLBP database, 1363 (73.3%) agreed to complete the survey. This sample was similarly distributed between males (49%) and females (51%), with mean age 54.8 years: 52% were employed at least part-time. CLBP severity was rated as mild, moderate and severe by 28.6%, 53.3%, and 18.2% of patients, respectively. With increasing CLBP severity, significant differences were observed in increased pain (P<0.0001), pain interference with function (P<0.0001), and impairment while working due to CLBP (P<0.01), mainly due to presenteeism. Increased work impairment resulted in higher costs related to lost work productivity; annual lost productivity costs were estimated at $7080, $16,616, and $25,032 per patient for mild, moderate, and severe CLBP, respectively (P<0.0001 for pairwise comparisons). Patient satisfaction with pain-related medication was inversely associated with CLBP severity. The association between patient-reported CLBP severity and other patient-reported outcomes demonstrates that in the clinical setting, patient-reported CLBP severity provides an accurate and suitable indicator of patient-reported health status. This indicator may be useful for guiding management strategies for CLBP patients.

GP support for self-care: the views of people experiencing long-term back pain

Promotion of self-care for persistent back pain and other long-term conditions has become a central component in health care policy in the UK, and general practitioners face increasing demands to support patients' self-care efforts. Gaining insight into patients' views may facilitate support. To describe patients' experience of self-care for long-term back pain and their views on provision of support for self-care. Adults experiencing persistent back pain were purposively sampled from a community-based survey. In-depth qualitative interviews were audiotaped, transcribed and analysed using the constant comparative method to inductively derive a thematic account of the data. Most of the 23 interviewees felt a responsibility to self-care. Individual capacity for self-care, however, was variable and could be inhibited by factors such as caring roles or lack of diagnosis and information. GP support for self-care was largely considered to be desirable, although the feasibility of greater provision of support was questioned. Some interviewees expressed a strong preference for alternative models of care and support. Self-care for back pain is contextualized by the individual's capacity to self-care and preferences for support. Doubt over the ability of GPs to provide support for self-care may mean that those who have specific needs are reticent to seek help. The role of self-care in the management of back pain should be discussed openly at the consultation level, and GPs may be well placed to signpost patients and provide guidance on the safety of specific self-care activities.

Pregnancy related back pain, is it related to aerobic fitness? A longitudinal cohort study

BackgroundLow back pain with onset during pregnancy is common and approximately one out of three women have disabling pain. The pathogenesis of the pain condition is uncertain and there is no information on the role of physical fitness. Whether poorer physical conditioning is a cause or effect of back pain is also disputed and information from prospective studies needed.MethodsA cohort of pregnant women, recruited from maternal health care centers in central Sweden, were examined regarding estimated peak oxygen uptake by cycle ergometer test in early pregnancy, reported physical activity prior to pregnancy, basic characteristics, back pain during pregnancy and back pain postpartum.ResultsBack pain during the current pregnancy was reported by nearly 80% of the women. At the postpartum appointment this prevalence was 40%. No association was displayed between estimated peak oxygen uptake and incidence of back pain during and after pregnancy, adjusted for physical activity, back pain before present pregnancy, previous deliveries, age and weight. A significant inverse association was found between estimated peak oxygen uptake and back pain intensity during pregnancy and a direct association post partum, in a fully adjusted multiple linear regression analysis.ConclusionsEstimated peak oxygen uptake and reported physical activity in early pregnancy displayed no influence on the onset of subsequent back pain during or after pregnancy, where the time sequence support the hypothesis that poorer physical deconditioning is not a cause but a consequence of the back pain condition. The mechanism for the attenuating effect of increased oxygen uptake on back pain intensity is uncertain.

The influence of 'significant others' on persistent back pain and work participation: A qualitative exploration of illness perceptions

BackgroundIndividual illness perceptions have been highlighted as important influences on clinical outcomes for back pain. However, the illness perceptions of 'significant others' (spouse/partner/close family member) are rarely explored, particularly in relation to persistent back pain and work participation. The aim of this study was to initiate qualitative research in this area in order to further understand these wider influences on outcome.MethodsSemi-structured interviews based on the chronic pain version of the Illness Perceptions Questionnaire-Revised were conducted with a convenience sample of UK disability benefit claimants, along with their significant others (n = 5 dyads). Data were analysed using template analysis.ResultsSignificant others shared, and perhaps further reinforced, claimants' unhelpful illness beliefs including fear of pain/re-injury associated with certain types of work and activity, and pessimism about the likelihood of return to work. In some cases, significant others appeared more resigned to the permanence and negative inevitable consequences of the claimant's back pain condition on work participation, and were more sceptical about the availability of suitable work and sympathy from employers. In their pursuit of authenticity, claimants were keen to stress their desire to work whilst emphasising how the severity and physical limitations of their condition prevented them from doing so. In this vein, and seemingly based on their perceptions of what makes a 'good' significant other, significant others acted as a 'witness to pain', supporting claimants' self-limiting behaviour and statements of incapacity, often responding with empathy and assistance. The beliefs and responses of significant others may also have been influenced by their own experience of chronic illness, thus participants lives were often intertwined and defined by illness.ConclusionsThe findings from this exploratory study reveal how others and wider social circumstances might contribute both to the propensity of persistent back pain and to its consequences. This is an area that has received little attention to date, and wider support of these findings may usefully inform the design of future intervention programmes aimed at restoring work participation.

Relationship of sacral articular surfaces and gender with occurrence of lumbosacral transitional vertebrae

Research on lumbosacral transitional vertebra (LSTV) has yielded important information on the structural alterations of the sacrum associated with LSTV. Nevertheless, very little data are available on the relationship of a given type of LSTV with either a typical pattern of sacral morphology or its gender distribution in the population. To investigate the probable relationship between different variants of LSTVs with sacral morphology at the articular surfaces of the bone and the gender distribution of the anomalies in the population. Cross-sectional descriptive study involving dried human sacral bones and meta-analysis of data available related to LSTVs. Three hundred twenty sacra were screened for the presence of LSTV, the type of auricular surface, and facet joints in them. Samples were grouped against their sexes, type of the auricular surfaces present in them, the nature of facet joints, and the variety of LSTV (if present). Data on LSTV from reliable Internet databases were collected to account for the prevalence of LSTV in the population in terms of the types of the anomaly and their gender distribution. The detection rates of LSTV in the present study were similar to those observed in available literature. Accessory L5-S1 articulations and lumbarization of S1 were more commonly observed in the women. Sacralization was seen to be predominantly distributed in men. Higher auricular surfaces were associated with accessory articulations; lower auricular surfaces were present with partially separated S1 segment and in L5-S1 specimens. Morphology of the facets significantly altered in LSTV with accessory articulations. Different lumbosacral transitions share a stronger, definite, and specific patterns of relationship with certain sacral morphologies and gender. It is important to recognize the nuances of these connections so as to understand low back pain conditions in the setting of a typical sacral articular morphology or the sex of the individual.

Usual Source of Care for Adults With and Without Back Pain: Medical Expenditures Panel Survey Data Pooled for Years 2000 to 2006

ObjectivesThe purpose of this study was to explore the extent to which individuals with back pain or other health conditions and individuals with no health problems report having a usual source of care (USC) for their health care needs. MethodsThis study evaluated longitudinal Medical Expenditures Panel Survey data (data pooled for survey calendar years 2000-2006). Comparisons were made between adult Medical Expenditures Panel Survey respondents identified as having a back pain condition (n = 10 194) compared with those without back pain but with other health condition (n = 45 541) and those with no back pain and no other condition (n = 5497). ResultsCompared with individuals with no health problems, those with back pain were almost 8 times more likely (odds ratio, 7.8; P < .001) to report having a USC, and those with other health problems besides back pain were 5 times more likely (odds ratio, 5.4; P < .001). For those with a USC, individuals with back pain and those with other problems but not back pain were both approximately one-and-a-half times more likely than those without any health problems to report a specific provider type as their USC (P < .001). ConclusionStudy findings suggest that relatively healthy adults without back pain are less likely to have a USC than those with back pain or other health problems.

Chiropractic and self-care for back-related leg pain: design of a randomized clinical trial

BackgroundBack-related leg pain (BRLP) is a common variation of low back pain (LBP), with lifetime prevalence estimates as high as 40%. Often disabling, BRLP accounts for greater work loss, recurrences, and higher costs than uncomplicated LBP and more often leads to surgery with a lifetime incidence of 10% for those with severe BRLP, compared to 1-2% for those with LBP.In the US, half of those with back-related conditions seek CAM treatments, the most common of which is chiropractic care. While there is preliminary evidence suggesting chiropractic spinal manipulative therapy is beneficial for patients with BRLP, there is insufficient evidence currently available to assess the effectiveness of this care.Methods/DesignThis study is a two-site, prospective, parallel group, observer-blinded randomized clinical trial (RCT). A total of 192 study patients will be recruited from the Twin Cities, MN (n = 122) and Quad Cities area in Iowa and Illinois (n = 70) to the research clinics at WHCCS and PCCR, respectively.It compares two interventions: chiropractic spinal manipulative therapy (SMT) plus home exercise program (HEP) to HEP alone (minimal intervention comparison) for patients with subacute or chronic back-related leg pain.DiscussionBack-related leg pain (BRLP) is a costly and often disabling variation of the ubiquitous back pain conditions. As health care costs continue to climb, the search for effective treatments with few side-effects is critical. While SMT is the most commonly sought CAM treatment for LBP sufferers, there is only a small, albeit promising, body of research to support its use for patients with BRLP.This study seeks to fill a critical gap in the LBP literature by performing the first full scale RCT assessing chiropractic SMT for patients with sub-acute or chronic BRLP using important patient-oriented and objective biomechanical outcome measures.Trial RegistrationClinicalTrials.gov NCT00494065

Evaluation of a Yoga Program for Back Pain

The objective of this study was to test the hypothesis that participants in a therapeutic yoga program for a variety of back pain conditions would show improvements in back pain, back-related functionality, symptoms, mood, quality of life, and reduction in stress and the use of medication for back pain. Participants were 24 adults with a complaint of chronic back pain who participated in a yoga program for back pain. The sample encompassed a variety of complaints including back pain, neck/shoulder problems, spondylolisthesis, sciatica/leg numbness, scoliosis, and herniated disc. The 12-week program consisted of weekly group yoga classes based on the methodology of the Krishnamacharya Healing Yoga Foundation (KHYF). This method includes asana, pranayama, core strengthening, meditation, bhavana (visualization) and mantra. Participants also practiced regularly at home and maintained a journal. A battery of self-report questionnaires were administered at baseline, 12 weeks, and 24 weeks. Statistical significance was evaluated with one-sample t-tests on change scores. Twenty-two subjects completed both baseline and end-program questionnaires and 19 completed followup questionnaires. Subjects showed statistically significant improvements from baseline to end-program on the following scales: disability, stress, physical health (physical functioning and bodily pain), mental health (vitality, social functioning, and psychological well-being), bothersomeness of symptoms, negative mood (depression/dejection, anger/hostility, fatigue, and confusion/bewilderment). There was no significant change on use of medication. The end-program changes were sustained, and even strengthened, at the 24-week follow-up. Qualitatively, subjects reported strengthening of their back, more flexibility, reduced stress, better posture, reduced pain, and increased awareness. The results demonstrated that KHYF yoga classes lead to significantly improved quality of life for adult sufferers of back pain, including decreased disability and pain, and improved physical functioning and mood (less depressive feelings, anger, fatigue, and confusion). This study provided evidence that this yoga method ameliorates the negative effects of a very broad range of back pain disorders.

Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan

There have been a few studies regarding detail of back pain in adolescents with idiopathic scoliosis (IS) as prevalence, location, and severity. The condition of back pain in adolescents with IS was clarified based on a cross-sectional study using a questionnaire survey, targeting a total of 43,630 pupils, including all elementary school pupils from the fourth to sixth grade (21,893 pupils) and all junior high pupils from the first to third year (21,737 pupils) in Niigata City (population of 785,067), Japan. 32,134 pupils were determined to have valid responses (valid response rate: 73.7%). In Niigata City, pupils from the fourth grade of elementary school to the third year of junior high school are screened for scoliosis every year. This screening system involves a three-step survey, and the third step of the survey is an imaging and medical examination at the Niigata University Hospital. In this study, the pupils who answered in the questionnaire that they had been advised to visit Niigata University Hospital after the school screening were defined as Scoliosis group (51 pupils; 0.159%) and the others were defined as No scoliosis group (32,083 pupils). The point and lifetime prevalence of back pain, the duration, the recurrence, the severity and the location of back pain were compared between these groups. The severity of back pain was divided into three levels (level 1 no limitation in any activity; level 2 necessary to refrain from participating in sports and physical activities, and level 3 necessary to be absent from school). The point prevalence was 11.4% in No scoliosis group, and 27.5% in Scoliosis group. The lifetime prevalence was 32.9% in No scoliosis group, and 58.8% in Scoliosis group. According to the gender- and school-grade-adjusted odds ratios (OR), Scoliosis group showed a more than twofold elevated odds of back pain compared to No scoliosis group irrespective of the point or lifetime prevalence of back pain (OR, 2.29; P = 0.009 and OR, 2.10; P = 0.012, respectively). Scoliosis group experienced significantly more severe pain, and of a significantly longer duration with more frequent recurrences in comparison to No scoliosis group. Scoliosis group showed significantly more back pain in the upper and middle right back in comparison to No scoliosis group. These findings suggest that there is a relationship between pain around the right scapula in Scoliosis group and the right rib hump that is common in IS.

Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer

Objective The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types. Methods A retrospective claims analysis was performed on Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured population between October 1, 2004 and September 30, 2006. The insured study population had open access to MDs and DCs through self-referral without any limit to the number of visits or differences in co-pays to these 2 provider types. Our analysis was based on episodes of care for low back pain. An episode was defined as all reimbursed care delivered between the first and the last encounter with a health care provider for low back pain. A 60 day window without an encounter was treated as a new episode. We compared paid claims and risk adjusted costs between episodes of care initiated with an MD with those initiated with a DC. Results Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. Conclusions Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.

The effects of a media campaign on beliefs and utilization of imaging examinations in Norwegian patients with low back pain

Aims: Several authors have reported an overuse of imaging examinations for unspecific low back pain conditions. In this study, we examined the influence of a media campaign for better understanding and management of back pain in the general population on utilization of imaging examinations. Methods: The media campaign Active Back ran for three years (2002-2005) in two Norwegian counties and the results were compared to the adjacent control county. Numbers of imaging examinations were collected manually from every radiology department in each of the three counties, while belief measures were collected through a telephone survey before, during and after the campaign. Beliefs of the health care providers were collected through questionnaires. Results: We observed a decrease of X-rays by 35% in the intervention counties and by 33% in the control county. The number of CT scans decreased by 51% and 57% respectively. The number of MRI scans increased by 152% in the intervention counties and by 596% in the control. Combining all modalities, the number of imaging examinations increased by 3% in the intervention counties and by 56% in the control county. There was a tendency both in the general public and among the health care providers towards less trust in the usefulness of X-rays in all counties during the study period. The health care providers in the control county seemed to recommend imaging more often than their colleagues in the intervention counties. Conclusion: Despite slightly increased scepticism among the general public and health care providers, we observed an overall increase in utilization of imaging modalities. The dramatically increased utilization in the control group was likely explained by an increased capacity for MRI examinations obtained by the opening of a new radiology clinic, and not as an effect of the media campaign.

Biopsychosocial Predictors of Pain, Disability, Health Care Consumption, and Sick Leave in First-Episode and Long-Term Back Pain: A Longitudinal Study in the General Population

Long-term outcome in back pain is related mainly to cognitive factors such as pain-related beliefs and expectations. Most research has been performed on patient samples. This study aimed at investigating changes over time in reported back pain, pain intensity, disability, health care consumption, and sick leave as well as biopsychosocial factors over a 12-month period. A second aim was to identify predictors of reported pain, pain intensity, disability, health care consumption, and sick leave. As parts of a large back pain sample from a general population (n = 1,024), two groups-one with first-episode pain (n = 77) and one with long-term pain (n = 302)-responded twice to a self-administered questionnaire. Among participants reporting pain at both assessments, changes over time were analyzed and predictive models were tested. Generally, the results demonstrated overall stability in the self-reports over time. However, reported pain decreased in both groups, while pain catastrophizing and pain expectations increased in the first-episode group. Pain intensity and disability were predicted in regression models including four cognitive factors and initially reported levels of pain intensity and disability. The significance of pain-related beliefs and expectations both in early and later stages of a back pain condition is pointed out. The results in this study based on a sample from the general population are in line with previous research on patient samples.

Transversus Abdominis and Obliquus Internus Activity During Pilates Exercises: Measurement With Ultrasound Scanning

Endleman I, Critchley DJ. Transversus abdominis and obliquus internus activity during Pilates exercises: measurement with ultrasound scanning. Objective To assess activity of transversus abdominis (TrA) and obliquus internus abdominis (OI) muscles during classical Pilates exercises performed correctly and incorrectly, and with or without equipment. Design Repeated-measures descriptive study. Setting Pilates studio. Participants A volunteer sample of women (n=18) and men (n=8), mean age ± SD (43±14y), with more than 6 months classical Pilates training and no back pain or other condition likely to influence abdominal muscle activity. Interventions Participants performed Pilates imprint, hundreds A and B, roll-up, and le g-circle exercises on a mat. The hundreds exercise was also performed on a reformer (sliding platform). Mat imprint and hundreds exercises were instructed to be performed correctly (with abdominal drawing-in) or incorrectly (without drawing-in). Main Outcome Measure Thickness of TrA and OI middle fibers measured with ultrasound imaging. Results TrA thickness increased during the mat imprint, hundreds A, hundreds B, leg-circle, and roll-up exercises (all P=.001) compared with resting. OI thickness increased during the mat imprint, hundreds A, hundreds B, leg-circle (all P=.001), and roll-up exercises ( P=.002) compared with resting. TrA thickness during reformer hundreds B was greater than during mat hundreds B ( P=.011); OI thicknesses were not different for this comparison. During incorrect imprint, neither TrA or OI thicknesses were different to resting. TrA and OI muscle thicknesses were moderately correlated ( R=.410; P=.001). Conclusions This study provides the first evidence that a selection of classic Pilates exercises activates TrA and OI. Use of the reformer exercise machine can result in greater TrA activation in some exercises. TrA and OI did not function independently during these exercises. Research into the training effects of Pilates or in patient populations can be undertaken using ultrasonography in submaximal exercises.

Minimum detectable and minimal clinically important changes for pain in patients with nonspecific neck pain

BackgroundThe minimal detectable change (MDC) and the minimal clinically important changes (MCIC) have been explored for nonspecific low back pain patients and are similar across different cultural settings. No data on MDC and MCIC for pain severity are available for neck pain patients. The objectives of this study were to estimate MDC and MCIC for pain severity in subacute and chronic neck pain (NP) patients, to assess if MDC and MCIC values are influenced by baseline values and to explore if they are different in the subset of patients reporting referred pain, and in subacute versus chronic patients.MethodsSubacute and chronic patients treated in routine clinical practice of the Spanish National Health Service for neck pain, with or without pain referred to the arm, and a pain severity ≥ 3 points on a pain intensity number rating scale (PI-NRS), were included in this study. Patients' own "global perceived effect" over a 3 month period was used as the external criterion. The minimal detectable change (MDC) was estimated by means of the standard error of measurement in patients who self-assess as unchanged. MCIC were estimated by the mean value of change score in patients who self-assess as improved (mean change score, MCS), and by the optimal cutoff point in receiver operating characteristics curves (ROC). The effect on MDC and MCIC of initial scores, duration of pain, and existence of referred pain were assessed.Results658 patients were included, 487 of them with referred pain. MDC was 4.0 PI-NRS points for neck pain in the entire sample, 4.2 for neck pain in patients who also had referred pain, and 6.2 for referred pain. MCS was 4.1 and ROC was 1.5 for referred and for neck pain, both in the entire sample and in patients who also complained of referred pain. ROC was lower (0.5 PI-NRS points) for subacute than for chronic patients (1.5 points). MCS was higher for patients with more intense baseline pain, ranging from 2.4 to 4.9 PI-NRS for neck pain and from 2.4 to 5.3 for referred pain.ConclusionIn general, improvements ≤ 1.5 PI-NRS points could be seen as irrelevant. Above that value, the cutoff point for clinical relevance depends on the methods used to estimate MCIC and on the patient's baseline severity of pain. MDC and MCIC values in neck pain patients are similar to those for low back pain and other painful conditions.

Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial)

Background Chronic back and leg pain conditions result in patients’ loss of function, reduced quality of life and increased costs to the society. Aims To assess health-related quality of life (HRQoL) and cost implications of spinal cord stimulation plus non-surgical conventional medical management (SCS group) versus non-surgical conventional medical management alone (CMM group) in the management of neuropathic pain in patients with failed back surgery syndrome. Methods A total of 100 patients were randomised to either the SCS or CMM group. Healthcare resource consumption data relating to screening, the use of the implantable generator in SCS patients, hospital stay, and drug and non-drug pain-related treatment were collected prospectively. Resource consumption was costed using UK and Canadian 2005–2006 national figures. HRQoL was assessed using the EuroQol-5D (EQ-5D) questionnaire. Costs and outcomes were assessed for each patient over their first 6-months of the trial. Results The 6-month mean total healthcare cost in the SCS group (CAN$19,486; €12,653) was significantly higher than in the CMM group (CAN$3994; €2594), with a mean adjusted difference of CAN$15, 395 (€9997) ( p < 0.001). However, the gain in HRQoL with SCS over the same period of time was markedly greater in the SCS group, with a mean EQ-5D score difference of 0.25 [ p < 0.001] and 0.21 [ p < 0.001], respectively at 3- and 6-months after adjusting for baseline variables. Conclusions The addition of SCS to CMM in patients with neuropathic leg and back pain results in higher costs to health systems but also generates important improvements in patients’ EQ-5D over the same period.

Core Stability Exercise Principles

Core stability is essential for proper load balance within the spine, pelvis, and kinetic chain. The so-called core is the group of trunk muscles that surround the spine and abdominal viscera. Abdominal, gluteal, hip girdle, paraspinal, and other muscles work in concert to provide spinal stability. Core stability and its motor control have been shown to be imperative for initiation of functional limb movements, as needed in athletics. Sports medicine practitioners use core strengthening techniques to improve performance and prevent injury. Core strengthening, often called lumbar stabilization, also has been used as a therapeutic exercise treatment regimen for low back pain conditions. This article summarizes the anatomy of the core, the progression of core strengthening, the available evidence for its theoretical construct, and its efficacy in musculoskeletal conditions.

Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: A randomized controlled clinical trial

Psychological treatments for chronic pain, particularly those based upon cognitive behavioural principles, have generally been shown to be efficacious. Recently, a treatment has been developed based upon the fear-avoidance model of chronic musculoskeletal pain, which suggests chronic pain can be relieved by exposing the individual to movements and tasks that have been avoided due to fear of (re)injury. This graded in vivo exposure treatment has been found to be beneficial in case studies. The present investigation utilized a randomized controlled trial method to assess the effectiveness of graded in vivo exposure relative to other conditions. Forty-four chronic low back pain patients were randomly assigned to graded in vivo exposure, graded activity, or a wait-list condition. While only trend differences were observed for pain-related disability, patients in the graded in vivo exposure condition demonstrated (a) significantly greater improvements on measures of fear of pain/movement, fear avoidance beliefs, pain-related anxiety, and pain self-efficacy when compared to those in the graded activity condition, and (b) significantly greater improvements on measures of fear-avoidance beliefs, fear of pain/movement, pain-related anxiety, pain catastrophising, pain experience, and anxiety and depression when compared to those in the wait-list control condition. Additionally, patients in the graded in vivo exposure condition maintained improvements in these areas at one month follow-up. Implications of these findings for the treatment of individuals with chronic low back and other pain conditions are discussed.