LBP Patients Research Articles

P48. Translation of the Interprofessional Spine Assessment and Education Clinic (ISAEC) to the New Brunswick population

BACKGROUND CONTEXT ISAEC is a shared-care model for LBP patients founded in Ontario. Patients are able to receive rapid assessment, education, and evidence based self-management plans. This successful model was adapted for the New Brunswick LBP population and implemented in two centers in Saint John and Moncton. PURPOSE To demonstrate the effective establishment, through knowledge translation of the ISAEC program in New Brunswick, assessed by examining patient outcome scores, patient compliance, and primary care provider satisfaction. STUDY DESIGN/SETTING Retrospective analysis of prospectively collected data. PATIENT SAMPLE Data from the NB-ISAEC database was included for all patients with both intake and 6 week follow-up data as of February 1, 2019 (N=111). OUTCOME MEASURES Outcome measures included the Oswestry Disability Index (ODI), NRS Scales for Back and Leg Pain (NRS-B/L), Pain Catastrophizing Score (PCS), patient compliance, and Primary Care Provider (PCP) satisfaction. METHODS Continuous variables were analyzed using a paired samples t-test, and one-way ANOVA and categorical variables were analyzed using chi-squared analysis. Significance was α RESULTS Six weeks following a NB-ISAEC appointment, participants reported statistically significant improvements in ODI scores (t(111)=8.384, p 30; χ2(1) =12.143, p≤0.001). At 6 weeks patients reported high compliance with their given exercise plan; 41.8% of patients reported daily exercise, and only 5.7% of patients reported not performing their exercise weekly. A repeated measures ANOVA was performed for a preliminary look at patients with 3 month outcomes, with changes in ODI (F(2,72)=5.983, p=0.004), PCS (F(2,64)=6.215, p=0.004). Preliminary PCP satisfaction results show a favorable attitude towards the program with 90.9% of PCPs indicating they believe this program improved patient support and management and 81.8% PCPs reporting improved access to care for their patients. CONCLUSIONS After participation in NB-ISAEC, the improvements in outcome scores, high patient activation and high PCP satisfaction suggest the successful translation and validation of the ISAEC program in the New Brunswick population. This presents a potential to improve the standard of care for low back pain across Canada. Future work should quantify longer term patient health and economic benefits, and Medicare cost avoidance and efficiency. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Opioid Prescribing Patterns for Low Back Pain Among Commercially Insured Children

Abstract INTRODUCTION Low back pain (LBP) may affect up to 20% of the pediatric population. No specific guidelines exist regarding pharmacotherapy for acute LBP in the pediatric population. Given this observation and the lack of data available regarding pharmacotherapy for pediatric LBP, we sought to characterize patterns of opioid prescribing in the pediatric population. METHODS We used a national database to identify pediatric patients (age 5-17) with newly diagnosed with LBP between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6 mo prior to diagnosis, and had 12-mo of continuous enrollment after diagnosis. We used logistic regression to model the association between sex, geographic region, categorical age, and our primary outcome, receipt of an opioid prescription in the year following diagnosis. RESULTS Our sample included 268 228 opioid-naïve pediatric patients diagnosed with LBP between 2008 and 2015. We observed that 47 631 (17.8%) patients received physical therapy, 29 903 (11.2%) patients received chiropractic manipulative therapy, 658 (0.25%) patients received epidural steroid injection, and 281 (0.10%) patients received surgery. A total of 35 274 (13.2%) pediatric LBP patients were prescribed opioids within 12 mo from their diagnosis. Opioid prescribing decreased in all age groups over the study period age group 5 to 9 decreased from 4.2% to 2.7%, age group 10 to 14 decreased from 10.3% to 7.7%, and age group 15 to 18 yr decreased from 20.9% to 17.1%. Female pediatric patients were more likely than male patients to receive an opioid prescription (OR, 1.12, P < .0001). Patients ages 10 to 14 (OR, 2.89, P < .0001) and 15 to 18 (OR, 6.98, P < .0001) were significantly more likely to be prescribed opioids compared to patients in the youngest age group. CONCLUSION To our knowledge, we report the first observational cohort study of opioids and LBP in the pediatric population. Our findings indicate that opioids are being used for newly diagnosed LBP and receipt of opioids are associated with patient demographic factors.

Comparing the effects of static stretching and strengthening in lengthened position on EMG activity of hamstring muscle in patients with chronic non-specific LBP having shortened muscle: a randomised controlled clinical trial

Introduction: Stretching and strengthening exercises are commonly used to improve muscle tightness. The objective of this trial was to compare the electromyography (EMG) activities of the shortened hamstring in chronic non-specific LBP patients after 12 sessions of static stretching or strengthening exercise.Methods: Forty-five patients were randomly allocated to either of three groups. All patients received the heat and transcutaneous electrical stimulation to the low back area. Also, specific interventions for (1) Static stretching group (n = 15), (2) Strengthening of hamstring muscle in its lengthened position group (n = 15) and no extra intervention for (3) Control group (n = 15) were applied. Blinded assessments of EMG of hamstring, disability and pain were undertaken at baseline and 12 sessions of interventions.Results: No significant difference in change in EMG records due to intervention was found between the three groups (p > .05). Comparing the post-intervention with the baseline results, change in hamstring EMG activity in the three groups was not different significantly (p > .05). Moreover, the result of comparison between groups did not show any significant differences in the mean of secondary outcome measures (pain and disability) either (p > .05).Conclusions: Neither static stretching nor strengthening exercise in the lengthened position for hamstring muscle tightness significantly affected EMG activity of this muscle.

Low Back Pain Treatment by Athletic Trainers and Athletic Therapists: Biomedical or Biopsychosocial Orientation?

Low back pain (LBP) remains a societal burden due to consistently high rates of recurrence and chronicity. Recent evidence suggested that a provider's treatment orientation influences patient beliefs, the clinical approach, and subsequently, rehabilitation outcomes. To characterize American athletic trainer (AT) and Canadian athletic therapist (C-AT) treatment orientations toward LBP. Cross-sectional study. Online survey. A total of 273 ATs (response rate = 13.3%) and 382 C-ATs (response rate = 15.3%). Participants completed demographic questions and the Pain Attitudes and Beliefs Scale (PABS) for ATs/C-ATs. The PABS measures the biomedical and biopsychosocial treatment orientation of health care providers and is scored on a 6-point Likert scale. Descriptive statistics characterized the participants; t tests and 1-way analyses of variance identified differences between group means; and Spearman correlations assessed relationships between the biomedical and biopsychosocial scores and age, number of LBP patients per year, and years of experience. Athletic trainers treating 9 to 15 LBP patients per year had higher biomedical scores (35.0 ± 5.7) than ATs treating 16 to 34 (31.9 ± 5.5, P = .039) or >34 (31.7 ± 8.6, P = .018) LBP patients per year. The C-ATs treating 16 to 34 (31.8 ± 6.3, P = .038) and >34 (31.0 ± 6.7, P < .001) LBP patients per year had lower biomedical scores than those treating ≤8 LBP patients per year (34.8 ± 5.9). The C-ATs with ≤5 years of experience had higher biomedical scores than those with 10 to 15 (31.0 ± 6.7, P = .011) and 16 to 24 (29.8 ± 7.5, P < .001) years of experience. Canadian athletic therapists treating the general public had higher (31.7 ± 4.0) biopsychosocial scores than ATs treating athletes (31.3 ± 3.5, P = .006). The C-ATs ≤35.6 years of age had higher biomedical scores (33.1 ± 5.9) than those >35.6 years of age (30.5 ± 7.0, P < .001). Athletic trainers and C-ATs who treated more LBP patients per year were more likely to score low on a biomedical treatment orientation subscale. Because this orientation has predicted poor outcomes in other health care providers, further research is needed to determine the effects of ATs' and C-ATs' biomedical orientations on rehabilitation outcomes.

Effect Of Core Strength Training On Efficiency, Core Strength Of Patients With LBP

PURPOSE: To observe the effect of core strength training on rehabilitation and core strength of patients with chronic low back pain. METHODS: 120 patients diagnosed as LBP in the affiliated sports hospital of Chengdu Sport Institute are divided into three groups by using randomized, controlled, single-blind experimental methods. The patients in the first group (group A) use basic treatment (acupuncture, massage, TDP irradiation) and core strength training. Basic treatment and gymnastics training are applied for the patients in the second group (group B), while basic treatment is used for the third group (group C). All the trainings continue 8 weeks. Spss19.0 is used for statistics analyses. Efficiency analysis, VAS score and core strength are tested before treatment, after 3 and 8 weeks of treatment. The efficiency is calculated by Ridit analysis. RESULTS: 106 patients participate the whole process and the baseline data before intervention are basically same, and there is no difference in three groups. After 8 weeks training, all the test indicators have changed as follows: 1.Efficiency: The total effective rate is 94.1% in group A, 88.6% in group B, 86.5% in group C. There is a significant difference between group A,B and C by Ridit analysis(P<0.01). There is no difference between group B and C (p>0.05). 2.VAS score: There is no significant difference before intervention. After intervention, the score of group A decreased by 4.68 points, 3.77 points in group B and 3.81 points in group C. There is a significant difference in three groups (p<0.01), while there is no significant difference between group B and C(p>0.05). 3.core strength: the strength of group A has a significant improvement between three groups(p<0.01). There is no significant difference in the ratio of extension/flexion strength, left/right flexural force(p>0.05). After 8 weeks, The ratio of extension/flexion strength changes significantly in group A (p<0.01); the ratio of muscle strength in left/right curve shows that group A and B has significant differences (p<0.05) while highly significant difference C (p<0.01). CONCLUSIONS: After 8 weeks intervention, basic treatment and core strength training can significantly improve the rehabilitation and the core strength, reduce pain and optimize the efficiency of LBP patients.

Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial)

BackgroundLow back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP. Methods and study designThe TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently. DiscussionThe TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT.Trial Registration: ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.

The Back Pain and Movement (B-PAM) registry; a study protocol

BackgroundLow back pain (LBP) is a ubiquitous, heterogeneous disorder that affects most people at some point in their lives. The efficient management of LBP remains elusive, with direct and indirect costs attributed to LBP surpassing many other common conditions. An emphasis on a structural basis of LBP often fails to recognize movement, specifically patterns of movement that may provide biomechanical signatures of painful conditions. The primary objective of this registry is to understand the differences in movement patterns among those with LBP and those without pain in a U.S. population sample.MethodsThis ongoing, non-randomized, prospective post-market registry will consist of two groups: patients with LBP, and age and sex-matched controls without LBP. We will seek to recruit 132 subjects in each group. Data collection will take place in two phases: (1) baseline assessment of LBP patients and matched controls; (2) assessment of LBP patients at 6 and 12-months follow up. The primary outcome measure will be differences in movement patterns between those with LBP and those without LBP. Secondary outcomes will include differences in patient reported outcomes including pain, disability and quality of life.DiscussionThe findings will help determine if there are meaningful differences in movement patterns between those with and those without LBP. Further, an initial understanding of movement signatures specific to certain subtypes of patients with LBP may be achieved.Trial registrationThe study was registered on the clinicaltrials.gov portal: NCT03001037. Trial retrospectively registered 12/22/2016.

The Preoperative Supplementation With Vitamin D Attenuated Pain Intensity and Reduced the Level of Pro-inflammatory Markers in Patients After Posterior Lumbar Interbody Fusion.

The aim of this experimental study was to assess whether 5 weeks of preoperative supplementation with vitamin D affects the intensity of pain and the level of inflammatory markers in patients undergoing posterior lumbar interbody fusion (PLIF) followed by rehabilitation. 42 patients were divided, by double-blind randomization, into two groups: supplemented (SUPL) vitamin D (3200 IU dose of vitamin D/day for 5 weeks) and placebo group (PL) treated with vegetable oil. The 10-week program of early rehabilitation (3 times a week) was initiated 4 weeks following PLIF. Measurements of serum 25(OH)D3 and CRP, IL-6, TNF-α, and IL-10 were performed. Pain intensity was measured using VAS. After supplementation with vitamin D serum, the concentration of 25(OH)D3 significantly increased in the SUPL group (∗p < 0.005) and was significantly higher as compared to the PL group (∗p < 0.001). A significant reduction in pain intensity was observed 4 weeks after surgery and after rehabilitation in both groups. In the SUPL group, serum CRP and IL-6 concentration significantly decreased after rehabilitation, compared with the postsurgical level (ap < 0.04). The level of TNF-α was significantly lower after rehabilitation only in the supplemented group (∗p < 0.02). There were no significant changes in the IL-10 level in both groups during the study. Our data indicate that supplementation with vitamin D may reduce systemic inflammation and when combined with surgery and early postsurgical rehabilitation, it may decrease the intensity of pain in LBP patients undergoing PLIF. Data indicate that LBP patients undergoing spine surgery should use vitamin D perioperatively as a supplement.

Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study

IntroductionLow back pain (LBP) is a common complaint originating from musclesMyofascial pain syndrome (MPS) is mainly associated with trigger points (TrP) in the muscle tissue. We compared the intravenously administered non-steroidal anti-inflammatory drug (NSAID) and trigger point injection (TPI) in the treatment of LBP patients admitted to the emergency department due to pain caused by TrPs. Material and methodAfter randomization, NSAID was administered intravenously in group 1 and TPIs were performed as specified by Travell and Simons in group 2. The TrPs were identified with the anamnesis and physical examinationDemographic characteristics and vital signs of the patients were recorded. Pain scores were measured with the Visual Analogue Scale (VAS) at admission; and in minutes 5, 10, 15, 30, and 60. ResultsThere were 32 patients in group 1 and 22 patients in group 2. The demographics, vital signs, and pain scores at admission were not statistically significantly different between the groups. The pain scores decreased significantly in the TPI group. During the 60 min' follow-up period, the mean VAS pain score decreased by 0.41 ± 1.30 in the TPI group and by 2.59 ± 2.37 in the NSAID group (p < 0.001). Respond the treatment was significantly higher group TPI than Group NSAID (21/22 vs 20/32 respectively, p = 0.008). ConclusionIn this small randomized study with several methodological limitations, TPI was superior to the intravenous NSAIDs in the treatment of acute LBP due to TrPs. TPI can be used in the emergency departments for the acute treatment of LBP in selected patients.

Can a training programme in motivationalinterviewing change musculoskeletalphysiotherapists’ practice?The example of low back pain

Background Low back pain (LBP) is a leading cause of disability nationally and globally, and forms between 40% and 65% of musculoskeletal physiotherapists’ caseloads in the UK. Despite professional expectations to deliver person-centred practice, a biomedical and practitioner-centred perspective continues to dominate within physiotherapy. Many physiotherapists lack the knowledge and skills to deliver psychologically informed practice, which for persistent LBP requires consideration of the needs, preferences and values of the patient. Motivational interviewing (MI) has been recommended as a psychologically informed approach for physiotherapists working with persistent LBP patients, although little research has been carried out into its use. Aim This study aims to investigate the effects of MI training on physiotherapists’ beliefs, attitudes and practice in relation to persistent LBP. Methods A convergent parallel mixed methods study was undertaken. Volunteer musculoskeletal physiotherapists (n=16) were recruited from two musculoskeletal physiotherapy departments within a Community NHS Trust in greater London and allocated to either a MI training Group A (n=10) or a comparison Group B (n=6). The MI training group received an initial two-day MI course followed up by monthly supervision sessions delivered in the workplace. Outcomes were measured pretraining (baseline) then at three and six months later for both groups. Beliefs and attitudes and to persistent low back pain were measured using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). Self-reported proficiency, confidence and intention to use MI were measured using visual analogues scales (VAS). The Motivational Interviewing Training Integrity scale (MITI) generated global ratings and behaviour counts from audio-recordings of initial consultations with persistent LBP patients. The implementation and impact of MI in practice was explored through semi-structured interviews with Group A physiotherapists only at six months. Results A significant post-training decrease in biomedical orientation was demonstrated between the MI training group and the comparison group at three months (HCPAIRS) and six months (PABS-PT and HC-PAIRS) using independent t-tests. The MI training group had significantly increased proficiency, confidence and intention to use MI at three and six months (VAS); and increased MITI global ratings of Spirit (at three months), Collaboration (at three months) and Evocation (at six months). Qualitative content analysis of the semi-structured interviews revealed that the physiotherapists embraced MI as an approach. They were able to overcome initial challenges of putting MI training into practice such as time pressure and level of difficulty in changing ingrained practice and language, and found positive individual and collective ways to introduce and sustain their use of MI. Discussion The results of this study contribute new insights into the understanding of the role and impact of training musculoskeletal physiotherapists in MI, although the small sample size means that the results should be interpreted with caution. MI is acceptable to physiotherapists. Physiotherapists were able to embrace the spirit of MI and to embed MI within their practice. This allows them to development their skills as person-centred practitioners and to cope more effectively with patients perceived as difficult and those with complex presentations. However, ongoing supervision is required to develop MI proficiency, which can be expensive. Mi is acceptable to physiotherapists who seem keen to adopt this psychologically informed approach However, for MI practice to become adopted more widely across the profession, sustainable training approaches and appropriate professional support structures are required.

Bertolotti's syndrome in low-backache population: Classification and imaging findings.

Objective:Lumbosacral transition vertebrae (LSTVs) are associated with alterations in biomechanics and anatomy of spinal and paraspinal structures, which have important implications on surgical approaches and techniques. LSTVs are often inaccurately detected and classified on standard anteroposterior radiographs and magnetic resonance imaging. The use of whole-spine images as well as geometric relationships between the sacrum and lumbar vertebra increases accuracy. The diagnosis of symptomatic LSTV is considered with appropriate patient history and imaging studies. This study aimed to classify the anatomical variations in LSTV and determine, by plain radiography, if there exists a relationship between sacralization and low backache (LBP).Materials and Methods:Five hundred lumbosacral radiographs of LBP patients were examined after obtaining prior consent from the patient and approval from the “institutional ethics committee.” Data collection consisted of the patient's age at the time of imaging gender and number of lumbar vertebral bodies. Dysplastic transverse processes were classified according to the Castellvi radiographic classification system. The incidence of sacralization in patients and the control groups was reported, and the anomaly was compared according to the groups.Results:Of these patient groups, 134 were classified as positive for sacralization, which resulted in an incidence of 26.8%. The most common anatomical variant was Castellvi Type IA (7.6%). There were no statistically significant differences between men and women who had anomaly (P = 0.9256). Higher incidences of Type IB and Type IIB were found in men, but those results were not statistically significant (P = 0.133 and P = 0.581, respectively) when compared with the female group. Daily frequency and intensity of LBP were assessed in patients using visual analog scale (VAS) scores. The patients with LBP and no malformation reported an average pain level on the VAS for pain of 2.2 versus 5.2 in patients with LBP and a transitional vertebra, respectively.Conclusion:Based on our data, we conclude that lumbosacral transitional segments are a common cause in the low-backache population. However, no relationship was found between age and genders in this study. However, in comparison with the nonspecific low-backache group, the VAS scores were significantly higher and the pain duration was significantly longer in the LSTV group.

Low back pain patients and controls display functional differences in endplates and vertebrae measured with T2-mapping

PurposeThe aim was to (1) verify our previous finding that endplates (EPs) display load-induced T2-changes, (2) investigate whether vertebrae display load-induced T2-changes and (3) investigate whether EPs and vertebrae in LBP patients and controls display T2-differences during conventional unloaded MRI and axial loaded MRI (alMRI).MethodsTwenty-seven patients (mean 39 years) and 12 (mean 38 years) controls were examined with T2-mapping on a 1.5 T scanner during conventional unloaded MRI and subsequently during alMRI (Dynawell® loading device), separated by approximately 20 min. For determination of EP and vertebral T2-values, volumetric regions of interest were manually segmented. Each vertebra was then divided into half to obtain superior and inferior units. The presence of EP changes (visual inhomogeneity in the EP zone), Schmorl’s nodules and Modic changes were registered.ResultsFor conventional unloaded MRI, the T2-values in the superior and inferior vertebral units and the EPs were significantly higher in the patients compared with controls (p < 0.03, p < 0.006) even when adjusted for the presence of Modic changes, Schmorl’s nodules and EP signal changes. alMRI induced significant changes in the superior EPs of the patients (p < 0.001). Additionally, the T2-value differed significantly between the superior and inferior EP, as well as between the superior and inferior vertebra with higher values in the inferior units (p < 0.001).ConclusionThis study demonstrated significantly higher EP and vertebral T2-values in LBP patients in comparison with controls. In addition, alMRI induced significant T2-changes in the superior EPs for patients but not for controls. Importantly, the T2-differences between the groups may indicate that EPs and vertebrae in LBP patients have altered biodynamical characteristics compared to controls and the higher T2-values measured in patients may represent early inflammation or impaired nutritional transport.Graphical abstractThese slides can be retrieved from electronic supplementary material.

The Effects of Pain Severity, Pain Catastrophizing, Depression, and Exercise on Perceived Disability in Acute Low Back Pain Patients.

Background/Purpose: The effectiveness of cognitive treatments for low back pain, a prevalent and costly condition, are commonly based on the principles of the Cognitive Behavioral Model of Fear of Movement/(Re)injury. In this model, persons with a painful injury/experience who also engage in pain catastrophizing are most likely to avoid activity leading to disability. The validation of this model in patients with acute low back is limited. The purpose of this project was to examine the relationship of perceived disability with variables identified in the Cognitive Behavioral Model of Fear of Movement/(Re)injury such as, pain severity, pain catastrophizing, depression, and exercise in persons with acute low back pain. Methods: A multiple linear regression model was used to assess the association of perceived disability with pain severity, pain catastrophizing, depression, and exercise at baseline among subjects with acute low back pain (N = 44) participating in a randomized clinical trial to prevent transition to chronic low back pain. Results: Controlling for age, the overall model was significant for perceived disability (F[5, 35] = 14.2; p < .001). Higher scores of pain catastrophizing (p = .003) and pain severity (p < .001) were associated with higher perceived disability levels. Exercise and depression were not significantly associated with perceived disability. Implications: The use of the Cognitive Behavioral Model of Fear of Movement/(Re)injury in acute LBP patients is appropriate; because this model is commonly used as rationale for the effectiveness of cognitive treatments, these findings have clinical relevance in the treatment of this condition.

Safety of intradiscal delivery of triamcinolone acetonide by a poly(esteramide) microsphere platform in a large animal model of intervertebral disc degeneration

BACKGROUND CONTEXTLocal corticosteroids have been used to relieve symptoms of chronic low back pain, although treatment effects have been shown to wear off relatively fast. Prolonging corticosteroid presence by controlled release from biomaterials may allow for longer pain relief while circumventing adverse effects such as high bolus dosages. PURPOSEThe purpose of this study was to evaluate the safety and efficacy of intradiscal controlled release of triamcinolone acetonide (TAA) by poly(esteramide) microspheres in a canine degenerated intervertebral disc (IVD) model. STUDY DESIGNIn a preclinical experimental large animal model, the effect of prolonged glucocorticoid exposure on disc degeneration was evaluated. METHODSDegeneration was accelerated by nucleotomy of lumbar IVDs of Beagle dogs. After 4 weeks, microspheres loaded with 8.4 µg TAA, and 0.84mg TAA were administered to the degenerated IVDs by intradiscal injection (n=6 per group). Empty microspheres (n=6) and all adjacent non-nucleotomized noninjected IVDs were included as controls (n=24). Immediately prior to TAA administration and after 12 weeks, magnetic resonance imaging was performed. Degenerative changes were evaluated by disc height index, Pfirrmann grading, T1ρ and T2 mapping values, postmortem CT scans, macroscopic and microscopic grading, and biochemical/immunohistochemical analysis of inflammation and extracellular matrix content. In addition, nerve growth factor (NGF) protein expression, a biomarker for pain, was scored in nucleus pulposus (NP) tissues. The study was funded by a research grant from Health Holland (1.3million euros = 1.5million US dollars). RESULTSMacroscopic evaluation and CT images postmortem were consistent with mild disc degeneration. Other abnormalities were not observed. Nucleotomy-induced degeneration and inflammation was mild, reflected by moderate Pfirrmann grades and PGE2 levels. Regardless of TAA dosage, local sustained delivery did not affect disc height index nor Pfirrmann grading, T1ρ and T2 mapping values, PGE2 tissue levels, collagen, GAG, and DNA content. However, the low dosage of TAA microspheres significantly reduced NGF immunopositivity in degenerated NP tissue. CONCLUSIONSThis is the first in vivo application in a preclinical large animal model of a controlled release formulation of corticosteroids in mild IVD degeneration. Sustained release of TAA locally in the IVD appeared safe and reduced NGF expression, suggesting its potential applicability for pain relief, although beneficial effects were absent on tissue degeneration. CLINICAL SIGNIFICANCEThe present platform seems to be promising in extending the local controlled delivery of TAA with the potency to provide long-standing analgesia in the subset of LBP patients suffering from discogenic pain.

The relationship between functionality and erector spinae activity in patients with specific low back pain during dynamic and static movements

BackgroundAlterations in the activity of the lumbar erector spinae (LES) muscles on both sides of the spine have been inconsistently reported in patients with specific low back pain (sLBP) after measuring the muscular activity with surface electromyography (sEMG). It also remains unclear whether these alterations in LES activity can be related to the functional level of patients with sLBP. Research questionThis study investigated the LES activity in patients with sLBP during activities of daily living (ADL) which included dynamic and static movement tasks. Moreover, the alterations in LES activity were correlated with the first seven questions of the Zurich Claudication Questionnaire (ZCQ-SS). MethodsThirty patients with specific LBP and twenty healthy subjects were recruited to perform five ADLs including ‘static waist flexion’, ‘sit to stand’,’ 30-seconds standing’, ‘6-minutes walking’ and ‘climbing stairs’. sEMG sensors were mounted on the left and right LES muscles. The integrated EMG (IEMG) was calculated from the preprocessed sEMG data as statistical comparison criteria. ResultsLES activity was significantly higher in patients during ‘sit to stand’,’ 30-seconds standing’ and ‘climbing stairs’ and significantly lower during ‘static waist flexion’ compared to healthy controls. All tasks showed a significant correlation with the ZCQ-SS score except for ‘6-minutes walking’, whereby LES activity and ZCQ-SS score correspondingly increased during ‘sit to stand’ and ‘climbing stairs’ and the LES activity decreased with an increasing ZCQ-SS score during ‘static waist flexion’ and’ 30-seconds standing’. SignificanceThere was a high correlation between alterations in LES activity and the level of functionality in LBP patients. However, the LES activity showed an opposite behavior during static and dynamic movement tasks. The methodology presented can be a useful tool for quantifying improvements in functionality after rehabilitation processes.

Effects of Lumbar Facet Nerve Block on Standing Balance among Lower Back Pain Patients

Lower Back Pain is one of the leading causes of disability globally. Its degradation to patients’ standing stability has been reported in the past. The goal of the current study was to evaluate the influence of immediate pain relief enabled by a lumbar facet joint anesthetic injection on patients’ standing stability. A total of 91 chronic LBP patients were recruited, each patient performed standing balance tests both before and after a lumbar facet nerve block treatment while their dynamic center of pressure data were recorded and compared. Results of our study showed that after the injection, participants showed 10% smaller total excursion and up to 30% smaller sway area. These results suggested patients’ balance might be used as an objective measurement to evaluate pain reduction among LBP patients.

Friday, September 28, 2018 1:00 PM–2:30 PM abstracts: a new look at imaging: 207. Noninvasive MR spectroscopy (MRS) of lumbar discs correlates with surgery outcomes in discogenic low back pain (DLBP) patients

BACKGROUND CONTEXT We previously showed that MRS+/− determinations of relative discogenic pain chemical biomarker levels correlates with provocative discography results (PD+/−) for painful (P) versus nonpainful (NP) discs in chronic, severe DLBP patients. PURPOSE This current study extends our previous work, and further evaluates if MRS+/− disc data predicts lumbar surgery (Sx) outcomes in DLBP patients. STUDY DESIGN/SETTING A single-center, nonsignificant risk investigational clinical development study was conducted under IRB approval and patient informed consent for developing and evaluating MRS techniques against gold standard controls for DLBP diagnosis and surgical success. PATIENT SAMPLE A total of 129 LBP patients with 262 discs receiving PD (118 PD+, 144 PD−), 22 discs that were physician-diagnosed painful by non-PD criteria (Dx+), and 607 discs receiving MRS. 81 PD+ (plus 14 Dx+) and 101 PD- discs served as P and NP controls, after excluding 73 discs for voxels failing optimal geometry (≥1cc, ≤4mm height) and 15 discs for poor spectral quality.A total of 65 patients (plus 4 technical exclusions) also received lumbar spine Sx by one of the authors (MG) at P disc levels, with two exceptions treated at NP discs that were MRS+. OUTCOME MEASURES Surgery outcomes were evaluated at 6 and 12 months post-Sx. Success rates (≥15 point improvement from baseline Oswestry Disability Index) were compared between patient sub-groups classified by MRS+/mild/− pre-Sx results for the treated and nontreated discs. METHODS PD (generally SIS guidelines) and Sx were performed, and discs were prescribed for MRS, per physician discretion. MR spectroscopy was performed via a custom protocol using a commercial Siemens MRS pulse sequence and 3T Verio MR scanner. Investigational postprocessing software enhanced spectral quality and calculated the biomarkers and scoring algorithms. Acid: matrix biomarker ratios were used to derive degenerative pain scores: MRS-SCORE Total and Normalized (to highest Total in-patient). MRS-SCORE ranges (high=MRS+, low=MRS−) were trained to correlate to the P and NP discs (MRSmild=intermediate). Standard statistics were calculated, with 10-fold repeat cross-validation performed for generalizability. RESULTS MRS-SCORES differed significantly between P and NP discs (p CONCLUSIONS Noninvasive, objective, quantitative MRS-SCORES and MRS+/− results accurately distinguish P from NP discs, especially in nonherniated axial LBP patients. 6-12 month Sx success rates were very high when treating all MRS+ discs in patients, but low when treating MRS- discs or leaving MRS+ discs untreated. These data suggest a valuable new approach to help doctors, in combination with other available information, better diagnose and evaluate treatment options toward more successful outcomes in DLBP patients.

O 053 - Femoral deformities affect gait performance more than hip muscle weakness

Alterations in the activity of the lumbar erector spinae (LES) muscles on both sides of the spine have been inconsistently reported in patients with specific low back pain (sLBP) after measuring the muscular activity with surface electromyography (sEMG). It also remains unclear whether these alterations in LES activity can be related to the functional level of patients with sLBP.This study investigated the LES activity in patients with sLBP during activities of daily living (ADL) which included dynamic and static movement tasks. Moreover, the alterations in LES activity were correlated with the first seven questions of the Zurich Claudication Questionnaire (ZCQ-SS).Thirty patients with specific LBP and twenty healthy subjects were recruited to perform five ADLs including ‘static waist flexion’, ‘sit to stand’,’ 30-seconds standing’, ‘6-minutes walking’ and ‘climbing stairs’. sEMG sensors were mounted on the left and right LES muscles. The integrated EMG (IEMG) was calculated from the preprocessed sEMG data as statistical comparison criteria.LES activity was significantly higher in patients during ‘sit to stand’,’ 30-seconds standing’ and ‘climbing stairs’ and significantly lower during ‘static waist flexion’ compared to healthy controls. All tasks showed a significant correlation with the ZCQ-SS score except for ‘6-minutes walking’, whereby LES activity and ZCQ-SS score correspondingly increased during ‘sit to stand’ and ‘climbing stairs’ and the LES activity decreased with an increasing ZCQ-SS score during ‘static waist flexion’ and’ 30-seconds standing’.There was a high correlation between alterations in LES activity and the level of functionality in LBP patients. However, the LES activity showed an opposite behavior during static and dynamic movement tasks. The methodology presented can be a useful tool for quantifying improvements in functionality after rehabilitation processes.

Comparing satisfaction with a participatory driven web-application and a standard website for patients with low back pain: a study protocol for a randomised controlled trial (part of the ADVIN Back Trial)

BackgroundLow back pain (LBP) is the most common musculoskeletal disorder and a leading cause of disability worldwide. It impacts daily life and work capacity and is the most common reason for consulting a general practitioner (GP). According to international guidelines, information, reassurance, and advice are key components in the management of people with LBP; however, the consultation time available in general practice for each patient is often limited. Therefore, new methods to support the delivery of information and advice are needed and online technologies provide new opportunities to extend the consultation beyond the GP’s office. However, it is not known whether GPs and people consulting their GP because of LBP will accept online technologies as part of the consultation. By involving patients in the development of online information, we may produce more user-friendly content and design, and improve patient acceptance and usage, optimising satisfaction and clinical outcomes. The purpose is to study satisfaction in people consulting their GP with LBP depending on whether they are randomised to receive supporting information through a new participant-driven web application or a standard reference website containing guideline-based information on LBP. It is hypothesised that patients offered information in a new web application will be more satisfied with the online information after 12 weeks compared to patients allocated to a standard website.MethodsTwo hundred patients with LBP aged ≥ 18 years consulting Danish general practice will be randomly allocated 1:1 to either the new web application or standard online information in permuted blocks of two, four, and six. Patients with serious spinal diseases (cancer, fractures, spinal stenosis, spondyloarthritis), those without Danish reading skills or without online access, and pregnant women will not be included in the trial. Patient satisfaction measured by the Net Promotor Score after 12 weeks is the primary outcome. Patients will be aware of their allocation. GPs will be blinded unless informed by the patient. Assessors are blinded.DiscussionTo our knowledge, this is the first trial evaluating whether involving LBP patients in the development of an online web application will result in higher patient satisfaction.Trial registrationClinicalTrials.gov NCT03088774. Registered on 23 March 2017. Last updated on 14 March 2018.

Impact of acupuncture treatment on the lumbar surgery rate for low back pain in Korea: A nationwide matched retrospective cohort study.

IntroductionLow back pain (LBP) is a globally prevalent disorder with high social significance. Invasive surgical procedures are increasingly being used to treat LBP despite a lack of solid evidence supporting their long-term benefits. This nationwide retrospective cohort study investigated the association between acupuncture treatment and lumbar surgery rate in patients with LBP.MethodsUsing the National Health Insurance Service Sample Cohort Database for 2002–2013, we identified newly diagnosed LBP patients in Korea between 2004 and 2010 and divided them into an acupuncture group and control group according to whether or not they received acupuncture. Propensity scores based on age, sex, income, and Charlson Comorbidity Index were matched between the two study groups. The lumbar surgery rate in the two years following the first visit (control group) or the first acupuncture session (acupuncture group) was calculated. In addition to the overall analysis, stratified analyses were also conducted in different age, sex, and income strata. Sensitivity analyses were further performed using varying definitions of acupuncture treatment.ResultsAfter matching, 130,089 subjects were included in each study group. The lumbar surgery rate was significantly lower in the acupuncture group than in the control group (hazard ratio [HR] 0.633, 95% confidence interval [CI] 0.576–0.696). Decrease in HR was consistently observed in the acupuncture group for all age strata, except for patients in their 20s (HR 1.031, 95% CI 0.804–1.323). HR for lumbar surgery tended to be further reduced in the older age groups upon acupuncture treatment, with no apparent sex-related differences. Lowered HR in the acupuncture group was continuously observed across all income groups; the higher income group showed a tendency of greater decrease. Sensitivity analyses showed that the number of acupuncture sessions had no major impact on the likelihood of lumbar surgery, but also that more intensive acupuncture treatment was associated with further reduction in lumbar surgery rates.ConclusionThe present results found that administration of acupuncture treatment is associated with lower lumbar surgery rates for LBP patients in Korea. Prospective studies are warranted in the future to further investigate the effect of acupuncture treatment on lumbar surgery incidence.