Idiopathic Chronic Low Back Pain Research Articles

Systematic review and meta-analysis on the association between chronic low back pain and cognitive function.

This study aimed to identify and assess the evidence on the association between idiopathic chronic low back pain (LBP) and cognitive function in individuals with LBP. A secondary aim was to explore whether changes in cognitive function are associated with pain characteristics and psychological factors (eg, catastrophizing and fear of movement). Eleven studies were included in this systematic review, and four meta-analyses were conducted. Low to very low-quality evidence suggests impaired cognitive function in individuals with LBP compared to asymptomatic controls for problem solving (k=5; d=0.33; CI=0.16-0.50; z=3.85 p=0.0001), speed of information processing (k=5; d=0.44; CI=0.22-0.65; z=4.02 p < 0.0001), working memory (k=6; d=0.50; CI=0.34-0.66; z=6.09 p < 0.0001), and delayed memory (k=3; d=0.34; CI=0.07-0.6, z=2.49 p=0.02). The association between LBP intensity and psychological factors and cognitive function was inconclusive. More studies are needed to explore these associations and improve evidence in this field. The results of this study suggest that cognitive aspects should be considered during the rehabilitation process of patients with LBP and raise further questions, including whether individuals with LBP are at a greater risk of developing dementia or whether targeting cognitive function will increase the probability of success of LBP treatment. These questions should, also, be considered in future studies.

Is There Any Association between the Severity of Disc Degeneration and Low Back Pain?

Objective To access the possibility that higher degrees of disc degeneration lead to higher levels of pain and dysfunction. Methods Magnetic resonance imaging (MRI) scans of 85 patients with low back pain lasting for more than 12 weeks were evaluated, and the degree of disc degeneration was quantified according to the Pfirrmann grading system. The Pfirrmann degree in each disc space from L1-L2 to L5-S1, the maximum degree of Pfirrmann (Pfirrmann-max) between the lumbar discs, and the sum of Pfirrmann (Pfirrmann-sum) degrees were correlated (through the Spearman test) with the Oswestry Disability Index (ODI) and the Visual Analogical Scale (VAS) for pain. Results In total, 87% of the patients had moderate to severe lumbar disc degeneration measured by Pfirrmann-max, and the most degenerated discs were L4-L5 and L5-S1. There was a week to moderate correlation regarding the Pfirrmann-max (r = 0,330; p = 0.002) and the Pfirrmann-sum (r = 0,266; p = 0,037) and the ODI, and the Pfirrmann scores in L1-L2 were correlated with the ODI and the VAS. Conclusion Patients with chronic idiopathic low back pain frequently have moderate to severe lumbar disc degeneration, which has a negative impact on the quality of life of the patients. Low degrees of degeneration in L1-L2 might be related with higher degrees of pain and of functional disability.

Quantified biomechanical properties of lower lumbar myofascia in younger adults with chronic idiopathic low back pain and matched healthy controls

BackgroundNon-specific chronic low back pain (LBP) is a prevalent condition that is poorly understood with respect to possible altered physical properties. Five biomechanical properties of stiffness, frequency, decrement, creep, and stress relaxation time of the L3-L4 myofascial tissue were quantified using the MyotonPro® in chronic idiopathic LBP and matched normal control subjects. MethodsMeasurements were obtained in the resting prone position on the left and right sides (initially and after 10 min rest) in 25 chronic LBP participants (16 female, 9 male) and 25 age- and sex-matched control subjects. Surface electromyography measurements were simultaneously conducted to ensure a resting state. FindingsFemale LBP had significantly greater median decrement (p < 0.001) and stiffness (p < 0.010) than female controls. In female LBP patients, BMI correlated with decrement (p < 0.010) and creep (p < 0.050); creep also correlated with decrement (p < 0.050). Significant male versus female differences were found in all five properties in both LBP and control subgroups, except decrement in control males versus females. InterpretationThis study showed that greater median decrement was found in LBP female subjects suggesting decrease in elasticity in the lumbar myofascia. Most of the biomechanical properties differed significantly by gender. This study further documented that right-handed dominance might correlate with greater right-sided lumbar myofascial stiffness.

The effect of vitamin D repletion and proposed walking program exercise on chronic idiopathic low back pain: a randomized controlled trial

Objective The aim was to evaluate the relationship between vitamin D deficiency and chronic idiopathic low-back pain (LBP), and to observe the effect of vitamin D correction and a proposed walking program exercise (WPE) on the severity of LBP.Patients and methods In this randomized, controlled study, 110 patients (100 with deficiency and 10 with insufficiency of vitamin D3), 95 women and 15 men with chronic idiopathic LBP were randomly assigned to receive either oral vitamin D3 or oral vitamin therapy and a proposed walking program exercise (WPE). Group A included 55 patients, 50 with deficiency and five with insufficiency Group B included 55 patients, 50 with deficiency and five with insufficiency over 3 months. Visual analog scale 0–10 was used to assess the degree of pain intensity.Results Findings have shown that 100% of the patients included in this study (n=110) (100 deficiencies and 10 insufficiencies) had an abnormally low level of vitamin D before treatment with vitamin D therapy and WPE. By the end of the study, all the 110 patients have normalized their vitamin D level after vitamin D oral therapy and WPE (100%). However, only 49 patients (group A) (44 deficiencies and five insufficiencies) reported disappearance of LBP after vitamin D oral therapy and only 51 patients (group B) (46 deficiencies and five insufficiencies) reported disappearance of LBP after vitamin D oral therapy and WPE so the total number of responders of both groups being 100 (90.9%) cases and the total number of nonresponders of both groups being10 (9.1%)Conclusion After correction of vitamin D3 over 3 months, the authors found that the chronic LBP has improved. A combination of both (correction of vitamin D3 and WPE) is more beneficial in improving chronic LBP.

Integral movement therapy versus local movement therapy approach in patients with idiopathic chronic low-back pain: study protocol for a randomized controlled trial

BackgroundChronic low-back pain (CLBP) is one of the most common reasons for seeking medical care and it imposes a significant burden on individuals and society at large. Systematic reviews evaluating the effectiveness of supervised exercise therapies commonly conclude that, to date, there is no evidence to support the superiority of one form of exercise over another. Randomized controlled trials (RCT) to date included mostly trunk strengthening exercises (e.g. bird dog, plank) and there is no evidence about supervised, individually graded integral movement therapy program for patients with CLBP.MethodsThe research design is a RCT with parallel-group design including two intervention groups: integral movement therapy and conventional local movement therapy. Participants in each group will receive 20 supervised sessions in a 10-week period, twice per week, for approximately 1 h per session. Outcome assessments will occur at baseline and immediately after intervention, follow-up will take place at six months and 12 months after the intervention. Prespecified analyses will evaluate the main effects of the treatment.DiscussionThis trial will use a novel, previously unexplored integral approach to CLBP through exercises. In contrast to commonly used exercise programs, the integral program does not include specific local strength exercises for hip and trunk flexors and extensors. However, learning dynamic trunk muscle control in various body positions with added limb movements could be beneficial because of the parallels to everyday work. The study will contribute to clinical practice by providing evidence to guide professionals when deciding for the proper and efficient treatment of patients with CLBP.Trial registrationClinicalTrials.gov, NCT03623802. Registered on 9th August 2018.

Effect of chronic idiopathic low back pain on the kinetic gait characteristics in different foot masks

Identification of kinetic variables in different masks of foot is important for the evaluation and treatment of chronic low back pain. The aim of this study was to investigate the effect of chronic idiopathic low back pain on kinetic variables of gait in different foot masks. 11 idiopathic chronic low back pain patients and 13 healthy matched controls participated in this study. Using Emed foot-scanner system, the ground reaction force and impulse were measured during barefoot normal walking. Then, the average footprints were divided into 10 masks using the Automask program and the data were extracted using Multimask Evaluation programs. The low back pain disability was measured by Quebec questionnaire. Our results revealed that the ground reaction force and impulse in medial and lateral midfoot and hallux masks of patients were significantly lower than controls. Furthermore, these patients demonstrated greater ground reaction force and impulse in 3–5th metatarsals mask than control group. There was a significant interaction between the low back pain and the foot masks factors. In conclusion, the ground reaction forces and impulses in different areas of foot are affected by low back pain. Therefore, the kinetic gait analysis should be considered as an appropriate tool in evaluation and prescribing proper treatment program in low back pain patients.

S99. Reliability of surface electromiography measures for latissimus dorsi, femoral biceps and paraspinal muscles in persons with low back pain

Eighty percent of the population have experienced at least one episode of low back pain (LBP) in their lifetime and approximately 13–19% of adults complain of suffering LBP associated to lifting loads. Latissimus dorsi (LD), femoral biceps (FB) and the paraspinal muscles (PS), have an important role in the stability of the lumbosacral spine. It has been observed that during daily life activities the muscles show different electromyographic responses, depending on factors such as the health condition in which they are studied and the posture in which the measurement is made, among others.The surface electromyography (sEMG) is a non-invasive method that assesses muscle activation and provides relevant information that helps to understand the motor control in people with idiopathic chronic LBP; however, there are no reports in literature about the sEMG reliability during lifting a load for the above-mentioned muscles in people with chronic LBP. Objective: to determine the inter-session reliability of the sEMG for LD, FB and PS muscles, during lifting a load in people with chronic LBP. There were included 10 people (7 women and 3 men) with chronic LBP, between 18 and 40 years (32 ± 4.1) and body mass index 27.4 ± 6.04. The sEMG activity of the LD, FB and PS muscles was assessed while lifting a load in a symmetrical bipedal position in two sessions, with five days between each assessment. The Root mean square (RMS) amplitude and the latency were calculated. The inter-session reliability was assessed through Intraclass Correlation Coefficient (ICC) 2,1 and Bland–Altman analysis. Surface EMG measurements presented moderate to good reliability in latency measures for all assessed muscles (ICC 0.49–0.77 for LD, 0.46–0.56 for FB and 0.59–074 for PS muscles) and displayed moderate to excellent reliability for the RMS amplitude (ICC values 0.46–0.8 for LD; 0.42–0.55 for FB and 0.43–0.68 for PS muscles). Bland–Altman analysis showed a mean value of the difference close to zero and limits of agreement between 2 and 4 ms. The sEMG is a reliable tool that can be useful to evaluate muscle activation during a functional activity, in order to help to understand the muscle activation patterns in people with idiopathic chronic LBP.

The effect of the Swedish Back School in chronic idiopathic low back pain. A prospective controlled study

A prospective controlled study of the effect of the Swedish Back School in chronic idiopathic Low Back Pain was conducted. Forty-eight patients entered the study. There were no significant pre-treatment differences between the experimental group members who attended the four lessons of the Back School, and the control group who received four detuned shortwave applications to the low back. Forty-three patients (21 in the experimental and 22 in the control group) completed the study. Subjects were repeatedly tested for one year. The following assessments were made: 1) subjective scores of pain and functional capacity, and 2) objective measurements of spinal mobility. After one year, no statistically significant differences between the two groups were observed. Given the proven efficacy of the Back School in (sub)acute Low Back Pain, it should be administered when it is most beneficial, i.e. in the early phase of Low Back Pain.

EEG and Functional MRI on Back Pain

Pain is a major health care problem worldwide. It affects the well-being of millions of individuals, and its financial burden upon our societies is considerable.1 Back pain (BP) is a particularly substantial health problem. It affects up to 70% of the adult population, and poses a considerable health care and socioeconomic burden. The diagnosis, evaluation, and treatment of BP is a major challenge, which leads to the limited effectiveness for the most commonly applied interventions and approaches.2 Evidence showing significant changes within the brain in chronic BP patients indicated that BP may be accompanied by cognitive abnormalities3 brain chemical changes,4 and cortical reorganization or degeneration.5 In recent years, this has been investigated using both advanced neuroimaging and electrophysiology. The advent of modern neuroimaging and electrophysiological techniques has enabled researchers to examine the pain processing network. There is important evidence that local cerebral blood flow (CBF) changes reflect variations in local synaptic activity, as measured using positron emission tomography (PET).6,7 This dramatic change in blood flow during neuronal activity is also detected using functional magnetic resonance imaging (fMRI), in which signal changes reflect alteration in local CBF and, more specifically, variations in the ratio of deoxyhemoglobin to oxyhemoglobin (termed blood oxygenation level dependent [BOLD] contrast). The BOLD fMRI, which has been widely successful in brain functional research, is based on the biological mechanism that neurovascular coupling exists between neuronal activity and the cerebral vascular response. Using a type of BOLD fMRI that shows when certain parts of the brain are activated, Wager et al recently addressed the critical question of the existence of a specific brain activity pattern for heat pain.8 The authors assessed this question in a rigorous and systematic approach. Their research leads to more objective assessments of pain. In addition to fMRI neural image technology, electroencephalography (EEG) is a more practical and cost effective technology to investigate the brain activity, which is generated by the firing of neurons within the brain.9 EEG is a direct measurement of neuronal activity with a sampling frequency as high as dozens of kHz (e.g., short-latency somatosensory evoked potentials),10,11 thus resulting in extremely high temporal resolution (only a tenth of a millisecond). Recently, we developed a new method to achieve robust single-trial estimate of even smaller ERP components.12 More advanced single-trial approaches, which make use of the temporal, frequency, and spatial information of multichannel EEG recordings based on this approach, will be developed to detect single-trial parameters and brain network accurately and reliably. In this new method, we may investigate those pain-related EEG features for specific EEG signature of pain perception, which may be used for objective and quantitative assessment for BP. Disclosure of Interest None declared References Brooks J, Tracey I. From nociception to pain perception: imaging the spinal and supraspinal pathways. J Anat 2005;207(1):19–33 Papageorgiou AC, Rigby AS. Review of UK data on the rheumatic diseases—7. Low back pain. Br J Rheumatol 1991;30(3):208–210 Giesecke T, Gracely RH, Grant MA, et al. Evidence of augmented central pain processing in idiopathic chronic low back pain. Arthritis Rheum 2004;50(2):613–623 Baliki MN, Chialvo DR, Geha PY, et al. Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. J Neurosci 2006;26(47):12165–12173 Wand BM, O’Connell NE. Chronic non-specific low back pain - sub-groups or a single mechanism? BMC Musculoskelet Disord 2008;9:11 Apkarian AV, Bushnell MC, Treede RD, Zubieta JK. Human brain mechanisms of pain perception and regulation in health and disease. Eur J Pain 2005;9(4):463–484 Disbrow E, Baron R, Baron Y. Examination of the role of the cerebral cortex in the perception of pain using functional magnetic resonance imaging. Curr Rev Pain 1999;3(4):281–290 Wager TD, Atlas LY, Lindquist MA, Roy M, Woo CW, Kross E. An fMRI-based neurologic signature of physical pain. N Engl J Med 2013;368(15):1388–1397 Niedermeyer E, Lopes da Silva FH. Electroencephalography: basic principles, clinical applications, and related fields. 5th ed. Philadelphia, PA: Lippincott Williams &amp; Wilkins; 2005 Inoue K, Hashimoto I, Nakamura S. High-frequency oscillations in human posterior tibial somatosensory evoked potentials are enhanced in patients with Parkinson's disease and multiple system atrophy. Neurosci Lett 2001;297(2):89–92 Ozaki I, Suzuki C, Yaegashi Y, Baba M, Matsunaga M, Hashimoto I. High frequency oscillations in early cortical somatosensory evoked potentials. Electroencephalogr Clin Neurophysiol 1998;108(6):536–542 Hu L, Mouraux A, Hu Y, Iannetti GD. A novel approach for enhancing the signal-to-noise ratio and detecting automatically event-related potentials (ERPs) in single trials. Neuroimage 2010;50(1):99–111

A compensation of angular displacements of the hip joints and lumbosacral spine between subjects with and without idiopathic low back pain during squatting

Low back pain (LBP) is one of the most common symptoms reported in adults. However, the contribution of postural control on the lumbar spine and hips during squatting has not been carefully investigated in individuals with LBP. The aim of this study was to compare three-dimensional kinematic changes of the lumbar spine and hips between subjects with and without idiopathic chronic LBP during squatting activities. In total, 30 subjects enrolled in the study (15 control subjects and 15 subjects with idiopathic chronic LBP). All participants were asked to perform squatting activities five times repeatedly while holding a load of 2kg in a basket. The outcome measures included the Oswestry Disability Index (ODI) and kinematic angular displacement for the hips and lumbar spine. The LBP group demonstrated increased range of motion (ROM) in flexion of the dominant (T=−2.14, p=0.03) and non-dominant (T=−2.11, p=0.03) hips during squatting. The lumbar spine flexion ROM significantly decreased (T=2.20, p=0.03). The kinematic changes demonstrated interactions with region×group (F=5.56, p=0.02), plane×group (F=4.36, p=0.04), and region×plane (F=2292.47, p=0.001). The ODI level demonstrated significant interaction on combined effects of body region and plane (F=4.91, p=0.03). Therefore, the LBP group utilized a compensation strategy to increase hip flexion with a stiffened lumbar spine in the sagittal plane during squatting. This compensatory kinematic strategy could apply to clinical management used to enhance lumbar spine flexibility in subjects with idiopathic chronic LBP.

The effect of exercise therapy on pain, disability and endurance of trunk flexor-extensor muscles in women with chronic idiopathic low back pain

Background: Exercise is a widely prescribed treatment for chronic low back pain. The purpose of the present study was to investigate the effect of 8 weeks exercise on pain, disability and endurance of trunk flexor-extensor muscles in female with chronic idiopathic low back pain. Methods: This clinical trial study has been done on 12 patients who referred to the Arak city clinics. The function of trunk flexor-extensor muscles in cases was compared to function of 18 normal females. We use the Quebec pain questionnaire, Oswerstry disability questionnaire and Sorenson and Sit-Up tests. Exercise therapy was performed in three 45 minute’s sessions per week. Each session was performed in 3 set. Exercises were repeated 8-12 point in each set. The data was analyzed using t-test. Results: Endurance of trunk flexor-extensor muscles of patients was significantly lower than normal subjects (P<0.05). Endurance of trunk flexor-extensor muscles of patients significantly improved after exercise therapy (P<0.05). Low back pain of patients was decreased significantly after treatment ((P<0.05). In addition, significant reduction of disability observed after exercise therapy (P<0.05). Conclusion: Exercise therapy may increase endurance of trunk flexor-extensor muscles in women with chronic idiopathic low back pain. In addition, it can reduce law back pain and disability in this population.

PR_046: Reliability of Posturographic Measures in Patients With Chronic Idiopathic Low Back Pain

Objective: To investigate both the short- and the long-term reliability of postural stability measures in patients with chronic low back pain (LBP). Design: Cohort study. Setting: Physical medicine and rehabilitation outpatient clinics. Participants: 33 patients (mean age, 44y) with chronic, idiopathic LBP. Interventions: Patients completed quantitative posturography (EquiTest) to determine subjects’ response to sensory (Sensory Organization Test [SOT]) and motor perturbation (Motor Coordination Test).

Evidence of augmented central pain processing in idiopathic chronic low back pain.

For many individuals with chronic low back pain (CLBP), there is no identifiable cause. In other idiopathic chronic pain conditions, sensory testing and functional magnetic resonance imaging (fMRI) have identified the occurrence of generalized increased pain sensitivity, hyperalgesia, and altered brain processing, suggesting central augmentation of pain processing in such conditions. We compared the results of both of these methods as applied to patients with idiopathic CLBP (n = 11), patients with widespread pain (fibromyalgia; n = 16), and healthy control subjects (n = 11). Patients with CLBP had low back pain persisting for at least 12 months that was unexplained by MRI/radiographic changes. Experimental pain testing was performed at a neutral site (thumbnail) to assess the pressure-pain threshold in all subjects. For fMRI studies, stimuli of equal pressure (2 kg) and of equal subjective pain intensity (slightly intense pain) were applied to this same site. Despite low numbers of tender points in the CLBP group, experimental pain testing revealed hyperalgesia in this group as well as in the fibromyalgia group; the pressure required to produce slightly intense pain was significantly higher in the controls (5.6 kg) than in the patients with CLBP (3.9 kg) (P = 0.03) or the patients with fibromyalgia (3.5 kg) (P = 0.006). When equal amounts of pressure were applied to the 3 groups, fMRI detected 5 common regions of neuronal activation in pain-related cortical areas in the CLBP and fibromyalgia groups (in the contralateral primary and secondary [S2] somatosensory cortices, inferior parietal lobule, cerebellum, and ipsilateral S2). This same stimulus resulted in only a single activation in controls (in the contralateral S2 somatosensory cortex). When subjects in the 3 groups received stimuli that evoked subjectively equal pain, fMRI revealed common neuronal activations in all 3 groups. At equal levels of pressure, patients with CLBP or fibromyalgia experienced significantly more pain and showed more extensive, common patterns of neuronal activation in pain-related cortical areas. When stimuli that elicited equally painful responses were applied (requiring significantly lower pressure in both patient groups as compared with the control group), neuronal activations were similar among the 3 groups. These findings are consistent with the occurrence of augmented central pain processing in patients with idiopathic CLBP.

Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain.

Balance performance in unstable sitting and trunk muscle response to quick force release were measured in 16 patients with chronic low back pain and 14 matched healthy control subjects. To determine whether patients with low back pain will exhibit poorer postural control, which will be associated with longer average muscle response times. Larger postural sway during standing and delayed trunk muscle response times for patients with low back pain have been reported in several independent studies. Unstable sitting test was accomplished by attaching different sized hemispheres to the bottom of a seat. Subjects performed trials with eyes open and closed while the displacements of the center of pressure were measured with a force plate underneath the seat. Response to a quick force release was recorded from 12 major trunk muscles with surface electromyography. Subjects performed isometric trunk exertions in a semi-seated position when the resisted force was suddenly released with an electromagnet. Average muscle response times and balance performance were correlated using a linear regression analysis. Patients with low back pain demonstrated poorer balance performance than healthy control volunteers, especially at the most difficult levels. Patients also had delayed muscle response times to quick force release. Average muscle onset times together with age and weight correlated significantly with balance performance with closed eyes (R(2) = 0.46), but not with eyes opened (R(2) = 0.18). Patients with chronic low back pain demonstrated poorer postural control of the lumbar spine and longer trunk muscle response times than healthy control volunteers. Correlation between these two phenomena suggests a common underlying pathology in the lumbar spine.

The Effect of Trancutaneous Spinal Electroanalgesia upon Chronic Pain: A single case study

D F Hilberstadt, P Barlas, N E L Foster Physiotherapy Subject Group, Coventry University Transcutaneous spinal electroanalgesia (TSE) is marketed as a non-invasive electrotherapy modality for the treatment of nonneurogenic chronic pain ('Xpain 2000', APM Ltd). As a relatively new modality it has not yet been extensively investigated. Following ethical approved by Coventry Health Authority Research Ethics Committee, two patients referred to the 'back class' at Coventry and Warwickshire Hospital physiotherapy outpatients department for idiopathic chronic low back pain volunteered to participate in the trial. The subjects were screened for psychological factors using a Hospital Anxiety and Depression (HAD) questionnaire and assessed by a qualified senior physiotherapist before and after the trial. This single case series study used an A-B-A format (baseline – treatment – baseline). The baseline phase consisted of postural advice and guidance on the management of the subjects’ condition, and the treatment phase consisted of the baseline components with the addition of TSE (Xpain 2000) treatment (average treatment time 66 minutes daily for subject 1 and 102 minutes daily for subject 2) according to the manufacturers’ instructions. Each phase was of 10 days duration giving a total of 30 days. Pain intensity was measured by a Numerical Rating Scale (NRS) and physical function measured by the Roland and Morris Disability Questionnaire (RMDQ); these were recorded daily by the subjects throughout the course of the trial. Results were plotted on to line graphs and visually analysed. In addition the level of significance was determined by the C-statistical time series analysis (Tyron, 1982). Subject 1 showed no significant change in NRS or RMDQ scores, while subject 2 Reliability of the Motor Club Assessment

Reliability of the Motor Club Assessment

D F Hilberstadt, P Barlas, N E L Foster Physiotherapy Subject Group, Coventry University Transcutaneous spinal electroanalgesia (TSE) is marketed as a non-invasive electrotherapy modality for the treatment of nonneurogenic chronic pain ('Xpain 2000', APM Ltd). As a relatively new modality it has not yet been extensively investigated. Following ethical approved by Coventry Health Authority Research Ethics Committee, two patients referred to the 'back class' at Coventry and Warwickshire Hospital physiotherapy outpatients department for idiopathic chronic low back pain volunteered to participate in the trial. The subjects were screened for psychological factors using a Hospital Anxiety and Depression (HAD) questionnaire and assessed by a qualified senior physiotherapist before and after the trial. This single case series study used an A-B-A format (baseline – treatment – baseline). The baseline phase consisted of postural advice and guidance on the management of the subjects’ condition, and the treatment phase consisted of the baseline components with the addition of TSE (Xpain 2000) treatment (average treatment time 66 minutes daily for subject 1 and 102 minutes daily for subject 2) according to the manufacturers’ instructions. Each phase was of 10 days duration giving a total of 30 days. Pain intensity was measured by a Numerical Rating Scale (NRS) and physical function measured by the Roland and Morris Disability Questionnaire (RMDQ); these were recorded daily by the subjects throughout the course of the trial. Results were plotted on to line graphs and visually analysed. In addition the level of significance was determined by the C-statistical time series analysis (Tyron, 1982). Subject 1 showed no significant change in NRS or RMDQ scores, while subject 2 Reliability of the Motor Club Assessment

The impact of stressful life events on exacerbation of chronic low-back pain

The impact of stressful life events on the development and onset of chronicity of low-back pain is not yet fully understood. Sixty-four consecutive patients with chronic low-back pain treated at the orthopedic out-patient unit of the Innsbruck University Hospital were investigated with regard to stressful life events. Patients were classified into two groups: one group consisting of patients whose pain had an organic etiology ( n=16), and another group consisting of those with pain of uncertain origin (idiopathic group, n=48). A method combining a semistructured interview with a self-assessment of the severity of stress caused by life events was employed for assessing the impact of such events on chronic low-back pain. In comparison to the patient group having organic causes of pain, the idiopathic group showed significantly more patients having at least one highly stressful event preceding the last substantial aggravation of pain ( p=0.028). The latter group experienced significantly more exhaustion ( p=0.016) and significantly more difficulties in active coping ( p=0.011) when confronted with stressful life events. Stressful life events that arouse feelings of helplessness may contribute to the development of chronic idiopathic low-back pain. Our results emphasize the importance of investigating the subjective meaning and appraisal of stressful life events, taking into consideration both individual predisposition and psychosocial resources available to the patient. Finally, it is also important that the attending physician be aware of any life event that is particularly stressful for the patient so that psychosocial help be made available at the appropriate time.

Slowly developing placebo responses confound tests of intravenous phentolamine to determine mechanisms underlying idiopathic chronic low back pain

Phentolamine (30 mg) was administered intravenously to subjects with idiopathic chronic low back pain in a novel placebo-controlled test to determine whether this α-adrenergic antagonist would reduce their pain. The effects of infusions on spontaneous pain and stimulus-evoked pains (touch, cold, tapping and deep pressure) were evaluated separately. All subjects gave strong placebo responses (reduced pain) that prevented assessment of specific drug effects. The placebo responses had onset latencies of 15–60 min, developed slowly over the next 15–45 min and persisted for hours or several days. These results not only reinforce the understanding that placebo controls are essential in the evaluation of drugs or other palliative procedures on patients with chronic pain but also indicate that the control paradigms must allow for placebo effects that are slow to develop and very persistent.

The Natural History of Idiopathic Low Back Pain. A Three-Year Follow-Up Study of Spinal Motion, Pain and Functional Capacity

During a three-year follow-up study of 31 chronic idiopathic low back pain patients significant spontaneous improvements of pain and disability scores were found, while range of motion of the lumbar spine decreased. It is argued that increasing stiffness of the low back may be the clinical manifestation of the process of stabilization, that takes place in previously painful instable motion segments. The present findings have also implications for the interpretation of changes of spinal motion. Restriction of range of motion seems to be a normal long-term development in low back pain patients and is accompanied by a diminution of pain and disability.

The effect of the Swedish Back School in chronic idiopathic low back pain. A prospective controlled study

A prospective controlled study of the effect of the Swedish Back School in chronic idiopathic Low Back Pain was conducted. Forty-eight patients entered the study. There were no significant pre-treatment differences between the experimental group members who attended the four lessons of the Back School, and the control group who received four detuned shortwave applications to the low back. Forty-three patients (21 in the experimental and 22 in the control group) completed the study. Subjects were repeatedly tested for one year. The following assessments were made: 1) subjective scores of pain and functional capacity, and 2) objective measurements of spinal mobility. After one year, no statistically significant differences between the two groups were observed. Given the proven efficacy of the Back School in (sub)acute Low Back Pain, it should be administered when it is most beneficial, i.e. in the early phase of Low Back Pain.