Assessment Of Chronic Low Back Pain Research Articles

(109) Aging Back Clinics – A Geriatric Syndrome Approach to Treating Low Back Pain in Older Adults: Results of a Preliminary Randomized Controlled Trial

Treating chronic low back pain (CLBP) with spine-focused interventions is common, potentially dangerous, and often ineffective. We posit that CLBP in older adults is a geriatric syndrome – a final common pathway for the expression of multiple contributors. We have published evidence and expert consensus-based algorithms to guide evaluation and treatment of key biopsychosocial CLBP contributors in older adults – hip osteoarthritis, myofascial pain, fibromyalgia, sacroiliac joint syndrome, lumbar spinal stenosis, leg length inequality, lateral hip/thigh pain, anxiety, depression, insomnia, and maladaptive coping. This preliminary trial tests the feasibility and efficacy of care based on these algorithms in Aging Back Clinics (ABC). Fifty-five English-speaking Veterans age 60-89 with CLBP and no red flags, prior back surgery, dementia, impaired communication, or uncontrolled psychiatric illness were randomized to ABC care or usual care (UC) over 6 months. ABC care was implemented by geriatricians trained in CLBP assessment who: 1) performed a structured history and physical examination to identify pain contributors, 2) provided structured education to participants about their contributors, and 3) recommended additional care using collaborative decision making. Primary outcomes were low back pain severity (0 to 10 current, and 7-day average and worst pain) and pain-related disability (Roland Morris [RM] questionnaire). Follow up data were collected monthly by telephone. ABC participants experienced significantly greater reduction in 7-day average (-1.22 points; p=0.023) and worst pain (-1.70 points; p=0.003) at 6 months. Neither present pain nor RM score at 6-months was statistically significant but favored ABC in magnitude. Descriptively, participants randomized to UC were more likely to experience pain-related emergency room visits (45.8 vs 30.8%; p=0.5136) and be exposed to Beers’ list medications, specifically non-COX2 nonsteroidal anti-inflammatory drugs (73.1% vs. 54.2) and muscle relaxants (42.3% vs. 16.7) . These preliminary data suggest that ABC care reduces pain and exposure to other potential morbidity.

What do clinicians consider when assessing chronic low back pain? A content analysis of multidisciplinary pain centre team assessments of functioning, disability, and health.

Beyond expert suggestions as to the appropriate subject matter for chronic pain assessments, little is known about the actual content of multidisciplinary pain centre (MPC) clinical assessments. The International Classification of Functioning, Disability and Health Low Back Pain Core Set (ICF LBP-CS) provides a universal language to support the consistent description of LBP-related assessments across disciplines within multidisciplinary teams (MDTs). This study sought to map the content of MPC clinical assessments to the ICF to: (1) identify and compare the content of clinical MDT assessments using a cross-disciplinary framework and (2) examine the content validity of the LBP-CS. A qualitative examination of MPC team clinical assessments of chronic low back pain was undertaken. Multidisciplinary team (pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology) assessments were audio-recorded and transcribed. Concepts were extracted from transcripts using a meaning condensation procedure and then linked to the ICF. Across 7 MDT assessments, comprised 42 discipline-specific assessments and 241,209 transcribed words, 8596 concepts were extracted. Contextual factors (ie, the person and environment), except for physiotherapy, accounted for almost half of each discipline's assessments (range: 49%-58%). Concepts spanned 113 second-level ICF categories, including 73/78 LBP-CS categories. Overall, the findings revealed novel insights into the content of MPC clinical assessments that can be used to improve health care delivery. International Classification of Functioning, Disability and Health-based assessment profiles demonstrated unique contributions from each discipline to chronic low back pain assessment. Finally, users of the LBP-CS can be confident that the tool exhibits sound content validity from the perceptive of MDT assessments of functioning, disability, and health.

Surface Electromyographic (SEMG) Biofeedback for Chronic Low Back Pain

Biofeedback is a process in which biological information is measured and fed back to a patient and clinician for the purpose of gaining increased awareness and control over physiological domains. Surface electromyography (SEMG), a measure of muscle activity, allows both a patient and clinician to have direct and immediate access to muscle functioning that is not possible with manual palpation or visual observation. SEMG biofeedback can be used to help “down-train” elevated muscle activity or to “up-train” weak, inhibited, or paretic muscles. This article presents a historical and clinical overview of SEMG and its use in chronic low back pain assessment and biofeedback training.

Development of a Questionnaire to Assess the Impact of Chronic Low Back Pain for Use in Regulated Clinical Trials

Chronic low back pain (CLBP) is the most common chronic pain condition and is associated with clinical, economic, social, and public health impacts. The effect of CLBP on patients' health-related quality of life (HRQoL) is significant. The symptoms and impacts most often associated with CLBP include pain and disability; patients most affected are often crippled by the condition. CLBP also affects patients' mental, physical, and psychosocial well-being. A variety of self-report measures have been developed for the assessment of CLBP, such as the Roland Morris Disability Questionnaire (RMDQ); however, existing measures may not meet current regulatory expectation for the development, documentation, and use of patient-reported outcomes (PRO) questionnaires (U.S. Department of Health and Human Services, Food and Drug Administration, 2009). This report describes the qualitative development of the Chronic Low Back Pain Impact Questionnaire (CLBP-IQ), created for use in clinical trials. A total of 22 CLBP patients recruited by clinicians participated in concept elicitation interviews to identify target measurement concepts. An instrument development team generated the instructions, items, and response options guided by patient input. Cognitive debriefing interviews were conducted with 21 patients recruited by the same clinicians who recruited for concept elicitation interviews. During cognitive interviews, a draft instrument composed of 28 items was presented to individuals with CLBP to evaluate its readability and comprehensiveness. All research activities were conducted in the US. During concept elicitation interviews, participants reported a variety of physical, emotional, and social impacts associated with CLBP. Participants also reported CLBP impacts on sleep, energy, daily activities, work, household activities, leisure activities, cognition, self-care, and sex life. Impacts deemed simple, important, and relevant to CLBP patients became targets of measurement for the CLBP-IQ. During cognitive debriefing, seventeen items were interpreted as intended by at least 90% of participants, and no items were interpreted incorrectly by more than five patients (24%). Additionally, seventeen items were experienced by at least 90% of participants, and no single item was experienced by less than 67% of participants (n=14). The CLBP-IQ was developed in accordance with current US Food and Drug Administration guidance on instrument development. Results from both concept elicitation and cognitive debriefing interviews support the content validity of the CLBP-IQ in patients with CLBP. Future development should proceed with psychometric evaluation.

Engendering Pain Management Practices: The Role of Physician Sex on Chronic Low-Back Pain Assessment and Treatment Prescriptions

The impact of physician sex on dimensions of medical care such as treatment prescriptions and referrals has been underexplored, especially in a pain context. Also, few studies have analyzed whether physician sex moderates the influence of patients' or clinical situations' characteristics on pain management practices or its mediating processes. Therefore, our goal was to explore whether physician sex moderates the effects of patient (distressed) pain behaviors and diagnostic evidence of pathology (EP) on treatment prescriptions and referrals for chronic low-back pain, and to explore the mediating role of pain credibility judgments and psychological attributions on these effects. A total of 310 general practitioners (GPs; 72.6% women) participated in a between-subjects design, 2 (patient pain behaviors) × 2 (EP) × 2 (GP sex) × 2 (patient sex). GPs were presented with vignettes depicting a fe(male) chronic low-back pain patient, with(out) distress and with(out) EP (eg, herniated disc). GPs judged the patient's pain and the probability of treatment prescriptions and referrals. Results showed that EP had a larger effect on male than on female physicians' referrals to psychology/psychiatry. Also, GP sex moderated the pain judgments that accounted for the effect of EP and pain behaviors on prescriptions. These findings suggest framing medical decision-making as a process influenced by gender assumptions. PerspectiveThis paper shows that physician sex moderates the influence of clinical cues on pain management practices and the mediating role of pain judgments on these effects. It may potentially increase clinicians' awareness of the influence of gender assumptions on pain management practices and contribute to the development of more gender-sensitive services.

Étude de faisabilité dˈun programme dˈévaluation de lˈécole du dos

OBJECTIVES: Testing the feasability of a back school assessment programme in two populations of people suffering with chronic low back pain. MATERIAL: Twenty-nine patients were randomly included in a chronic low back pain assessment programme (15 patients waiting for back school and 14 patients after back school). METHODS: The programme was made of the measure of the age, the sex, the body mass index, the pain (VAS, St Antoine Hospitalˈs Pain Questionnaire - SAPQ), the anxiety, the depression, the RIII nociceptive reflex, the fingertip-floor distance, the strength of the flexors and of the extensors of the lumbar spine (CybexR 6000 isocinetic dynamometer), the lumbar function (EIFEL, Dougados), the Dallas self-questionnaire. The Back School Education programme was made of five sessions (information, ergonomies, extension exercises). RESULTS: Comparing the two populations we didnˈt observe significant differences concerning the age, the body mass index, the anxiety and depression levels, the pain (VAS, SAPA, RIII nociceptive reflex), the lumbar stiffness, the lumbar disability, the quality of life; the patients who had achieved back school had a peak torque of the flexors and a ratio flexors/extensors significantly lower. Comparing men and women we observed significant differences in the SAPQ and the musclesˈstrength. The SAPQ was correlated with the depression and anxiety levels, the lumbar disability, the peak torque of the flexors. The VAS was correlated with the age, the lumbar stiffness, the depression level, the peak torque of the flexors. The RIII nociceptive reflex was correlated with the ratio flexors/extensors. CONCLUSION: This study present some biases but this objective assessment of chronic low back pain appeared as feasible. The pain must be investigated in term of intensity, expression, alleviation. The impairment of the flexors muscles in women and after back school has to be confirmed. The different tests are relevant to determinate the efficiency of the back school programmes.