Chronic Spinal Disorders Research Articles

To evaluate responsiveness and minimal important change (MIC) for the Persian versions of FABQ, TSK, and PCS.

Fear avoidance beliefs questionnaire (FABQ), Tampa scale of kinesiophobia (TSK), and pain catastrophizing scale (PCS) are tools widely used to measure fear-avoidance beliefs, fear of movement, and pain-related catastrophic thinking in people with chronic spinal disorders. To evaluate responsiveness and minimal important change (MIC) for the Persian version of FABQ, TSK, and PCS. One hundred people with chronic non-specific neck pain participated in an intervention program including routine physiotherapy plus pain neuroscience education. They fulfilled FABQ, TSK, and PCS questionnaires at baseline and 4-week follow-up. The 7-point global rating of change (GRC) as the external anchor was also completed in follow-up by patients. Responsiveness was evaluated using receiver operating characteristic (ROC) curve analysis and correlation analysis. According to GRC, patients were classified into two groups (improved vs. unimproved). The best cutoff or MIC was estimated via the ROC curve. Acceptable responsiveness obtained for FABQ, TSK, and PCS with the area under the curve ranging from 0.84 to 0.94 and spearman coefficient > 0.6. The MIC values reflecting improvement were 9.5, 10.5, and 12.5 points, respectively, for FABQ, TSK, and PCS. The results of this study demonstrated that the Persian version of FABQ, TSK, and PCS have sufficient responsiveness and good ability to measure meaningful clinical changes in people with patient CNNP. The MIC scores of the FABQ, TSK, and PCS can help clinicians and researchers to detect changes significant to the patient following a rehabilitation program.

The axial spondyloarthritis clinical phenotype in idiopathic hypoparathyroidism: critical review of concept that muscular hypercontractility can induce enthesopathy lesions.

Idiopathic hypoparathyroidism (iH-PoPT) is a rare condition infrequently associated with axial spondyloarthritis (SpA) which may mimic ankylosing spondylitis (AS). Axial SpA is a unifying clinical term for chronic inflammatory spinal disorders, although biomechanical factors may play a role. The primary objective of this review is to critically describe the iHPoPT/SpA phenotype defined by established criteria and its differentiation from AS. Five databases were comprehensively searched without time limit to retrieve 14 (11M, 3F) iH-PoPT/SpA cases. Their demographic, clinical, laboratory, radiographic, and HLA-B27 status were compared to two national series of AS patients. Mean (SD) onset age of musculoskeletal symptoms [32.5 (9.7)] was significantly older than 943 German AS patients [25.1 (8.5), (p=0.004)] and 842 Spanish AS patients [26.1 (9.7), (p=0.030)]. Radiographic lesions of iHPoPT/SpA differ morphologically from skeletal alterations in hyperparathyroid and hypophosphataemic syndromes which often have inadequate bone mineralisation and decreased bone mineral density (BMD). Clinical musculoskeletal manifestations were greater (p<0.001) in iHPoPT/SpA than AS patients at cervical (62 vs. 10%) and hip (85 vs. 22%) localisations, respectively. Typical AS sacroiliac joint structural lesions of erosions and bony bridging were reported in only 1 iHPoPT/SpA case and HLA-B27 was positive in 2 of 10 tested. The iHPoPT/SpA phenotype may be a natural experiment on the novel concept of how chronic hypocalcaemia of iHPoPT causes axial neuromotor hypercontractility and biomechanically induces the rare SpA association. In iHPoPT/SpA, neuromuscular hyper-contractility may predispose to axial radiographic enthesopathy lesions and contribute knowledge on biomechanical contributions and pathways for further research.

Facilitators and barriers to employment for persons with chronic spinal cord injury or disorder: A qualitative study framed by the person-environment-occupation model

Context/Objective: Prolonged unemployment is common for people living with a spinal cord injury or disorder (SCI/D) and can impact negatively on quality of life. The present study examines stakeholder perspectives and experiences with the job search process in order to identify service gaps and return-to-work solutions. Design: In-depth semi-structured interviews were thematically analysed, with questions focused on factors that can help or hinder efforts to gain employment. Generated themes were then applied to the Person-Environment-Occupation (PEO) systems model of participation. Setting: Community-based disability service provider in South Australia. Participants: Purposive sample of persons with SCI/D (n = 8) and rehabilitation professionals (n = 4). Results: Person-centred themes were strongly endorsed by both groups and focused on incentives of, and motivation for, employment. Equally important to the job search process were individual expectations and attitudes, particularly job readiness. Environmental facilitators included employers’ positive attitude, although workplace discrimination remained a concern. Occupation-based barriers, rather than opportunities, were identified – namely, difficulties in SCI/D self-management, the need for timely functional assessments, and more opportunities for education, upskilling and retraining. Conclusions: The PEO model provides a broad framework to better understand the complex return-to-work process for people with a SCI/D and, potentially, uncover tangible solutions. The suggestion is that vocational rehabilitation should go beyond skills training and include motivational support to enhance job readiness. This must be done on a case-by-case basis. There is also a need for active and covert discrimination to be addressed through employment policies. The findings will be used to develop intervention targets for a newly established vocational rehabilitation service.

Quercetin Alleviates Intervertebral Disc Degeneration by Modulating p38 MAPK-Mediated Autophagy.

Intervertebral disc degeneration (IVDD) is a degenerative and chronic spinal disorder often associated with the older population. Oxidative stress is a major pathogenic factor of aging that results in the apoptosis of nucleus pulposus cells (NPCs) and extracellular matrix (ECM) degradation. Quercetin (QUE), a naturally occurring flavonoid with antioxidant and anti-inflammatory properties, has been studied in research on degenerative diseases. However, the potential effects and mechanisms of action of QUE on IVDD remain unclear. In this study, the effects of QUE on antiapoptosis and ECM metabolism were firstly investigated in TBHP-treated NPCs. Meanwhile, the autophagy inhibitor, 3-MA, and p38 MAPK inhibitor, SB203580, were used in subsequent TBHP-induced NPC experiments to determine whether QUE exerted its protective effects through autophagy and the p38 MAPK/mTOR signaling pathway. Finally, the therapeutic effects of QUE were confirmed in vivo using a rat tail needle puncture-induced model of IVDD. We found that QUE treatment significantly alleviated oxidative stress-decreased cell viability and intracellular ROS levels in NPCs treated with TBHP. Furthermore, treatment with QUE led to a decrease in apoptosis as measured by decreased Bax and increased Bcl-2 expression and PE/7-AAD flow cytometry analysis. QUE also promoted ECM stability as measured by increased collagen II and aggrecan and decreased MMP13 levels. Our results also showed that QUE promoted the expression of autophagy markers beclin-1, LC3-II/I, and decreased p62. Inhibition of autophagy by inhibitor 3-MA may partially reverse the protective effect of QUE on apoptosis and ECM degeneration, indicating that autophagy was involved in the protective effect of QUE in NPCs. Further study confirmed that QUE partially inhibited the p38 MAPK signaling pathway and inhibition of p38 MAPK by SB203580 activated autophagy, indicating that QUE protected NPCs against apoptosis and prevented ECM degeneration via the p38 MAPK-autophagy pathway. Finally, using a rat tail puncture-induced model of IVDD, we confirmed that QUE had a protective effect against IVDD. Our results suggest that QUE could prevent IVDD by modulating p38 MAPK-mediated autophagy and, therefore, is a potential therapeutic strategy in the treatment of IVDD.

Symptomatic Syringomyelia Associated with Acute Bacterial Meningitis in a 3-Year-Old Patient

Syringomyelia is very rare in children specially in younger than 5 years. As it has slow progression therefore it takes years to become symptomatic and to be diagnosed. In most cases syringomyelia is a chronic spinal disorder which progress slowly. We report a case of symptomatic syringomyelia associated with acute bacterial meningitis in a 3 years old patient in French Medical Institute for Mothers and Children (FMIC)

Is T9-11 the true thoracolumbar transition zone?

ObjectiveDegenerative thoracic stenosis has been shown to most frequently involve the lower thoracic segments (T9-T12) where there is greater mobility and vulnerability due to flexion, extension and rotation of the spine. The thoracolumbar junction is considered anatomically to be T12-L1; the anatomical transition between the relatively immobile thoracic spine and relatively mobile lumbar spine. From anecdotal experience at our institution, we hypothesise that the true thoracolumbar junction is higher, at T10-11; the point of transition from floating to false ribs resulting in increased mobility at T10-11. Methods and materialsA retrospective review was performed of MRI lumbar and whole spine performed on patients aged 10–40 years in our institution over a 5-year period. Patients with previous surgery, chronic spinal disorders and congenital abnormalities were excluded from the study. Intervertebral discs from T8-9 to L1-2 were assessed for evidence of degeneration using the Pfirrmann grading system. Data obtained from a study using computer-based models to assess mean resultant loads in flexion, sitting and standing from T8-9 to L1-2 on patients aged 18–35 years was also analysed. The mean load gradients between two consecutive discs from T8 to L2 were analysed. Statistical analysis was performed with SPSS (p < 0.05 was considered statistically significant). ResultsThree-hundred and twenty-two MRI studies were reviewed. Mean Pfirrmann grade was highest at T8-9 and T9-10 (1.35 ± 0.99 and 1.32 ± 0.93 respectively).Pfirrmann grade differed significantly at each level (χ2 = 45.137 p = 0.001). Difference in mean load gradient from T9 to T11 was significantly higher than mean load gradient across T11 to L1 in both sitting and standing (0.095 ± 0.062 vs 0.050 ± 0.044 kN; p = 0.007, and 0.101 ± 0.061 kN vs 0.040 ± 0.054 kN; p = 0.007). ConclusionThe changes in segmental loads and more severe disc degeneration at T9-11 compared to T11-L1 support our hypothesis that the true thoracolumbar transition is higher than expected, at T10-11; where the rib cage transitions from floating to false ribs.

Evaluation outcome of the regional approach of physiotherapy, conventional approach of physiotherapy and non-steroidal anti-inflammatory drugs (NSAID) on anxiety for chronic mechanical spinal pain disorder

Evaluation outcome of the regional approach of physiotherapy, conventional approach of physiotherapy and non-steroidal anti-inflammatory drugs (NSAID) on anxiety for chronic mechanical spinal pain disorder

Use of the Central Sensitization Inventory (CSI) as a treatment outcome measure for patients with chronic spinal pain disorder in a functional restoration program

Background ContextThe Central Sensitization Inventory (CSI) is a valid and reliable patient-reported instrument designed to identify patients whose presenting symptoms may be related to central sensitization (CS). Part A of the CSI measures a full array of 25 somatic and emotional symptoms associated with CS, and Part B asks if patients have previously been diagnosed with one or more specific central sensitivity syndromes (CSSs) and related disorders. The CSI has previously been validated in a group of patients with chronic pain who were screened by a trained psychiatrist for specific CSS diagnoses. It is currently unknown if the CSI can be a useful treatment-outcome assessment tool for patients with chronic spinal pain disorder (CSPD) who are not screened for comorbid CSSs. It is known, however, that previous studies have identified CS-related symptoms, and comorbid CSSs, in subsets of patients with CSPDs. Studies have also shown that CS-related symptoms can be influenced by cognitive and psychosocial factors, including abuse history in both childhood and adulthood, sleep disturbance, catastrophic and fear-avoidant cognitions, and symptoms of depression and anxiety. PurposeThis study aimed to evaluate CSI scores, and their associations with other clinically relevant psychosocial variables, in a cohort of patients with CSPD who entered and completed a functional restoration program. Study Design/SettingA retrospective study of prospectively collected data from a cohort study of patients with CSPD, who completed the CSI at admission to, and discharge from, an interdisciplinary function restoration program (FRP) was carried out. Patient SampleA cohort of 763 patients with CSPD comprised the study sample. Outcome MeasuresClinical interviews evaluated mood disorders and abuse history. A series of self-reported measures evaluated comorbid psychosocial symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance, at FRP admission and discharge. MethodsPatients were grouped into five severity level groups, from mild to extreme, based on total CSI scores, at FRP admission, and then again at discharge. The FRP included a quantitatively directed and medically supervised exercise process, as well as a multimodal psychosocial disability management component. ResultsThe CSI severity groups were strongly associated with Major Depressive Disorder and previous abuse history (p<.01), which are known risk factors for CS-related symptoms and diagnoses. The CSI scores were also strongly associated with patient-reported CSS diagnoses on CSI Part B. The percentage of patients who reported a comorbid CSS diagnosis increased in each higher CSI-severity group, from 11% in the Subclinical group, to 56% in the Extreme group. The CSI severity groups were significantly related to other CS-related patient-reported symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance (p's<.001). The CSI scores, along with all other psychosocial measures, decreased at treatment discharge. ConclusionsIn the present study, admission CSI scores were highly associated with previous CSS diagnoses, CS-related symptoms, and clinically relevant patient-reported psychosocial variables. All psychosocial variables, as well as scores on the CSI, were significantly improved at FRP discharge. The CSI may have important clinical utility, as a screener and as a treatment outcome measure, for patients with CSPD participating in an interdisciplinary FRP.

Prevalence and Location of Neuropathic Pain in Lumbar Spinal Disorders: Analysis of 1804 Consecutive Patients With Primary Lower Back Pain.

A cross-sectional study of 1804 consecutive patients. The aim of this study was to investigate the prevalence of pathological pain and its distribution features in patients with chronic lumbar spinal disorders. Clinical spinal disorders can involve pathological neuropathic pain (NeP) as well as physiological nociceptive pain (NocP), as they have varied pathology, including spinal cord injury, stenosis, and compression. A study conducted by the Japanese Society for Spine Surgery and Related Research (JSSR) has determined a prevalence of 29.4% for NeP in patients with lumbar spinal disorder. However, the data did not include information on pain location. Patients aged 20 to 79 years with chronic lower back pain (≥3 months, visual analog scale score ≥30) were recruited from 137 JSSR-related institutions. Patient data included an NeP screening questionnaire score and pain location (lower back, buttock, and legs). The association between the pain pathology and its location was analyzed statistically using the unpaired t test and Chi-square test followed by Fisher test. P < 0.05 was considered significant. Low back pain subjects showed 31.9% of NeP prevalence, and the pain distribution showed [NocP(%)/NeP(%)] low back pain only cases: 44/22, while low back pain with leg pain cases showed a prevalence of 56/78. This indicates that low back pain alone can significantly induce NocP rather than NeP (P < 0.01). Buttock pain was revealed to significantly induce both lower back pain and leg pain with NeP properties (P < 0.01). Leg pain was revealed to be predominantly neuropathic, especially when it included peripheral pain (P < 0.01). Low back pain with no buttock pain induces NocP rather than NeP. Buttock pain is significantly associated with NeP prevalence whether or not leg pain exists. Leg pain can increase the prevalence of NeP, especially when it contains a peripheral element. 3.

Quantitative assessment of hand motor function in cervical spinal disorder patients using target tracking tests.

Cervical spondylotic myelopathy (CSM) is a chronic spinal disorder in the neck region. Its prevalence is growing rapidly in developed nations, creating a need for an objective assessment tool. This article introduces a system for quantifying hand motor function using a handgrip device and target tracking test. In those with CSM, hand motor impairment often interferes with essential daily activities. The analytic method applied machine learning techniques to investigate the efficacy of the system in (1) detecting the presence of impairments in hand motor function, (2) estimating the perceived motor deficits of CSM patients using the Oswestry Disability Index (ODI), and (3) detecting changes in physical condition after surgery, all of which were performed while ensuring test-retest reliability. The results based on a pilot data set collected from 30 patients with CSM and 30 nondisabled control subjects produced a c-statistic of 0.89 for the detection of impairments, Pearson r of 0.76 with p < 0.001 for the estimation of ODI, and a c-statistic of 0.82 for responsiveness. These results validate the use of the presented system as a means to provide objective and accurate assessment of the level of impairment and surgical outcomes.

Management of chronic spinal cord dysfunction.

Both acute and chronic spinal cord disorders present multisystem management problems to the clinician. This article highlights key issues associated with chronic spinal cord dysfunction. Advances in symptomatic management for chronic spinal cord dysfunction include use of botulinum toxin to manage detrusor hyperreflexia, pregabalin for management of neuropathic pain, and intensive locomotor training for improved walking ability in incomplete spinal cord injuries. The care of spinal cord dysfunction has advanced significantly over the past 2 decades. Management and treatment of neurologic and non-neurologic complications of chronic myelopathies ensure that each patient will be able to maximize their functional independence and quality of life.

What is the best screening test for depression in chronic spinal pain patients?

Background contextHigh prevalence rates of depression have been found in patients with chronic spinal disorder (CSD). The biopsychosocial model has become widely adopted and, with it, the role of psychopathology in the development and/or exacerbation of CSD has become increasingly recognized. Standardized diagnostic criteria, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), have been used to diagnose major depressive disorder (MDD). Many measures of MDD (and depressive symptom inventories) have been developed during the past 50 years, but their comparative utility in CSD populations is still unclear. PurposeTo systemically compare the performance of depression screening questionnaires in detecting MDD among a large sample of patients with CSD. Study design/settingProspective cohort study comparing the screening ability of four popular depression measures for diagnosing MDD against the “gold standard” Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), using a receiver operating characteristic (ROC) analysis in a CSD population. Patient sampleA consecutive cohort of 546 patients with CSD admitted to an interdisciplinary functional restoration program. Outcome measuresSensitivity, specificity, ROC curves, area under the curve (AUC), and optimal cutoff points that are most closely related to the prevalence rates of MDD, with balanced sensitivity and specificity analysis. MethodsUsing the SCID-I diagnosis as a “gold standard,” the ability of four screening measures in detecting MDD were compared. These included: the Beck Depression Inventory (BDI); Hamilton Rating Scale for Depression (HRSD); 9-Item Patient Health Questionnaire Depression Module (PHQ-9); and the Short Form-36 (SF-36). ResultsOf 542 CSD patients, 331 (61.1%) were diagnosed with MDD by the SCID-I. Results of the ROC analysis revealed that the BDI (AUC 0.768), HRSD (AUC 0.796), and PHQ-9 (AUC 0.768) have similar abilities to discriminate between depressed and nondepressed patients in this population. These depression measures outperformed the two mental health scales derived from the SF-36 (Mental Component Summary score/5-Item Mental Health Index; AUC 0.679–0.715). The optimal cut-off scores of 15 (for the BDI), 17 (for the HRSD), and 10 (for the PHQ-9) were also determined. Although the greatest overall accuracy (sensitivity of 81.3% and specificity of 65.4%) was obtained with the HRSD, it is the only clinician-administered instrument. Self-report measures of depression (the BDI and PHQ-9) showed comparable abilities to detect depression, only slightly less than the HRSD. ConclusionsCompared to the HRSD, both BDI and PHQ-9 are relatively short and easy to self-administer. The cut-off scores established in this study may be used to reliably determine whether a person should be evaluated more thoroughly for an MDD diagnosis. Using an acknowledged “gold standard,” the HRSD, BDI and PHQ-9 showed similar validity to recommend their use for future clinical and research purposes. The SF-36 is less appropriate for diagnosing MDD.

The chaperone protein clusterin may serve as a cerebrospinal fluid biomarker for chronic spinal cord disorders in the dog

Chronic spinal cord dysfunction occurs in dogs as a consequence of diverse aetiologies, including long-standing spinal cord compression and insidious neurodegenerative conditions. One such neurodegenerative condition is canine degenerative myelopathy (DM), which clinically is a challenge to differentiate from other chronic spinal cord conditions. Although the clinical diagnosis of DM can be strengthened by the identification of the Sod1 mutations that are observed in affected dogs, genetic analysis alone is insufficient to provide a definitive diagnosis. There is a requirement to identify biomarkers that can differentiate conditions with a similar clinical presentation, thus facilitating patient diagnostic and management strategies. A comparison of the cerebrospinal fluid (CSF) protein gel electrophoresis profile between idiopathic epilepsy (IE) and DM identified a protein band that was more prominent in DM. This band was subsequently found to contain a multifunctional protein clusterin (apolipoprotein J) that is protective against endoplasmic reticulum (ER) stress-mediated apoptosis, oxidative stress, and also serves as an extracellular chaperone influencing protein aggregation. Western blot analysis of CSF clusterin confirmed elevated levels in DM compared to IE (p < 0.05). Analysis of spinal cord tissue from DM and control material found that clusterin expression was evident in neurons and that the clusterin mRNA levels from tissue extracts were elevated in DM compared to the control. The plasma clusterin levels was comparable between these groups. However, a comparison of clusterin CSF levels in a number of neurological conditions found that clusterin was elevated in both DM and chronic intervertebral disc disease (cIVDD) but not in meningoencephalitis and IE. These findings indicate that clusterin may potentially serve as a marker for chronic spinal cord disease in the dog; however, additional markers are required to differentiate DM from a concurrent condition such as cIVDD.

Biomechanics of Posterior Dynamic Stabilization Systems

Spinal rigid instrumentations have been used to fuse and stabilize spinal segments as a surgical treatment for various spinal disorders to date. This technology provides immediate stability after surgery until the natural fusion mass develops. At present, rigid fixation is the current gold standard in surgical treatment of chronic back pain spinal disorders. However, such systems have several drawbacks such as higher mechanical stress on the adjacent segment, leading to long-term degenerative changes and hypermobility that often necessitate additional fusion surgery. Dynamic stabilization systems have been suggested to address adjacent segment degeneration, which is considered to be a fusion-associated phenomenon. Dynamic stabilization systems are designed to preserve segmental stability, to keep the treated segment mobile, and to reduce or eliminate degenerative effects on adjacent segments. This paper aimed to describe the biomechanical aspect of dynamic stabilization systems as an alternative treatment to fusion for certain patients.

Prevalence of Chronic Kidney Disease in Patients with Spinal Cord Injuries/Disorders

Background and Objectives: Chronic kidney disease (CKD) and spinal cord injury and disorders (SCI/D) are common and costly conditions among Veterans. However, little is known about CKD among adults with SCI/D. Methods: We conducted cross-sectional analyses of Veterans with SCI/D across all VA facilities in 2006. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² and categorized by standard eGFR strata. eGFR was calculated in two ways: (a) the Modification of Diet in Renal Disease (MDRD) equation and (b) the MDRD equation + an empirically derived correction factor for SCI/D (MDRD-SCI/D). Logistic regression models were used to examine the relationship between patient characteristics and CKD. Results: Among 9,333 SCI/D Veterans with an available eGFR, the proportion with CKD was substantially higher based on the MDRD-SCI/D equation (35.2%) than based on the MDRD equation (10.2%). In adjusted analyses, while older age (OR for >65 years = 2.53; 95% CI: 2.21–2.89), female sex (OR 2.18; 95% CI: 1.62–2.92), and a non-traumatic cause for injury (OR 1.39; 95% CI: 1.23–1.57) were associated with an increased odds of CKD, black race (OR 0.64; 95% CI: 0.56–0.72) and a duration of injury of ≥10 years (OR 0.76; 95% CI: 0.67–0.86) were associated with a decreased odds of CKD. Diagnostic codes for CKD and nephrology visits were infrequent for SCI/D Veterans with CKD (27.51 and 6.58%, respectively). Conclusion: Using a recently validated version of the MDRD equation with a correction factor for SCI/D, over 1 in 3 Veterans with SCI/D had CKD, which is more than 3-fold higher than when traditional MDRD estimation is used.

Commentary: More or less satisfied?

Hazard RG, Spratt KF, McDonough CM, etal. Patient-centered evaluation of outcomes from rehabilitation for chronic disabling spinal disorders: the impact of personal goal achievement on patient satisfaction. Spine J 2012;12:1132-7 (in this issue).

Commentary: Is patient satisfaction a reasonable outcome measure?

Hazard RG, Spratt KF, McDonough CM, etal. Patient-centered evaluation of outcomes from rehabilitation for chronic disabling spinal disorders: the impact of personal goal achievement on patient satisfaction. Spine J 2012;12:1132-7 (in this issue).

Patient-centered evaluation of outcomes from rehabilitation for chronic disabling spinal disorders: the impact of personal goal achievement on patient satisfaction

The multiplicity of biopsychosocial and economic facets of chronic disabling back and/or neck pain complicates the treatment outcomes measurement. Our previous work showed that personal functional goal achievement contributed more toward patient satisfaction with the outcome than did traditional self-reports of pain and physical function or measured strength, flexibility, and endurance among functional restoration program (FRP) graduates with chronic disabling back and/or neck pain. The primary goal was to compare the impact on patient satisfaction of pain and functional goal achievement versus self-reports of pain and physical function. This was an observational study of all patients with chronic disabling back and/or neck pain completing an FRP between June 2008 and May2009. Before the treatment, participants recorded personal 3-month goals for pain, work, recreation, and activities of daily living. At least 3 months later, all graduates were sent a follow-up survey displaying the patient's pretreatment functional goals and eliciting the patient's assessment of functional goal achievement; current pain magnitude, "satisfaction with the overall results for your pain problem;" and responses to the Short Form-36v2 Physical Functioning subscale (PF-10). Pain goal achievement was calculated as the difference between the pretreatment pain goal and follow-up pain magnitude. Linear regression was used to evaluate the association between satisfaction and four variables (follow-up pain; PF-10; pain goal achievement; functional goal achievement), individually and then together in a full model. Of the 82 patients surveyed, 62 responded completely. Mean age was 44 years, with 48% female and 35% on worker's compensation. The model R(2) combining all four variables explained 0.6033 of the variance in satisfaction. Each variable by itself was significantly related to patient satisfaction at p<.001, but the overlap in association was large. The unique contributions (R(2)) to the variation in satisfaction were the following: functional goal achievement: 0.0471; PF-10 score: 0.0229; pain magnitude: 0.0178; and pain goal achievement: 0.0020. At least 3 months after the treatment, functional goal achievement had by far the greatest impact on patient satisfaction, followed by PF-10 score, pain magnitude, and, finally, pain goal achievement. Functional goal achievement has great potential as a tool for patient-centered treatment decision-making and outcomes measurement for people with chronic disabling back and/or neck pain and their health care providers.

Do Severe Pain Symptoms of Central Sensitization and Fibromyalgia Resolve with Functional Restoration Treatment in Chronic Spinal Disorders? Prevalence and Treatment Responsiveness

Non-organic symptoms are frequently seen in chronic spinal disorder (CSD) populations. A new neurologic theory called Central Sensitization (CS) may help explain these symptoms: In the CS model, physical trauma and/or sustained pain cause dysregulation and hyper-excitability of the CNS, resulting in amplified pain responses and sensitivity to stimuli. Fibromyalgia (FM) involves widespread bodily pain and tenderness to palpation and is perhaps the most common example of a CS syndrome. Studies have shown that CSDs may be associated with many CS-related disorders, such as FM.

Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain

A case-control study. To examine the function of the diaphragm during postural limb activities in patients with chronic low back pain and healthy controls. Abnormal stabilizing function of the diaphragm may be an etiological factor in spinal disorders. However, a study designed specifically to test the dynamics of the diaphragm in chronic spinal disorders is lacking. Eighteen patients with chronic low back pain due to chronic overloading, as ascertained via clinical assessment and magnetic resonance imaging, and 29 healthy subjects were examined. Both groups presented with normal pulmonary function test results. A dynamic magnetic resonance imaging system and specialized spirometric readings were used with subjects in the supine position. Measurements during tidal breathing (TB) and isometric flexion of the upper and lower extremities against external resistance with TB were performed. Standard pulmonary function tests, including respiratory muscle drive (PI(max) and PE(max)), were also assessed. Using multivariate analysis of covariance, smaller diaphragm excursions and higher diaphragm position were found in the patient group (P<.05) during the upper extremity TB and lower extremity TB conditions. Maximum changes were found in costal and middle points of the diaphragm. A 1-way analysis of covariance showed a steeper slope in the middle-posterior diaphragm in the patient group both in the upper extremity TB and lower extremity TB conditions (P<.05). Patients with chronic low back pain appear to have both abnormal position and a steeper slope of the diaphragm, which may contribute to the etiology of the disorder.