Related Back Pain Research Articles

Lumbar multifidus muscle morphology is associated with low back-related pain duration, disability, and leg pain: A cross-sectional study in secondary care.

Systematic reviews and studies exploring associations between morphologic change of paraspinal muscles and low back pain or related outcomes such as disability, radiculopathy, and physical workload, have reported conflicting results. This study explores the associations between lumbar multifidus muscle quality and clinical outcomes relating to low back pain. Cross-sectional study of spinal clinic outpatients presenting with a primary complaint of low back and/or leg symptoms. Univariable and multivariable regression models were used to investigate associations between MRI-based multifidus muscle cross-sectional area at L4 and L5 and clinical outcomes for low back pain, leg pain, disability, restricted motion, and strenuous nature of work. Results were reported with β-coefficients, odds ratios (OR), or incidence rate ratios (IRR) and their corresponding 95% confidence intervals, based on a 10% difference in muscle quality for each clinical variable. Multivariable analyses were adjusted for age, sex, and BMI. 875 patients [487 females; mean (SD) age: 43.6 (10.2) years] were included. In the multivariable analyses, muscle quality was significantly associated with disability (0-23 scale) [β: -0.74, 95% CI: -1.14, -0.34], leg pain intensity (0-10 scale) [β: -0.25, 95% CI: -0.46, -0.03], and current pain duration of more than 12 months [OR: 1.27, 95% CI: 1.03, 1.55]. No associations were found for low back pain intensity, morning stiffness, painful active range of motion, or work nature. Patients with higher lumbar multifidus muscle quality reported lower levels of low back pain-related disability and leg pain intensity, indicating that muscle quality may play a role in the etiology of lumbar spine disorders. However, the clinical importance of these associations is uncertain due to the low magnitude of identified associations. Future longitudinal studies are needed to understand the effect of lumbar multifidus muscle quality on lumbar-related pain and disability.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain.

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Do Physical Therapy and Yoga Improve Pain and Disability through Psychological Mechanisms? A Causal Mediation Analysis of Adults with Chronic Low Back Pain.

To investigate whether indirect effects via psychological mechanisms explain the effects of physical therapy (PT) or yoga versus education on back-related outcomes. Mediation analyses using data from a randomized controlled trial of PT, yoga, and education interventions for chronic low back pain. Primary outcomes were changes in back-related pain on the 11-point numeric rating scale and disability on the modified 23-point Roland-Morris Disability Questionnaire, measured at 52 weeks after randomization. Hypothesized mediators were 12-week changes in pain self-efficacy, fear-avoidance beliefs, depression, anxiety, perceived stress, and sleep quality. We used causal mediation analysis to estimate the total effect, direct effect, indirect effect, and proportion mediated. We analyzed data from 230 adults (mean age = 46.2 years, 69.6% female, 79.6% non-White). In the PT-versus-education model, when the mediator was perceived stress, the total effect on disability was 2.6 points (95% confidence interval [CI]: 0.3, 4.9) and decomposed into a direct effect of 1.7 points (95% CI: -0.4, 3.8) and an indirect effect 0.9 points (95% CI: 0.1, 2.0; proportion mediated, 34%). No other psychological construct was a significant mediator. Improvements in perceived stress mediated improvements in disability after PT treatment compared to education. Other psychological outcomes did not mediate the effect of yoga or PT on pain or disability outcomes compared to education. J Orthop Sports Phys Ther 2022;52(7):470-483. Epub: 18 May 2022. doi:10.2519/jospt.2022.10813.

“I don't want to be a burden” A qualitative study of the beliefs of women with chronic low back pain in relation to their painful experience

BackgroundWomen's pain is still poorly understood. Moreover, maladaptive pain beliefs contribute to the disability associated with low back pain and play a key role in the transition from acute to chronic symptoms. ObjectivesTo explore the beliefs of women with non-specific chronic low back pain in terms of nature of symptoms, fears associated with pain, expectations for recovery, family, social and work-related limitations, and perceived self-efficacy. Design and methodsA qualitative study with an interpretative approach was undertaken. Face-to-face, semi-structured individual interviews were performed. Study participants were 10 women with non-specific chronic low back pain living in the Metropolitan Region of Chile. Thematic analysis was used to analyze the data. A deductive process was used to code the text and categorize the data. ResultsParticipants described maladaptive beliefs about pain, leading to fearful attitudes and low expectations for recovery. These beliefs seemed to perpetuate pain and limit engagement in daily tasks and meaningful activities. Some of these beliefs were associated with information provided by healthcare professions. Despite having maladaptive beliefs, women perceived themselves as self-effective. ConclusionWomen with chronic low back pain described a range of different pain beliefs across a complex categorial structure. The contents of such structure may interfere with their decisions about therapeutic options. Their beliefs were often ungrounded in scientific principles, even if the information may have been provided by healthcare providers. Physical therapists would benefit from these findings to improve communication with their patients and assess the role of beliefs in decision-making.

Lower Back Complaints in Adolescent Competitive Alpine Skiers: A Cross-Sectional Study

Background: Little is known about lower back complaints in adolescent competitive alpine skiers. This study assessed their prevalence and severity (i.e., intensity and disability) with respect to sex, category, discipline preference, and training attributes. Methods: 188 competitive skiers aged 15 to 18 years volunteered in this study. Data collection included (i) questions on participants’ demographics, sports exposure, discipline preferences, and other sports-related practices; (ii) the Nordic Musculoskeletal Questionnaire on lower back complaints; and (iii) the Graded Chronic Pain Scale. Results: As many as 80.3% and 50.0% of all skiers suffered from lower back complaints during the last 12 months and 7 days, respectively. A total of 50.7% reported their complaints to be attributable to slalom skiing, and 26% to giant slalom. The majority of complaints were classified as low intensity/low disability (Grade I, 57.4%) and high intensity/low disability complaints (Grade II, 21.8%). The Characteristic Pain Intensity was found to be significantly related to the skiers’ years of sports participation, number of competitions/season, and number of skiing days/season. Conclusion: This study further supports the relatively high magnitudes of lower back-related pain in adolescent competitive alpine skiers, with a considerable amount of high intensity (but low disability) complaints, and training attributes being a key driver.

Different types of low back pain in relation to pre- and post-natal maternal depressive symptoms

BackgroundLow back pain (LBP) is a common musculoskeletal problem during pregnancy, with an estimated prevalence ranging from 30–78% (Mota MJ et al. J Back Musculoskelet Rehabil 28(2):351-7,2015 and Abebe E et al. J Med Sc Tech 3(3). 37-44,2014). Women reporting LBP are at increased risk of developing perinatal depression. Pregnancy-related LBP is highly heterogeneous and can be divided into lumbar pain (LP), posterior pelvic pain (PPP), and combined pain (CP). Therefore, the purpose of this study was to investigate the associations between LBP and perinatal depressive symptoms.MethodsThis was a retrospective case-control study conducted from January 2016 to April 2019. A total of 484 pregnant women were enrolled in this study: a case group of 242 pregnant women who were diagnosed with LBP and an age-matched control group of 242 pregnant women without LBP. The Edinburgh Postnatal Depression Scale (EPDS), LBP characteristics, and questionnaires about pregnancy that included demographic, parity, work, comorbidity, and previous pregnancy data were completed and compared between the case group and the control group.ResultsA total of 68 of 242 (28.1%) women experienced PPP, 142 (58.7%) had lumbar pain(LP), and 32 (13.2%) had combined pain. Furthermore, 26.5% of women with prenatal depression in the LP subgroup remained depressed 6 months postnatally, while the percentages for women in the PPP subgroup and CP subgroup were just 10.6% and 15.6%, respectively. The percentage of women who recovered anytime between delivery and six months postnatally in the PPP subgroup was significantly higher than that in the LP subgroup (31.7% vs. 14.7%, P < 0.001).ConclusionsThere is a difference in the prevalence of prenatal, postnatal, and perinatal depressive symptoms among pregnant women with different types of LBP. It is necessary to screen prenatal and postnatal depression separately and differentiate the types of LBP during pregnancy. Attention to these factors may help to outline better management strategies to improve maternal health.

Diffuse central sensitization in low back patients: A secondary analysis of cross-sectional data including tender point examination and magnetic resonance imaging of the lumbar spine.

Consistency between back pain intensity and degenerative changes on magnetic resonance imaging (MRI) of the lumbar spine is poor. This study aimed to show whether tender point (TP) examination, used as a test for diffuse central sensitization, may add valuable information to clinical assessment of patients with low back pain (LBP).This was a cross-sectional study including 141 patients with LBP on sick leave. Baseline measures comprised back pain, leg pain intensity, and LBP examination including TP examination. Degenerative MRI findings were assessed in a standardized manner and blinded for clinical data. The number of TPs was analyzed in relation to sex, widespread pain, radiculopathy, pain duration, and degenerative changes on MRI.The number of TPs was positively associated with the female sex, widespread pain, and pain duration. It was negatively associated with degenerative manifestations and radiculopathy, the latter displaying a low level similar to that of the general population. A positive association between back pain intensity and TPs was present in patients with and without radiculopathy and in patients with substantial degenerative changes. Men with >7-8 TPs and women with >10-11 TPs had more back pain and similar or fewer degenerative changes than patients with few TPs (<3 and <6 TPs, respectively), thereby identifying 34% to 44% of patients with nonspecific LBP and 5% to 8% of patients with radiculopathy, respectively, with disproportionate back pain in relation to degenerative changes.Supplemental TP examination improved clinical and MRI evaluation of patients with LBP. By using gender-specific cut points, patients with disproportionate back pain were identified, presumably indicating diffuse central sensitization.

A Critical Analysis of the Exercise Prescription and Return to Activity Advice That Is Provided in Patient Information Leaflets Following Lumbar Spine Surgery.

Background and objectives: Lumbar spine surgery may be considered if pharmacologic, rehabilitation and interventional approaches cannot provide sufficient recovery from low back-related pain. Postoperative physiotherapy treatment in England is often accompanied by patient information leaflets, which contain important rehabilitation advice. However, in order to be an effective instrument for patients, the information provided in these leaflets must be up to date and based on the best available evidence and clinical practice. This study aims to critically analyse the current postoperative aspects of rehabilitation (exercise prescription and return to normal activity) that are provided in patient information leaflets in England as part of an evaluation of current practice following lumbar spine surgery. Materials and Methods: Patient information leaflets from English National Health Service (NHS) hospitals performing lumbar spine surgery were sourced online. A content analysis was conducted to collect data on postoperative exercise prescription and return to normal activities. Results: Thirty-two patient information leaflets on lumbar surgery were sourced (fusion, n = 11; decompression, n = 15; all lumbar procedures, n = 6). Many of the exercises prescribed within the leaflets were not based on evidence of clinical best practice and lacked a relationship to functional activity. Return to normal activity advice was also wide ranging, with considerable variation in the recommendations and definitions provided. Conclusions: This study highlights a clear variation in the recommendations of exercise prescription, dosage and returning to normal activities following lumbar spine surgery. Future work should focus on providing a consistent and patient-centred approach to recovery.

Observational study to correlate BMI with low back pain in young adults

Introduction: Low back pain is a common condition comprising a major health problem worldwide&amp; will eventually affect almost everyone in life, men and women equally. In the present generation Overweight and obesity a major health hazard and predisposing to major non communicable disease. Young adults between 20-30yrs presenting with low back ache were taken and measured BMI with standard method. Results:In our the study correlation of low back pain in relation to the duration and BMI was analyzed, in which we observed as the BMI increases the duration of LBA also increases. Conclusion: our study the strong association of body mass index in relationship with development of low back ache in young adults of both genders is greatly implicated.

Considering Spine Surgery: A Web-Based Calculator for Communicating Estimates of Personalized Treatment Outcomes.

Prospective evaluation of an informational web-based calculator for communicating estimates of personalized treatment outcomes. To evaluate the usability, effectiveness in communicating benefits and risks, and impact on decision quality of a calculator tool for patients with intervertebral disc herniations, spinal stenosis, and degenerative spondylolisthesis who are deciding between surgical and nonsurgical treatments. The decision to have back surgery is preference-sensitive and warrants shared decision making. However, more patient-specific, individualized tools for presenting clinical evidence on treatment outcomes are needed. Using Spine Patient Outcomes Research Trial data, prediction models were designed and integrated into a web-based calculator tool: http://spinesurgerycalc.dartmouth.edu/calc/. Consumer Reports subscribers with back-related pain were invited to use the calculator via email, and patient participants were recruited to use the calculator in a prospective manner following an initial appointment at participating spine centers. Participants completed questionnaires before and after using the calculator. We randomly assigned previously validated questions that tested knowledge about the treatment options to be asked either before or after viewing the calculator. A total of 1256 consumer reports subscribers and 68 patient participants completed the calculator and questionnaires. Knowledge scores were higher in the postcalculator group compared to the precalculator group, indicating that calculator usage successfully informed users. Decisional conflict was lower when measured following calculator use, suggesting the calculator was beneficial in the decision-making process. Participants generally found the tool helpful and easy to use. Although the calculator is not a comprehensive decision aid, it does focus on communicating individualized risks and benefits for treatment options. Moreover, it appears to be helpful in achieving the goals of more traditional shared decision-making tools. It not only improved knowledge scores but also improved other aspects of decision quality. 2.

Neck pain and low back pain in relation to functional disability in different sport activities.

This population-based, cross-sectional study aimed to determine the frequency of neck pain, low back pain (LBP) and also the LBP related functional disability in five sport categories including football, volleyball, basketball, wrestling, and other sports in one of the Iranian sport Olympiads. The prevalence of neck pain and LBP in different time points was evaluated with the use of an interview questionnaire. A visual analogue scale was used to evaluate the athlete’s current pain. Furthermore, the functional disability related to LBP was assessed by the Athletes Disability Index Questionnaire (ADI). A total of 452 male athletes aging between 12 and 20 were screened. Three hundred seventy-seven participants responded to the questionnaires in which their mean age (standard deviation) was 15.95 (1.25). Collectively, the life-time prevalence of neck pain and LBP in all the athletes was 38.8% and 42.0%, respectively. The highest risk of neck pain at all-time points was observed among basketball players compared to other sport groups (P<0.05). The risk of LBP in most time points was the least among wrestlers (P<0.05). The ADI score was significantly higher among basketball players (13.89%) compared to volleyball players and wrestlers (P<0.05). Our study revealed a high prevalence of neck pain and LBP among Iranian young male athletes. A higher risk of neck pain and LBP among basketball players predisposes this sport at high risk of developing spine injuries which needs further consideration.

Return-to-Duty Rates Following Minimally Invasive Spine Surgery Performed on Active Duty Military Patients in an Ambulatory Surgery Center.

Low back pain is a primary health care utilization driver in the US population. Health care evaluation visits for low back pain are as common as medical evaluation for the common cold. Low back pain is the most common reason for reductions in activities of daily living and work activity in the general population. Although these statistics are compelling, in the military population, there is arguably a significantly greater economic impact on the military population, as the cost to train, retain, and deploy a service member is a tremendous cost. The current study retrospectively examines surgical outcomes, return to duty, and patient-centric outcomes among 82 active duty or reserve military patients who underwent an outpatient minimally invasive spine surgery Laminotomy Foraminotomy Decompression for the treatment of lumbar spinal stenosis in an ambulatory surgery center. Overall, our results indicate that within the 82 active duty military service members, 100% of the service members return to duty within 3 mo. Additionally, there was a significant reduction in self-reported pain and disability 12 mo postoperative, whereas the average length of surgery was 62 min with an average estimated blood loss of 30.64 mL. The current study indicates that minimally invasive procedures for the treatment of lumbar spinal stenosis in an ambulatory surgery center setting are an effective option for active duty servicemen to reduce return-to-duty rates and symptomatic back-related pain and disability.

The effectiveness of laser therapy on the management of chronic low back pain

Background/Aims: Chronic low back pain is a global musculoskeletal challenge, resulting in pain and disability on individuals. Laser therapy can be used to treat chronic low back pain. This review evaluates the effectiveness of laser therapy including high level laser therapy (HLLT) and low level laser therapy (LLLT) on chronic low back pain in relation to pain or functional disability. Methods: The authors conducted a systematic review of randomised controlled trials (RCTs) and searched the Cochrane Library, MEDLINE, CINAHL, AMED and PEDro from their start to June 2015. All studies that met predetermined inclusion and exclusion criteria were appraised with The Cochrane Collaboration's tool for assessing risk of bias and Critical Appraisal Skills Programme tools in June 2015. Results: Six RCTs met the inclusion criteria: two RCTs reported significant improvement in pain and functional disability with the use of HLLT but with a small sample size (n=103); one RCT (n=61) reported significant improvement and three RCTs (n=215) reported insignificant improvement in pain and functional disability with the use of LLLT. Conclusions: On the strength of the evidence available, HLLT and LLLT are not currently recommended to be replaced or be offered in addition to conventional treatment. Further rigorous research is required to confirm the potential use of laser therapy on individuals presenting with chronic low back pain.

Chronic low back pain in relation to Modic changes, bony endplate lesions, and disc degeneration in a prospective MRI study.

To clarify the significance of Modic changes, bony endplate lesions, and disc degeneration as predictors of chronic low back pain (LBP) during 1-year follow-up. 49 patients with severe, non-specific, chronic LBP, and Modic 1 lesion (M1) were prospectively studied with MRI and questionnaire. Changes in grade of disc degeneration, severity of Modic changes, Schmorl lesions, and bony endplate irregularities were evaluated and changes assessed in LBP intensity on numeric rating scale 0-10 and severity with Oswestry disability index 0-100 (ODI). Association between change in MRI findings and symptoms was computed using generalized estimating equations analysis. Although pain decreased in most patients during 1-year follow-up, it increased or persisted in 36%. Change in M1, M2, bony endplate lesions, and signal intensity (SI) and height of the disc associated with change of pain intensity, while change in M1, bony endplate lesions, and disc height associated with change of ODI. Not only persistent M1s, increasing bony endplate lesions, decreasing disc height, and M2s, but also new M2s predicted persistence of pain, while decrease of M1s and SI of the disc and increase of size of M2s predicted decrease of pain. Changes in disc bulges did not associate with pain. In patients with chronic non-specific LBP, persisting M1, decreasing disc height, and increasing bony endplate lesions associated with persisting pain while decrease of SI of the disc with decrease of pain. Such changing MRI findings in the same disc space have earlier been shown to progress abnormally fast. They may be signs or biomarkers of a prolonged pain causing, deforming degenerative process, and should lead to considering early intervention or specific treatments to affect that process.

Using Provocative Discography and Computed Tomography to Select Patients with Refractory Discogenic Low Back Pain for Lumbar Fusion Surgery.

Background ContextControversy remains over the use of provocative discography in conjunction with computed tomography (CT) to locate symptomatic intervertebral discs in patients with chronic, low back pain (LBP). The current study explores the relationship between discogenic pain and disc morphology using discography and CT, respectively, and investigates the efficacy of this combined method in identifying surgical candidates for lumbar fusion by evaluating outcomes.Methods43 consecutive patients between 2006 and 2013 who presented with refractory low back pain and underwent discography and CT were enrolled in the study. For this study, "refractory LBP" was defined as pain symptoms that persisted or worsened after 6 months of non-operative treatments. Concordant pain was defined as discography-provoked LBP of similar character and location with an intensity of ≥ 8/10. Fusion candidates demonstrated positive-level discography and concordant annular tears on CT at no more than two contiguous levels, and at least one negative control disc with intact annulus. Surgical outcomes were statistically analyzed using Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) for back-related pain and disability preoperatively, and 2 weeks, 3, 6, 12, and 24 months postoperatively.ResultsAnnular tears were found in 87 discs. Concordant pain was reported by 9 (20.9%) patients at L3-L4, 21 (50.0%) at L4-L5, and 34 (82.9%) at L5-S1; pain occurred significantly more often in discs with annular tears than those without (p<0.001). Painless discs were independent of annulus status (p=0.90). 18 (42%) of the original 43 patients underwent lumbar fusion at L3-L4 (n=1(6%)), L4-L5 (n=6 (33%)), L5-S1 (n=5 (28%)), and two-level L4-S1 (n=6 (33%)) via a minimally invasive transforaminal lumbar interbody fusion (MITLIF) approach with the aim to replace the nucleus pulposus with bone graft material. Median follow-up time was 18 months (range: 12–78 months). VAS, ODI, and SF-36 scores demonstrated significant improvements at 10 out of 12 postoperative time points compared with preoperative baseline.ConclusionsLumbar discography with post-discography CT can be an effective method to evaluate patients with discogenic back pain refractory to non-operative treatments. Those patients with one- or two-level high concordant pain scores with associated annular tears and negative control disc represent good surgical candidates for lumbar interbody spinal fusion.

Is Disc Degeneration Painful?

Low back pain (LBP) is the world's most debilitating condition, affecting every population. Although LBP can be multifactorial, disc degeneration has been suggested to be a determinant. Disc degeneration is characterized by chemical and morphological changes to the disc, which may usher in changes to its biomechanics, interplay with the endplates and subchondral bone, and may lead to an inflammatory response that can irritate invading nerve fibers. Such changes to the disc and its surrounding area may contribute to pain generation, whose duration and intensity is uncertain. However, a divide is present in epidemiological studies regarding the association of disc degeneration and LBP, leading to the conclusion that disc degeneration is not always synonymous with LBP. This could be attributed to study design, inadequate statistical analyses, and phenotyping issues of degenerative spine changes as well as LBP. In addition, throughout the years, advances in medical imaging have helped broaden the understanding of disc degeneration and imaging pain generators as well the predictive utility of such imaging for future pain development/severity. The evolution of pain genetics research has provided further understanding why some individuals may be more likely to experience pain than others in the setting of degenerative spine changes. Further attention to the phenotyping of spine degeneration has noted that patterns of spine changes may play a role in LBP. The field of OMICS-epidemiology and the identification of additional biomarkers (e.g., metabolomics, adipokines, etc.) could further broaden the understanding between the association of disc degeneration and LBP. In addition, the phenotyping of disc degeneration requires further attention, demanding revisitation and reclassification of long-held classification schemes as well as being conscious of a direct link to their clinical relevance. A global standardization of disc degeneration and LBP is needed to help facilitate the collaboration of large-scale consortiums to address such salient spine-related concerns. Disclosure of Interest None declared References Battié MC, Videman T, Levalahti E, Gill K, Kaprio J. Heritability of low back pain and the role of disc degeneration. Pain 2007;131(3):272–280 Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72(3):403–408 Cheung KM, Samartzis D, Karppinen J, Luk KD. Are “patterns” of lumbar disc degeneration associated with low back pain?: new insights based on skipped level disc pathology. Spine 2012;37(7):E430-E438 Chou D, Samartzis D, Bellabarba C, et al. Degenerative magnetic resonance imaging changes in patients with chronic low back pain: a systematic review. Spine 2011;36(21, Suppl)S43-S53 Eskola PJ, Lemmelä S, Kjaer P, et al. Genetic association studies in lumbar disc degeneration: a systematic review. PLoS ONE 2012;7(11):e49995 Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach. Spine 2011;36(21, Suppl)S1-S9 Karppinen J, Shen FH, Luk KD, Andersson GB, Cheung KM, Samartzis D. Management of degenerative disk disease and chronic low back pain. Orthop Clin North Am 2011;42(4):513-528, viii Livshits G, Popham M, Malkin I, et al. Lumbar disc degeneration and genetic factors are the main risk factors for low back pain in women: the UK Twin Spine Study. Ann Rheum Dis 2011;70(10):1740–1745 Luoma K, Riihimäki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen A. Low back pain in relation to lumbar disc degeneration. Spine 2000;25(4):487–492 Samartzis D, Karppinen J, Mok F, Fong DY, Luk KD, Cheung KM. A population-based study of juvenile disc degeneration and its association with overweight and obesity, low back pain, and diminished functional status. J Bone Joint Surg Am 2011;93(7):662–670 Takatalo J, Karppinen J, Niinimäki J, et al. Does lumbar disc degeneration on magnetic resonance imaging associate with low back symptom severity in young Finnish adults? Spine 2011;36(25):2180–2189 Waris E, Eskelin M, Hermunen H, Kiviluoto O, Paajanen H. Disc degeneration in low back pain: a 17-year follow-up study using magnetic resonance imaging. Spine 2007;32(6):681–684 Samartzis D, Ito K, Wang JC. Disk degeneration and pain. Global Spine J 2013;3(3):125–126

Occupational Back Pain among Rehabilitation Nurses in Saudi Arabia

Occupational low back pain among nurses has been the subject of research studies worldwide. However, evidence of the influence of nurses' awareness of safe handling practices and compliance with standard guidelines on low back pain remains scarce. This study examined the association between occupational low back pain and level of awareness of back care, and described the self-reported nature of low back pain in relation to organizational policies among nurses in Saudi Arabia. A total of 155 nurses working in a rehabilitation hospital participated in the study. The lack of a patient handling policy at the workplace was identified as a significant risk factor for the development of low back pain, whereas exercising regularly was a protective factor. Not only mechanical exposure but also organizational factors and level of awareness were related to the development of low back pain. This study highlights the need to develop institutional plans for injury reporting, and provides evidence of the importance of incorporating awareness as part of prevention strategies.

Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients With Acute Low Back Pain

Randomized controlled trial. To assess changes in pain levels and physical functioning in response to standard medical care (SMC) versus SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain (LBP) among 18 to 35-year-old active-duty military personnel. LBP is common, costly, and a significant cause of long-term sick leave and work loss. Many different interventions are available, but there exists no consensus on the best approach. One intervention often used is manipulative therapy. Current evidence from randomized controlled trials demonstrates that manipulative therapy may be as effective as other conservative treatments of LBP, but its appropriate role in the healthcare delivery system has not been established. Prospective, 2-arm randomized controlled trial pilot study comparing SMC plus CMT with only SMC. The primary outcome measures were changes in back-related pain on the numerical rating scale and physical functioning at 4 weeks on the Roland-Morris Disability Questionnaire and back pain functional scale (BPFS). Mean Roland-Morris Disability Questionnaire scores decreased in both groups during the course of the study, but adjusted mean scores were significantly better in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). Mean numerical rating scale pain scores were also significantly better in the group that received CMT. Adjusted mean back pain functional scale scores were significantly higher (improved) in the SMC plus CMT group than in the SMC group at both week 2 (P < 0.001) and week 4 (P = 0.004). The results of this trial suggest that CMT in conjunction with SMC offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.

Effects of Running Exercise on Disk Degeneration and Low Back Pain in Mice

Introduction Chronic low back pain (LBP) affects over 10% of the adult population and seriously decreases quality of life. The aging intervertebral disk (IVD) is prone to degeneration, which is associated with an increased risk of LBP. (Luoma et al., 2000) Physical activity influences IVD physiology. Animal studies show that cyclic loading increases proteoglycan synthesis in the disk suggesting a role for running exercise in disk repair. (Brisby et al., 2010) Additionally, an active lifestyle has been shown to either contribute to the onset of chronic pain onset or to be protective against chronic pain depending on the circumstances. Our laboratory has validated a rodent model of LBP, the aging SPARC-null mouse. These mice demonstrate accelerated lumbar disk degeneration as they age, similar to the degeneration observed in human subjects with LBP. SPARC-null mice also display axial and radiating pain that mirrors LBP in humans and is pharmacologically reversible. (Millecamps, Tajerian, Sage, &amp; Stone, 2011) Hypothesis Habitual running exercise will delay disk degeneration and decrease pain behavior in aging SPARC-null mice. Materials and Methods Total 2- to 3-month-old male SPARC-null and C57B wild type mice were used in this study. After recording baseline behavioral measurements, animals had free access to either a circular treadmill (exercise group) or a fixed nonrotating treadmill (control group) in their home cages. Axial LBP was assessed using the tail suspension test and radiating LBP was assessed using the acetone test for cold hypersensitivity in the hindpaw. SPARC-null mice exhibit signs of both axial and radiating LBP in these assays that is sensitive to pharmacological manipulation. Additional assays included tests for mechanical sensory thresholds and motor capacity. Tests were performed at 2 weeks and monthly thereafter. Results After 2 months with access to running wheels, SPARC-null mice show significantly reduced cold sensitivity in the hindpaw compared to baseline ( p &lt; 0.05) and control group ( p &lt; 0.01) with no accompanying change in mechanical sensitivity, indicating a reduction of radiating pain. No effect on axial pain was detected in the tail suspension test, suggesting an effect specific to radiating pain. Conclusion Total 2 months of voluntary running exercise partially reversed the development of radiating LBP in SPARC-null mice. Reversal of axial pain may require longer exposure. Future studies These mice will be followed for 6 months postwheel exposure. Following sacrifice, disk degeneration will be assessed using radiographic and histological methods. Disk innervation will be determined by immunohistochemistry, and the relationships between anatomical and behavioral measures will be determined. I confirm having declared any potential conflict of interest for all authors listed on this abstract No Disclosure of Interest None declared Brisby, H., Wei, A. Q., Molloy, T., Chung, S. A., Murrell, G. A., Diwan, A. D. The effect of running exercise on intervertebral disk extracellular matrix production in a rat model Spine 2010;35(15):1429–1436 Luoma, K., Riihimäki, H., Luukkonen, R., Raininko, R., Viikari-Juntura, E., Lamminen, A. Low back pain in relation to lumbar disk degeneration Spine 2000;25(4):487–492 Millecamps, M., Tajerian, M., Sage, E. H., Stone, L. S. Behavioral signs of chronic back pain in the SPARC-null mouse Spine 2011;36(2):95–102

The Effect of Link N on the Differentiation of Human Mesenchymal Stem Cells

Introduction The degeneration of intervertebral disk (IVD) can cause low back pain, and invoking the regeneration of degenerated IVD can relieve the pain.1,2 Mesenchymal stem cells (MSCs) are multipotent cells that can differentiate into chondrocytes and can be employed in cartilage regeneration.3,4 Link N (DHLSDNYTLDHDRAIH) is the amino terminal peptide of link protein in the extracellular matrix of cartilage. It can stimulate the biosynthesis of collagens II and IX and aggrecan in IVD cells in vitro as well as in vivo.5–7 We hypothesized that Link N can enhance the chondrogenic differentiation of MSCs, and can be applied with MSCs in bio-regeneration of IVDs. The specific aim of this research is to determine the effect of Link N on gene expression of MSCs. Materials and Methods MSCs were isolated from the bone marrow of osteoarthritis (OA) patients. The cells were cultured in 24-well plates (3000 cells/well) in chondrogenesis differentiation medium (Invitrogen, Canada) according to the manufacturer's instructions. Link N was dissolved in the media with a final concentration of 0.1 µg/mL and 1 µg/mL, respectively. Medium without Link N was applied as a control. The media were changed every 3 days, and the used media were collected and stored at −20°C for GAG analysis. For gene expression analysis, the cells were cultured for 7, 14, and 21 days, then were washed twice with PBS and dissolved in Trizol (Invitrogen, Canada). Total RNA was isolated and cDNA was synthesized by reverse transcription. Gene expression was analyzed by real-time PCR and relative expression was calculated using GAPDH as a reference gene. MSCs from three OA patients were analyzed and statistical significance was calculated using analysis of variance followed by Fisher protected least significant difference (PLSD) comparison test. Results With the concentrations of 0.1 and 1.0 µg/mL, no toxic effect of Link N on MSCs was observed. After MSCs were cultured for 7 days and 14 days, the expression of aggrecan (ACAN) (Fig. 1), collagen II (COL2A1) (Fig. 2) and the transcription regulator SOX9 increased significantly in the media with 0.1 µg/mL or 1.0 µg/mL Link N. No significant differences were observed at day 21 (Figs. 1 and 2). When cells were cultured with 0.1 or 1.0 µg/mL Link N, the quantity of GAG in the media increased significantly at day 9, 12, and 15, but no major difference was observed at day 3 and 6 and at day 18 and 21. When MSCs were cultured for 7, 14, and 21 days, no significant effect of Link N on the expression of alkaline phosphatase (ALP) was observed. Furthermore, Link N significantly inhibited osteocalcin (OC) gene expression after culturing MSCs for 21 days. Conclusion Link N can improve the chondrogenic differentiation of MSCs and inhibit their osteogenic differentiation. It can therefore be used in conjunction with MSCs in the repair of IVD degeneration. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Luoma K, Riihimaki H, Luukkonen R, Raininko R, Viikari-Juntura E, Lamminen A. Low back pain in relation to lumbar disk degeneration. Spine 2000;25:487–492 Roughley PJ. Biology of intervertebral disk aging and degeneration: involvement of the extracellular matrix. Spine 2004;29:2691–2699 Xian CJ, Foster BK. Repair of injured articular and growth plate cartilage using mesenchymal stem cells and chondrogenic gene therapy. Current Stem Cell Research Therapy 2006;1:213–229 Koga H, Engebretsen L, Brinchmann JE, Muneta T, Sekiya I. Mesenchymal stem cell-based therapy for cartilage repair: a review. Knee Surgery Sports Traumatol Arthroscopy 2009;7:1289–1297 Mwale F, Demers CN, Petit A et al. A synthetic peptide of link protein stimulates the biosynthesis of collagens II, IX and proteoglycan by cells of the intervertebral disc. Journal of Cell Biochemistry 2003;88:1202–1213 Petit A, Yao G, Rowas SA, et al. Effect of synthetic Link N peptide on the type I and type II collagens in human intervertebral discs cells. Tissue Engeneering Part A 2011;17:899–904