Chronic Low Back Pain Syndrome Research Articles

Clinical outcomes measurement: Studies of patients with cancer, low back pain, and irritable bowel syndrome demonstrate that short forms of the Multidimensional Affect and Pain Survey (MAPS) and other questionnaires must be tailored to each patient group

Responses by 100 cancer outpatients to the 101-item MAPS were analyzed using item analysis to obtain measures of inter-item consistency and discriminability, as well as Cronbach’s alpha. These data were then used to select one item from each of the 30 101-MAPS clusters, thus ensuring that the hierarchical structure of the 101-MAPS dendrogram was preserved. In other, separate studies, two groups of experienced medical personnel (attending physicians, residents, and nurse practitioners) rated the relevance of each of the 101 MAPS items to the assessment of patients with (a) chronic low back pain (CLBP) and (b) irritable bowel syndrome (IBS). The 30 questions, one from each cluster, rated as most relevant were selected for the shorter questionnaires. Of the 30 items selected for the assessment of the patients with CLBP, there was agreement with the cancer patients on 10 of 17 items (59%) in the Somatosensory Pain supercluster, 5 of 8 items (63%) in the Emotional Pain supercluster, and 1 of 5 items (20%) in the Well-being supercluster. Of the 30 items selected for the assessment of the patients with IBS, there was agreement with the cancer patients on 11 of 17 questions (65%) in the Somatosensory Pain supercluster, 1 of 8 items (12%) in the Emotional Pain supercluster, and 4 of 5 (80%) of the items in the Well-being supercluster. Comparison of questions selected for short forms for patients with CLBP and IBS demonstrated agreement on 13 of 17 items (76%) in the Somatosensory Pain supercluster, 6 of 8 items (75%) in the Emotional Pain Supercluster and with none of the 5 items (0%) in the Well-being supercluster. Because different questionnaire items are important to different groups of patients, short questionnaires must be tailored to the specific patient population that is being assessed.

Complex assessment of regional hemodynamics with tetrapolar rheography and laser Doppler fluometry in patients with low back pain syndrome

Objective. To assess hemodynamic disturbances in pts with low back pain syndrome (LBPS). Material and methods. 57 pts with LBPS were examined (12 female and 45 male) aged 18 to 53 years (mean age 36,7 years). Spine osteochondritis was diagnosed in most of them. 34 had subacute and 23 - chronic LBPS course. In 32 pts peripheral hemodinamic indices were examined with tetrapolar rheo- vasography by “ARM-RhEO apparatus. In 25 pts total local blood flow was assessed in pain points with laser-Doppler fluometry (LDF-2 apparatus). 35 healthy individuals of comparable age and sex were included in control group. Results. 77% of pts showed small vessels tone decrease most prominent in pts with subacute LBPS course. Arterial wall elasticity diminution was revealed in 63% of cases, significant reduction of blood filling level - in 82%, venous flow-out obstacle - in 87%. There was a connection between degree of local blood flow increase in back pain points and (PI) score: 0,19 V in pts with PI>60 u and 0,13 V in pts with PK40 u (in control group - 0,08 V, p<0,05) what shows perifocal edema in most painful points. Conclusion. Revealed regional hemodynamic and microcirculation disturbances can objectively confirm participation of hemodynamic disturbances in pain syndrome genesis and serve as a basis for perfection of LBPS treatment methods.

SOFT STABILIZATION OF THE LUMBAR SPINE USING THE GRAF SYSTEM FOR SPINAL INSTABILITY SYNDROMES AND PSEUDOARTHROSIS — 5 YEARS' RESULTS

There is considerable controversy in the diagnosis and management of lumbar spinal instability. Most clinicians agree that patients suffering from the chronic low back syndrome who have suspected instability and have not responded to conservative measures, should be considered for operative treatment with stabilization using rigid or semi-rigid systems to reduce or eliminate movement at the painful segment.The concept of soft stabilization was introduced by Henri Graf in 1988 and has become a routine procedure in various centres throughout the world for stabilization for clinical instability syndromes.The Graf system was introduced into Western Australia in October, 1991. The aim of this paper is to report the independently reviewed retrospective results of the first 25 patients with respect to clinical outcome and radiological features.The clinical outcomes were consistent with other reported treatment measures for the chronic low back pain syndrome. The radiological results do not show any evidence of implant loosening or breakage.

A unidimensional pain/disability measure for low-back pain syndromes

A new measure is presented, suitable for documenting severity and response to treatment in chronic low-back pain syndromes. It is self-administered and combines two pain and seven mobility items. These were selected from pre-existing validated instruments on the basis of their sensitivity to change after treatment. Their Italian validated translation was adopted. The measure was administered to 32 chronic low-back pain Italian patients, all refractory to previous conservative treatments. In most cases they presented with herniation or protrusion of 1–3 lumbar discs. Patients were treated with 3–6 sessions of autotraction over a 5- to 15-day period. Scores on the scale were recorded at admission, discharge and follow-up, 1–3 months after treatment. At discharge and at follow-up, patients were asked if, overall, they felt improved, the same or worse. At follow-up, 20 patients out of 32 reported overall improvement. Scalometric properties of the measure were tested using Rasch analysis. For admission and follow-up, items followed a consistent hierarchical relationship along a unidimensional pain/disability variable, which is being called back illness. The items were not redundant, in that they spread well along a wide range of difficulty/severity. The hierarchy matched well with the expected expression of the conditions of the patients. A study was conducted on 34 chronic back pain patients, showing satisfactory test-retest reliability. Depending on the various items, Cohen's unweighted K ranged from 0.27 to 0.78, with ten of the 11 items above the 0.45 level of acceptability, while intraclass correlation coefficients ranged from 0.42 to 0.89. At follow-up, changes in BACKILL of plus 15% or more, with respect to admission, were consistent with patients' reports of improvement in 19 out of 20 cases. Changes in BACKILL of less than 15% were consistent with patients reports of being the same or worse in 11 out of 12 cases.

Effectiveness of therapies currently employed for persistent low back and leg pain

I n the Focus article, Drs. Loeser and Sullivan marshal several lines of argument to suggest that disability in the chronic low back pain syndrome is iatrogenic. The concept is intriguing, but not new. Shorter, in his excellent review of psychosomatic illness in the era of modern medicine, developed the thesis that somatization by patients follows a variety of societal and medical fashlons. There is much merit in what Loeser and Sullivan present. However, it is my view that the problem is much more broadly based than the contribution of physicians alone. The medical profession, society in general, and all of our legal and administrative institutions have failed to understand the concept of somatization. I believe this is the key to the problem. The real issue is the diagnosis of psychogenic physical symptoms and their appropriate treatment. Separating organic from psychogenic disease and appropriately determining the causes of both is key to improving the current confused situation. The documented history of psychosomatic symptoms begins early in the 18th century. About this time pseudoseizures, generally called hysteric fits, were recognized. Later in the century much unexplained malaise and pain was ascribed to gout. The erroneous physiology of the uterine theorists and the concept that psychiatric symptoms began in the sympathetic ganglia of the abdomen were used to explain most psychosomatic complaints. Toward the end of the century, William Cullen defined neuroses and firmly settled the nervous system as the source of these complaints, but many of these early physicians continued to invoke spurious causes, such as irritation or inflammation of nerves, to explain symptoms. This fallacious pathophysiology cul-

The frequency of transition of chronic low back pain to fibromyalgia.

In a retrospective study, the outcome of the chronic low back pain syndrome was investigated in a group of 53 patients. Average time since the diagnosis was established was 18 years. 25% of the patients--all female but one--developed fibromyalgia. The criteria of Yunus and Wolfe, modified by Müller and Lautenschläger, were applied to establish the diagnosis of fibromyalgia. In 60% of the patients chronic low back pain persisted at the time of final examination, while 8 patients were asymptomatic. Predictive parameters for the chance of getting fibromyalgia were sex and postural disorders such as scoliosis. Other radiological findings, for example degenerative changes of the spine, did not coincide with the group of patients who developed fibromyalgia. The predictive value of pain localisation, number of tender points, presence and severity of functional and vegetative symptoms, and the psychosocial situation is uncertain and should be investigated in further long term prospective studies.

Isthmic spondylolisthesis among patients receiving disability pension under the diagnosis of chronic low back pain syndromes.

This study evaluated the incidence of lumbar isthmic spondylolisthesis among subjects permanently disabled because of low back pain syndromes. Previous information pointed to whether spondylolisthesis is associated with more frequent or intensive low back pain than that found in the general population. One may expect severe deformity, neurologic deficits, and hence impairment and disability accompanying such a spinal disorder. However, natural history of spondylolisthesis has also been reported to be benign. Files from 952 subjects receiving temporary or permanent disability pension because of musculoskeletal disorders of the vertebral column were investigated; 81% had low back pain syndromes. From the radiologic report of the lumbar spine, which was available in 519 (70%) cases, the radiologic findings were recorded. In 2.5%, isthmic lumbar spondylolisthesis was present. In more than half of the subjects, the location of the defect was on L4. Only minor neurologic findings were present. The finding that the incidence corresponds well with the incidence in the normal population may suggest that lumbar isthmic spondylolisthesis does not invariably lead to severe impairment or disability, although location of the defect at the level proximal to L5 may be connected to an increased risk for permanent low back disability.

Chronic pain?the end of the welfare state?

The problem of low back pain has reached epidemic proportions in the industrialized nations. The predicament of back pain is common, 30-40% of our populations from 10-65 years old report such trouble to occur on a monthly basis. In 1-8% this results in work-disabling back pain. Only in very few of these patients can physicians diagnose a definite pathoanatomical cause for the pain. It can be deduced that psychosocial factors, including insurance benefits are of importance for this variation. Sweden, with 100% sickness benefits, has the highest disability rate. Few non-surgical methods have proven effective in rendering the patient better for him to return to work. Even fewer studies demonstrate any benefit from surgery, simple open removal of a proven disc hernia being the only exception. For patients with unproven diagnostic labels such as facet arthritis, degenerative disc disease, internal disc resorption and instability, no evidence exists that any type of surgery is cost-effective. More attention must be paid to illness behaviour by anyone treating chronic low back pain syndromes (> 3 months). Such psychological reactions to an originally nociceptive pain stimulus somewhere in the motion segment, must be elucidated and addressed, before embarking on risky and expensive treatment modalities including surgery. It is time for all of us, politicians as well as physicians, to distinguish what types of support will contribute to our nations' future and which ones will undermine it. Our welfare systems are at stake.

MBHI hos patienter med kroniske rygsmerter

Twenty-six patients with chronic non-malignant low-back pain syndrome completed the MBHI (Millon Behavioral Health Inventory) before and after an intensive outpatient treatment program of 6 weeks' duration carried out by a psychologist, a physiotherapist, and a nurse at the Pain Clinic in Herlev, Copenhagen. Patients were contacted by telephone at half-year follow-up to evaluate any changes in the use of analgetics and the intensity of the pain. Compared with a group of patients with acute pain, the chronic pain patients were more sensitive, less confident, and less sociable. Scale PP, measuring possible psychologic factors affecting the chronicity of the pain syndrome, had a high positive predictive power (0.83) for outcome of the psychologically oriented treatment. The negative predictive power was low (0.50), no better than by chance selection. Patients doing better after treatment were better on the following scales: chronic tension, premorbid pessimism, somatic anxiety, and sociability. MBHI may be a...

Improved Physical Performance Outcomes After Functional Restoration Treatment in Patients with Chronic Low-Back Pain

Functional restoration, a medically supervised team treatment approach that addresses deficits that accompany the deconditioning process in patients with chronic low-back pain, has emerged as a viable rehabilitation alternative. While the primary emphasis of this treatment approach has remained unchanged since its inception over 6 years ago, recent rapid advances in quantification technology and understanding of the complexity of the chronic low-back pain (CLBP) syndrome have led to more sophisticated and aggressive rehabilitation efforts. In the current study, the authors examined two groups of patients with CLBP, from the treatment program's initial (n = 45) and most recent years (n = 57) of operation, respectively, to determine if the evolution of the treatment program has resulted in increased gains in physical capacity between these groups of patients. Patients in each group were assessed on measures of isokinetic trunk strength and spinal range of motion at program admission and discharge. Both groups demonstrated improved physical capacity levels, but the recent group also demonstrated considerably higher physical capacity levels than the early group, at both program admission and discharge. It was concluded that functional restoration continues to be successful with CLBP patients, and that increased preprogram training and education may facilitate a more rapid elimination of inhibitory factors (ie, pain, fear of reinjury), which often impede and slow physical training.

Fibrinolytic activity in the chronic low-back pain syndrome.

Recently, decreased fibrinolytic activity (FA) in plasma of heterogenous groups of patients with chronic low-back pain (CLBP) has been demonstrated1,2). A decreased FA may lead to impaired removal of fibrin, deposited secondary to lesions and tissue damage of the lumbar spine. Fibrin is able to induce an inflammatory reaction(3), thus leading to pain and possibly fibrosis. This could explain why some individuals develop arachnoiditis, post-laminectomy syndrome or symptoms due to spondylosis and disc degeneration, while others do not.In this study we have investigated whether decreased FA could be demonstrated in a prospectively and consecutively collected population of patients with CLBP.

The chronic low back pain syndrome(CLBPS) and its correlation with the apparent etiologic diagnosis

The chronic low back pain syndrome(CLBPS) and its correlation with the apparent etiologic diagnosis

Computed Tomography in the Evaluation of Acute and Chronic Low Back Pain Syndromes Commonly Seen

The purpose of this article has been to provide the results of a survey of the more common conditions, and their CT findings, causing chronic low back pain. There is an extensive literature on this subject, providing much more detail and discussing less common entities, of which the reader may avail himself.

Comparing physical and behavior therapy for chronic low back pain on physical abilities, psychological distress, and patients' perceptions

A treatment-outcome study was conducted to study the impact of behavior and physical therapy on components of the chronic low back pain syndrome. Eighteen patients received behavior therapy and 15 patients received physical therapy. All patients had at least a 6-month history of seeking treatment for chronic low back pain. Prior to treatment patients were assessed in four principal areas of functioning: (1) physical abilities; (2) current physical functioning; (3) psychological and psychosocial functioning; and (4) pain intensity and pain perception. Treatments were conducted in a group (five to eight patients) outpatient setting. Both behavior therapy and physical therapy groups met for 10-weekly sessions, each lasting 2 hr. Behavior therapy was designed to address the environmental, social, and emotional components of the low back pain syndrome as well as the depression and decreased activity that result from chronic low back pain. Physical therapy was based upon traditional rehabilitation theory and was designed to improve low back function. Patients were reevaluated at posttreatment, 6 months, and 1 year. The results showed a general improvement for patients in both groups and a few treatment-specific differences in outcome measures.