Chronic Low Pain Research Articles

Low back pain, somatic dysfunction, and segmental bone mineral density T-score variation in the lumbar spine.

Identifying objective measures that correlate with somatic dysfunction palpatory findings will aid in establishing clinical relevance of the findings and provide outcome measures for future studies. To investigate the association of altered segmental lumbar vertebral mechanics (ie, somatic dysfunction) as assessed by palpation with bone mineral density (BMD) T-score variability in participants, some with chronic low back pain (CLBP) and others without low back pain (LBP). Individuals with CLBP and individuals without LBP were examined by 2 blinded examiners for the presence or absence of paraspinal tissue texture abnormalities, vertebral rotational asymmetry, anterior motion restriction, and tenderness from L1 to L4. All participants then received a dual-energy x-ray absorptiometry scan of the lumbar spine. Bone mineral density T scores were compared between the CLBP and non-LBP groups. Sixty-three individuals (16 CLBP, 47 non-LBP) participated in the study. Lumbar segments with perceivable rotational asymmetry had higher mean BMD T scores (95% confidence interval [95% CI]) than lumbar segments with no asymmetry (0.5 [0.4-0.7] vs -0.2 [-0.6 to 0.2], respectively; P=.002). Additionally, lumbar segments with anterior motion restriction had higher mean BMD T scores (95% CI) than lumbar segments with no motion restriction (0.6 [0.4-0.7] vs 0.1 [-0.2 to 0.3], respectively; P=.03). Participants with CLBP demonstrated higher regional mean lumbar BMD T scores (95% CI) than those without CLBP (0.9 [0.6-1.1] vs 0.3 [0.2-0.5], respectively; P<.001). After accounting for sex and body mass index, vertebral segments with rotational asymmetry (in non-LBP participants only) and vertebral segments with motion restriction had higher mean BMD T scores than vertebral segments with no asymmetry or motion restriction. Participants with CLBP had significantly higher lumbar BMD than participants without LBP. The presence of rotational asymmetry or motion restriction was associated with elevated BMD at the affected vertebrae.

Surgery Doesn't Trump Rehabilitation in Patients with Degenerative Disk Disease

Two surgical procedures are performed commonly in patients afflicted with chronic low back pain and degenerated disks: spinal fusion surgery and prosthetic disk replacement surgery. However, in a previous trial, spinal fusion surgery was not better than disk replacement or nonsurgical rehabilitation (JW Gen Med Jul 1 2005); whether disk replacement is …

Comparison of acupuncture and baclofen treatment in patient with chronic tension myositis syndrom

Low back pain is one of the most prevailing illnesses, which is paramount importance among disabling illnesses. Inspite of being various factors for low back pain the main course of it hasnot been recognised yet. In this study we investigated the effects of two methods on treating chronic tension myositis syndrom. That is one kind of low back muscles spasm due to high stress and psychic problems that doesnot respond to current drug treatments. In this study we selected 50 subjects with chronic low back pain with credit clinical and para clinical documents based on being no other organic problem. They were 35 female and 15 male with average age of 34.5 and low and high ages of 21 and 48 years, the average weight was 58.5 kg. None of the woman was pregnant and the least time of low back pain was about 6 mounth.25 person of patients treated with baclofen and 25 others with acupuncture. In the group cured with baclofen, in the last days of treatment, 11 subjects were with relative reduction of pain and 14 subjects were without it. Where as in the patients treated with acupuncture, there were 22 subjects with the clear reduction of syndrom, 2 subjects with relative reduction, 1 subject was with no effect. In conclusion according to the results obtained in this study acupuncture in curing chronic tension myositis syndrom caused by high stress was more effective and stable than baclofen.

Treatment Satisfaction in Patients with Chronic Low Back Pain: Results of a Qualitative and Quantitative UK Study

Treatment Satisfaction in Patients with Chronic Low Back Pain: Results of a Qualitative and Quantitative UK Study

Options for Treatment of Chronic Intractable Low Back Pain: A Controlled Randomized Clinical Trial between Pulsed Radiofrequency Stimulation and Topical Steroid Injection of the L2 Intervertebral Foramen Nerve Root

Objective: A comparison of the effects of pulsed radiofrequency stimulation and topical steroid injection of the L2 intervertebral foramen nerve root for chronic intractable low back pain was made in a prospective, randomized, double blind controlled trial. Methods: Twenty-five screened out of 81 patients entered the study. One was excluded just before the intervention and 2 were lost to follow-up. In one group of patients (N=11, group Ⅰ) pulsed radiofrequency was used and in the other group (N=11, group Ⅱ) only a topical steroid was given. The visual analog scale (VAS), Oswestry disability index (ODI), Roland-Morris disability questionnaire (RMDQ), and Short-Form 36 (SF-36) questionnaire were used to measure the treatment effects. Results: Six months after treatment a significant reduction in ODI and RMDQ scores was demonstrated in both groups, but there was no significant difference between the two groups. The quality of life scales showed a positive trend in both groups in the SF-36 domain physical functioning, bodily pain, role emotional and mental health, but significance was reached only in the domain bodily pain at 6 months in group I. Conclusions: This study suggests that for chronic intractable low back pain, treatment with PRF stimulation of the L2 intervertebral foramen nerve root is equally effective in comparison with treatment of intervertebral foramen nerve root steroid injection.

Treatment of Chronic and Complicated Low Back Pain with Epiduroscopy

われわれは2002年から2008年までの間に, 慢性の腰痛, 下肢痛患者137例のエピドラスコピーを行った. これらの症例を効果と合併症についてレトロスペクティブに調べた. エピドラスコピーを受けた患者の62%で有意な痛みの軽減がみられた. 術後合併症として, 4例の大腿前面の知覚障害, 2例の下肢筋力低下, 2例の遷延性の頭痛を経験したが, これらはすべて3週間以内に消失した. 網膜出血やくも膜下出血などの重篤な合併症は経験していない. これらの結果に加え, これまでの経験で培ったエピドラスコピーのコツと要点として, 適応, 硬膜外腔造影, 手術時の体位, 麻酔法, 手術手技について述べたい.

A special type of discogenic low back pain: normal signal intensity of magnetic resonance imaging with abnormal discography

To report a group of special patients showing a normal signal intensity of MRI with a positive discography and discuss its pathogenesis and clinical significance. From August 2003 to November 2008, 288 patients with chronic low back pain were treated. Of these patients, 12 showed a normal intensity signal of MRI in lumbar intervertebral discs with a positive discography. There were 7 males and 5 females aged 20 - 44 years with an average of 29.6 years. The duration of disease was 8 months to 3 years with an average of 1.8 years. Dallas CT grading method was used for assessing the degree of annular disruption. Of these 12 patients, 33 lumbar discs underwent discography. Twelve discs in 12 patients showed annular disruption and low back pain reproduction. Among 12 painful discs, 3 showed grade 2 annular disruption and 9 showed grade 3 annular disruption. Patients who are refractory to conservative care and have normal signal intensity in lumbar disc MRI and who are suggested as discogenic origin and might need further treatment such as minimal invasive surgery or lumbar interbody fusion should still be examined by discography.

Intradiscal interventional therapy for degenerative chronic discogenic low back pain with end-plate Modic changes

To observe the different efficacies of intradiscal interventional therapy for patients with degenerative chronic discogenic low back pain and end-plate Modic changes through different types of injection and to evaluate the potential therapeutic value of intradiscal injection treatment for degenerative chronic discogenic low back pain with different types of end-plate Modic changes by using appropriate injection. Patients with single segmental degenerative chronic discogenic low back pain proved by discography were classified as Modic type I predominant change (including Modic Type I & Modic type I predominant mixed Type I/II) and Modic type II predominant change (including Modic Type II & Modic Type II predominant mixed Type II/I) according to the end-plate Modic changes on MRI. All received the intradiscal injection treatment. Patients were divided into three groups: (1) A group (control group): intradiscal injection of normal saline 3 ml; (2) B group (treatment group): intradiscal injection of diprospan (compound betamethasone) 3 ml; (3) C group (treatment group): interventional injection of diprospan (compound betamethasone) 1 ml + songmeile (cervus & cucumis polypeptide injection) 2 ml. Pain and function were evaluated by pain visual analogue scale (VAS) and Oswestry disability index (ODI). T-test was applied for efficacy comparison in each group at pre-operation, 3 months and 6 months post-operation. Sixty patients were included. There were 39 males and 21 females with a mean age of 41.6 years old (26 - 58). There were 10 patients in each group: A-Modic I, A-Modic II; B-Modic I, B-Modic II; C-Modic I, C-Modic II. There was no significant statistical difference in preoperative VAS and Oswestry scores among groups; VAS and Oswestry scores of B group and C group at 3 months and 6 months post-operation were significantly better than those pre-operative scores, and also better than that of control group (A group) at the same time. But there was no significant difference in scores between 3 months and 6 months in ether B group or C group, and there was also no significant difference in VAS and Oswestry scores between B group and C group at various time points. Various Modic types had no correlation with either VAS score or Oswestry score in each group at various time points. Intradiscal interventional therapy can relieve discogenic low back pain and improve Oswestry disability index score of function between 3 and 6 months post-operation. There is no significant difference in post-operative efficacy between Modic Type I and Modic Type II. Steroids are the major analgesic factor of intradiscal injection. But the synergistic application of songmeile (cervus & cucumis polypeptide injection) can maintain the analgesic effect and duration with a decreased dose of steroids.

The effect of William's exercise on non-specific and chronic referral low back pain

Introduction: William's flexion exercise is recommended for any kind of non-specific low back pain. However, no clinical trial study has yet determined its effect. This study examines the effect of William's flexion exercise on pain intensity and disability in patient s with chronic non-specific and referral low back pain. Materials and Methods: This clinical t rial study included 32 patients with CLBP, assigned into 2 groups of non-specific low back pain (n=16) and referral low back pain (n=16). Both groups received a two-week Flexion exercise intervention. Data was collected using Mc-Gill pain questionnaire and Roland Morris disability questionnaire completed once on the first and again on the last day of the period before and after the intervention. The data were then analyzed using independent and paired t-tests. Results: For the non-specific group, Mc-Gill pain score decreased from 17.6 ± 3.4 to 7.1 ± 2.8 ( P <0.05), and in referral group from 23.2 ± 4.7 to 8.8 ± 3.3 (P<0/05). A significant statistical difference was observed in the mean score obtained from Roland Morris disability questionnaire after the treatment (p<0.05) for the two groups. Disability score for the non-specific group was lower than that of the referral group. Conclusion: Our result supported the effectiveness of William's flexion exercise in reducing the pain in patients with chronic non-specific and referral low back pain . In terms of reducing disability, better result was observed for the non-specific group compared to the referral group.

The relationship between discography pressure and outcome of anterior lumbar interbody fusion for discogenic low back pain.

Objective To explore the relationship between discography pressure and outcome of an-terior lumbar interbody fusion (ALIF) for discogenic low back pain. Methods From April 2004 to June 2006, 65 patients with chronic low back pain were identified as diseogenic origin by pressure controlled discography, 22 cases of which received ALIF after failed conservative treatment for at least 6 months. The surgically treated patients aged 43.6 on the average (range, 25-67). The treated discs located: 8 in L4-5, 12 in L5S1, 2 in both L4-5 and L5S1. 22 cases received ALIF in 24 levels via retroperitoneal approach. The pressure as soon as accordant initially induced pain was recorded during discography. Low pressure (pressure ≤ 300kPa) in 10 cases and high pressure (pressure 300-500 kPa) in 12 cases. At 3 days postoperative, the patients were allowed to leave bed with a brace, and the brace should be used for 3 months. Results All the cases were followed up for average 18 months (range, 6-26 months). At the end of follow-up all the patients recov-ered normal social life and work without any symptoms. Disc height increased from 9.5 mm preoperatively to 13.5 mm postoperatively. Surgery time averaged 90 rain (70-120 rain); blood loss averaged 220 ml (100-400ml). Low pressure group and high pressure group showed no significant different in VAS, ODI, disc height,surgery time and blood loss preoperatively. At 6 months follow up, VAS and ODI improve rates of low pres-sure group account for 82.4% and 90.1% respectively; and those of high pressure group account for 71.7%and 80.6% respectively. No ileus, retrograde ejaculation nor artificial disc translation was noticed during fol-low-up. Conclusion Pressure-controlled discography can increase the diagnostic accuracy of discogenic lowback pain, and a positive discography on low pressure indicates better surgical outcome. Key words: Lumbar vertebrae; Intervertebral disk; Pain; Pressure

Is Posterior Lumbar Interbody Fusion with Titanium Cages Alone Suitable for Lumbar Degenerative Disease

Objective: Posterior lumbar interbody fusion (PLIF) techniques have been used for many years for the treatment of a variety of lumbar spine degenerative diseases. Patients with herniated disc disease in the lumbar spine at one or two levels, unilateral or bilateral leg (s) pain, chronic low back pain and a failed conservative treatment, were considered for this procedure. This paper discusses how many levels of the spine are suitable for cages alone which the patient needs for the operation, and which level is better than others when the patient undergoes single-level surgery. Methods: Twenty-three patients (21: single level, 2: two levels) underwent a posterior lumbar interbody fusion procedure in which A-spine titanium vigor cages were used. At follow-up, the outcomes were assessed using the Prolo Scale. All the patients safely underwent surgery without severe complications. Results: At the time of the last follow-up visit, 21 patients (100% of single-level cases) were content with the result of the surgery. A patient (2-level case) underwent pedicle screw fixation at a single level due to persistent lower back pain (LBP), which pseudarthrosis was suspected. During the follow-up period, the patients who underwent 2-level surgery have multiple complaints. The other patient (female, 2- level case) suffered from LBP for 24 months. Under conservative treatment, low back pain improved. Conclusion: With regard to the preservation of the posterior element for utmost benefits, a single-level operation has a better prognosis than a two-level operation. In single level surgery, a PLIF by cages alone produces more satisfactory clinical results at L3/4 and L4/5 than at L5/S1.

Non-pharmacological treatment for chronic low back pain

Non-pharmacological treatment for chronic low back pain

Discogentic lumbar pain: association with MRI and discography

Objective To evaluate the correlation between MRI and X-Ray discography findings and pain response at provocative discography in patients with discogenic back pain. Methods Two hundred and fifty-six lumbar intervertebral discs in 93 patients who underwent MRI and X-Ray discography were included in this study. MR images were retrospectively evaluated regarding disc degeneration, endplate abnormalities and high intensity zone. Disc degeneration was graded according to the modified criteria of Pearce, et el. Evaluation of disc morphology was performed with X-Ray discography by using the classification of Adams, et al. Endplates and adjacent bone marrow abnormalities were classified according to Modic,et al. During discography concordant pain was regarded as positive, whereas discordant pain and no pain were regarded as negative. The data were analyzed using the Chi-squnre test. Results There were 116 discs with concordant pain and 140 discs with discordant pain or no pain. Of 256 discs on discography, 17 discs were type Ⅰ17(6.6%),type Ⅱ were 25(9.8%),type Ⅲ were 91(35.5%), type Ⅳ were 77(30.1%) and type Ⅴ were 46(18.0% ). On MR images, discs of grade Ⅰ were 23 (9.0%) ,grade Ⅱ were 34(13.3%), grade Ⅲ were 84(32.8%), grade Ⅳ were 85 (33.2%) and grade Ⅴ were 30(11.7%). There was positive correlation between Pearce graded of MRI and classification of Adams of discography (r=0.62, X2 =160.87,P <0.01).In 123 discs of type Ⅳ to type Ⅴ on discography, 104 discs were with concordant pain. There was positive correlation between type Ⅳ-Ⅴ and concordant pain( r=0.60, X2 = 144.08, P < 0.01). In 115 discs of Ⅳ-Ⅴ grade degeneration, 99 discs presented with concordant pain. There was positive correlation between Ⅳ-Ⅴ grade disc degeneration and concordant作者单位:510120 广州,中山大学附属第二医院放射科 pain(r = 0.59, X2 = 137.11, P <0.01 ). In 60 discs with high intensity zone(HIZ), 52 discs presented with concordant pain. There was positive correlation between HIZ and concordant pain ( r=0.41, X2= 51.93, P <0.01 ). In 58 discs with endplate degeneration, 51 presented with concordant pain. There was positive correlation between Modic degeneration and concordant pain ( r = 0.41, X2= 52.76, P < 0.01 ). Conclusion In patients with chronic low back pain, MR imaging may present moderate to severe disc degeneration, high intensity zone, endplates and adjacent bone marrow abnormalities. MR findings with concordant pain can raise the diagnostic possibility of discogenic lumbar pain. Typical discography findings, fissured or ruptured disc, with concordant pain are important diagnostic evidence for discogenic lumbar pain. Key words: Arthrography; Intervertebral disk; Magnetic resonance imaging; Low back pain

Dorsal lumbar interbody fusion for chronic axial, mechanical low back pain: a modification of two established techniques.

Lumbar spinal fusion is a popular method for treating degenerative disc disease leading to chronic low back pain. Some of the techniques most commonly undertaken are posterior lumbar interbody fusion and transforaminal lumbar interbody fusion. These techniques have their own advantages and disadvantages. In this article, we briefly describe a modified technique, dorsal lumbar interbody fusion, which retains the advantages and avoids the disadvantages of the others. The goal of this procedure is to combine the aggressive decompression of both the thecal sac and bilateral nerve roots and symmetrical bilateral graft placement obtained via the posterior lumbar interbody fusion with the transforaminal placement of interbody grafts obtained via the transforaminal lumbar interbody fusion procedure. This modification has several advantages: it permits more aggressive removal of the disc bilaterally, larger and more symmetrical lordotic-shaped carbon fiber cages and structural allograft can be placed bilaterally, and the nerve roots can be aggressively decompressed bilaterally.

Efficacy and Safety of Piroxicam Beta-Cyclodextrin Sachets for Treating Chronic Low Back Pain: A Randomized, Parallel, Active-Controlled Trial

Background: The clinical effects of the sachet form of piroxicam beta-cyclodextrin have been studied for their efficacy against acute or osteoarthritic pain in Western populations, but studies are sparse for chronic low back pain. We evaluated the effects of the sachet form on local Asian people with chronic backache, compared with conventional piroxicam tablets. Methods: Forty-seven eligible patients were randomized into a sachet treatment group (n=24) and a tablet treatment group (n=23). Both groups received dosages of 20 mg per day orally for 28 days. Efficacy was evaluated using a pain score and a disability index. Results: The efficacy of the two application methods was compared based on 42 patients included in the per-protocol population. The sachet-form drugs showed greater improvement than tablets in lowering the pain score by 1.93 units. This mode of delivery also showed a greater improvement in the patients’ disability index. Sachet application produced 12.5% of adverse incidences versus 19% for tablets, with no statistically significant difference. Conclusion: Piroxicam betacyclodextrin sachets extended the spectrum of analgesic activity for the treatment of these patients with chronic low back pain and provided a low incidence of side effects.

Intradiscal Steroid Injection for Chronic Discogenic Low Back Pain

Objectives: To treat patients with chronic discogenic low back pain with intradiscal steroid injections (IDSI) and observe clinical outcomes and complications. Methods: We studied 65 patients with chronic discogenic low back pain of more than 6 months' duration, who underwent IDSI. All subjects underwent magnetic resonance imaging to identify the degenerative discs, which had high-intensity zones at the posterior annulus and positive discographic examinations. We injected 1 ml of 1% xylocaine and 1 ml of 40 mg/ml triamcinolone acetonide mixture into the degenerative disc. All patients were monitored at 1, 3, 6, and 12 months postinjection. We used the Denis pain scale, Denis work scale, Roland-Morris scale, and finger-to-floor distance for clinical evaluation and all patients were monitored for at least 1 year. Results: Fifty-two patients (80%) displayed improvement 1 month after undergoing IDSI and 47 (72%) continued to feel satisfied 12 months after undergoing this procedure. No complications were encountered. Conclusion: IDSI appears to be a simple and safe treatment for chronic discogenic low back pain. Provided that the indication for IDSI is correct, clinical improvement can be expected.

Description of the effects of the protocol school of modern column in individuals with chronic low back pain

Introduccion: Describir los efectos del protocolo “escuela de columna moderna” sobre la aptitud cardiorrespiratoria (ACR) y la aptitud fisica (AF) en portadores de lumbalgia cronica atendidos en la Clinica Escuela de Fisioterapia de la UNIPAR - campus Toledo - PR. Materiales y Metodos: Estudio casi experimental, cuya muestra fue compuesta por portadores de lumbalgia cronica de origen mecanica, de ambos los sexos y mayores de 18 anos. Los criterios de exclusion adoptados fueron: sugerencia de dolor lumbar de origen no-mecanica; y la falta de adhesion al programa. Los voluntarios habian sido divididos, por conveniencia, en grupo control (GC), sometido al tratamiento fi sioterapico conservador, y grupo experimental (GE), sometido al programa “escuela de columna moderna”. Ambas las intervenciones habian sido realizadas 2 veces semanales durante 4 semanas. Inicialmente, habian sido entrevistados 43 voluntarios, resultando en una muestra fi nal compuesta por 23 voluntarios, siendo 8 en el GC y 15 en GE. Las variables del estudio fueron: la AF, mensurada por el Indice de Kasari; y la ACR, estimada indirectamente por un formulario sin ejercicios. Las variables habian sido medidas antes y tras la aplicacion de las intervenciones. El test estadistico utilizado fue el test t pareado, adoptandose ( =0,05). Resultados: Las comparaciones hechas para ambos los grupos, en relacion a la AF, no mostraron diferencias signifi cativas. En cambio, la ACR presento alteracion estadisticamente signifi cativa (p=0,0106) solo en GE. Conclusion: El protocolo “escuela de columna moderna” fue capaz de infl uenciar positivamente la ACR de la muestra, pero no la AF

Antidepressants and Antiepileptic Drugs for Chronic Non-Cancer Pain

The development of newer classes of antidepressants and second-generation antiepileptic drugs has created unprecedented opportunities for the treatment of chronic pain. These drugs modulate pain transmission by interacting with specific neurotransmitters and ion channels. The actions of antidepressants and antiepileptic drugs differ in neuropathic and non-neuropathic pain, and agents within each medication class have varying degrees of efficacy. Tricyclic antidepressants (e.g., amitriptyline, nortriptyline, desipramine) and certain novel antidepressants (i.e., bupropion, venlafaxine, duloxetine) are effective in the treatment of neuropathic pain. The analgesic effect of these drugs is independent of their antidepressant effect and appears strongest in agents with mixed-receptor or predominantly noradrenergic activity, rather than serotoninergic activity. First-generation antiepileptic drugs (i.e., carbamazepine, phenytoin) and second-generation antiepileptic drugs (e.g., gabapentin, pregabalin) are effective in the treatment of neuropathic pain. The efficacy of antidepressants and antiepileptic drugs in the treatment of neuropathic pain is comparable; tolerability also is comparable, but safety and side effect profiles differ. Tricyclic antidepressants are the most cost-effective agents, but second-generation antiepileptic drugs are associated with fewer safety concerns in elderly patients. Tricyclic antidepressants have documented (although limited) efficacy in the treatment of fibromyalgia and chronic low back pain. Recent evidence suggests that duloxetine and pregabalin have modest efficacy in patients with fibromyalgia. Copyright © 2005 American Academy of Family Physicians.) Permission from the AAFP was granted to publish this article in the hardcopy only. Kindly refer to www.aafp.org or subscribe to the hardcopy of South African Family Practice. (SA Fam Pract 2005;47(3): 30-36)

Liaison-psychiatric approach for patients with chronic low back pain

There are a number of chronic low back pain patients who have not only the somatic disorder as disability of the trunk but also the mental disorder, i.e. insomnia, depression. It should pay attention to the mental state of the patients and human relationship in home and career, as background of low back pain. Liaison-Psychiatric Approach means that orthopedist works in cooperation with psychiatrist. Medical team including orthopedist, psychiatrist, and co-medical stuff such as psychiatric social worker, physiotherapist, etc. is made up to discuss the curative course dependent on each psychosomatic problems of the patients with chronic low back pain in Liaison conference.

The indication and clinical value of neural blocks for low back pain

Neural blocks are commonly used for patients with acute or chronic low back pain. It is important to do correctly technical procedure of neural blocks and more important to be well aware of the indication and clinical value of neural blocks. Neural blocks have two aspects of diagnostic and therapeutic value. In this article, the indication and clinical value of neural blocks were reviewed in trigger point blocks, epidural blocks, selective nerve root blocks, facet blocks and lumbar posterior medial branch blocks.