Low Back Pain Outcomes Research Articles

Development and structural validity of a Nigerian culture- and environment-friendly low back pain outcome measure: Ibadan Low Back Pain Disability Questionnaire.

Low Back Pain (LBP) is the leading cause of disability globally. Standardized outcome measures for measuring LBP disability exist but none was developed with consideration for the Nigerian culture and environment. This study was aimed to develop a Nigerian culture- and environment-friendly LBP scale, the Ibadan Low Back Pain Disability Questionnaire (ILBPDQ). Items on ILBPDQ were devised from literature review, interview of patients (231 consecutively-sampled patients with chronic non-specific LBP) and 12 professionals experienced in LBP management and were contentvalidated. The first draft of the questionnaire underwent pretesting twice among individuals with chronic non-specific LBP (n=35 and 114 respectively), factor analysis and experts' reviews to produce the final version. The final scale comprised 18 items with a two-factor structure (common Activity of Daily Living [ADL] and culture-specific ADL). It has eigen value ≥ 1 and explained 60% of variance. Items on ILBPDQ covered important constructs relevant to an average Nigerian patient with LBP. A scale for assessing disability in LBP is made available for use in Nigeria and similar populations. None declared.

The impact of income support systems on healthcare quality and functional capacity in workers with low back pain: a realist review protocol

BackgroundLow back pain is the greatest contributor to the global burden of disease and can result in work disability. Previous literature has examined the influence of personal factors, the healthcare system, workplace, and income support systems on work disability due to low back pain. Income support systems may also influence healthcare and the workplace, leading to an impact on healthcare quality and functional capacity. However, there has been little insight as to how or in what contexts this influence occurs. This realist review aims to provide an explanation of how and in what contexts income support systems impact the healthcare quality and functional capacity of people who are unable to work due to low back pain.MethodsRealist reviews are a type of literature review that seek to determine how and in what contexts a social programme such as income support leads to an outcome, rather than simply determining whether or not it works. Five initial theories about how income support systems impact healthcare quality and functional capacity are posited in this protocol. An iterative search of electronic databases for academic literature will be used to acquire and synthesise evidence that may support or refute these initial theories. Grey literature such as policy documents will be identified to characterise income support and healthcare systems and supplement contextual details. Semi-structured interviews with income support, healthcare, and low back pain experts will also be performed to complement literature searching with anecdotal and experiential evidence. At the conclusion of the review, initial theories will be supported or refuted and refined into programme theories that will be explained by evidence in context-mechanism-outcome configurations.DiscussionIncome support and healthcare systems are highly complex and fluid programmes. At the intersection between these systems are those with low back pain. By using realist review methods, we will provide explanatory rather than judgemental findings. The resulting multi-dimensional and contextual understanding of the impact of income support systems on important low back pain outcomes will provide valuable insight for future income support and healthcare policy development.

Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain: 2-Year Results From a Prospective Randomized Double-Blind Sham-Controlled Multicenter Study

The purpose of the present study is to report the 2-year clinical outcomes for chronic low back pain (CLBP) patients treated with radiofrequency (RF) ablation of the basivertebral nerve (BVN) in a randomized controlled trial that previously reported 1-year follow up. A total of 147 patients were treated with RF ablation of the BVN in a randomized controlled trial designed to demonstrate safety and efficacy as part of a Food and Drug Administration-Investigational Device Exemption trial. Evaluations, including patient self-assessments, physical and neurological examinations, and safety assessments, were performed at 2 and 6 weeks, and 3, 6, 12, 18, and 24 months postoperatively. Participants randomized to the sham control arm were allowed to cross to RF ablation at 12 months. Due to a high rate of crossover, RF ablation treated participants acted as their own control in a comparison to baseline for the 24-month outcomes. Clinical improvements in the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and the Medical Outcomes Trust Short-Form Health Survey Physical Component Summary were statistically significant compared to baseline at all follow-up time points through 2 years. The mean percent improvements in ODI and VAS compared to baseline at 2 years were 53.7 and 52.9%, respectively. Responder rates for ODI and VAS were also maintained through 2 years with patients showing clinically meaningful improvements in both: ODI ≥ 10-point improvement in 76.4% of patients and ODI ≥ 20-point improvement in 57.5%; VAS ≥ 1.5 cm improvement in 70.2% of patients. Patients treated with RF ablation of the BVN for CLBP exhibited sustained clinical benefits in ODI and VAS and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of CLBP.

Lumbar disc degeneration is longitudinally associated with low back pain presence in older adults

Purpose: Low back pain (LBP) is the most prevalent musculoskeletal complaint throughout the world and causes activity limitation and work absenteeism. The large majority of people with LBP are given the label ‘non-specific’, meaning that a specific patho-anatomical cause for the pain cannot be established. As a phenotype of spinal osteoarthritis, lumbar disc degeneration (LDD) was found to be associated with LBP and can be one of the pain contributing factors. Nevertheless, the predictive value of LDD for long-term LBP outcomes has not been investigated. This study assessed the longitudinal association between LDD and long-term outcomes in older adults presenting with LBP in primary care. Methods: The BACE cohort study was used, including 675 patients aged >55 years visiting a general practitioner with a new episode of non-specific LBP. Osteophytes and disc space narrowing were considered LDD features, and they were investigated as categorical and dichotomous determinants. The 4-grade Lane Atlas classification was used (i.e. grade 0= none, grade 1= mild, grade 2= moderate, grade 3= severe); osteophytes of grade 2 or higher at two or more levels for L1-2 to L5-S1 were defined as LDD presence, likewise disc space narrowing grade 1 or higher at two or more levels from L1-2 to L5-S1. Outcomes at 1-year follow-up were: LBP presence (yes/no), and LBP severity [measured on an 11-point numeric rating scale (NRS)] defined as a NRS score ≥ 4/10. The association between LDD at baseline and 1-year follow-up outcomes was assessed with logistic regression models. Models were adjusted for age, gender and BMI. Results: Five-hundred and forty-three patients (85% of the cohort) with baseline and 1-year follow-up data were included in this study. Mean age was 67 years (SD 8), 59% was female and 62% reported severe LBP at baseline. One-hundred eighty-six patients (34%) met the LDD definition for osteophytes and 389 (72%) the LDD definition of disc space narrowing. The LDD definition of osteophytes was significantly associated with LBP presence, but not the 4-grade classification of osteophytes (Table 1). The LDD definition of disc space narrowing was not associated, but patients with grade 1 to 3 narrowing displayed higher odds (compared to grade 0) of having LBP at follow-up (Table 1). LDD definitions for osteophytes (OR=1.4, 95% CI 0.9-2.1) and narrowing (OR=1.5, 95% CI 0.9-2.4) were not associated with LBP severity. Patients with grade 3 disc space narrowing exhibited higher odds (compared to grade 0 patients) of having severe LBP (OR=2.9, 95% CI 1.0-8.3); patients with other LDD grade classification did not show an association with pain severity. Conclusions: This study found an association between some of the features of LDD at baseline and the presence of LBP at 1-year follow-up (Table 1). On the other hand, LDD features were not associated with LBP severity, with the sole exception of grade 3 disc space narrowing (as compared to grade 0). This study warrants further investigation of LDD features as potential prognostic factors in future longitudinal studies.

Prevalence, Risk Factors and Outcomes of Neck, Shoulders and Low-Back Pain in Secondary-School Children.

Musculoskeletal pain (MSP) is a public health problem among school-adolescents. This study aimed to identify the prevalence, risk factors and consequences of neck, shoulders and low-back pain among school-adolescents. A cross-sectional study. School-adolescents aged from 12 to 18 years between October 2017 and February 2018 in South of Tunisia were recruited. Eligible participants were randomly selected and were asked to respond a four-section questionnaire. Factors independently associated with MSP were determined through multivariate logistic regression analysis. Among 1221 enrolled subjects, shoulders, low-back and neck pain were reported in 43%, 35.8% and 32%, respectively. Multivariate analysis showed that independent risk factors of neck pain were female gender (Adjusted odds ratio AOR=1.55; P=0.002), using computer ≥4 hours/week (AOR=1.50; P=0.010), too low desk (AOR=2.30; P<0.001) and carrying schoolbag ≥60 minutes (AOR=1.58; P=0.008). Female gender (AOR=3.30; P<0.001), BMI ≥25 Kg/m2 (AOR=1.6; P=0.018), playing videogames ≥2 hours/day (AOR=2.37; P<0.001) and schoolbag weight to body weight ≥10% (AOR=1.46; P=0.026) were independently associated with shoulders pain. For low back-pain, independent risk factors were high-school grade (AOR=2.70; P<0.001), playing videogames ≥2 hours/day (AOR=1.83; P<0.001), watching TV≥12 hours/week (AOR=1.5; P=0.016), too low seat backrest (AOR=1.4; P=0.005) and too far seat-to-black (board) distance (AOR=1.5; P=0.041). School-adolescents consumed drugs for MSP in 19.5%, had sleep disturbance in 34% and aggressive behaviors in 22.8%. The prevalence of MSP was substantially high among school-adolescents and their associated risk factors included sociodemographic factors, leisure activities and classroom furniture. An ergonomic specific and behavior-based school program is urgently needed.

Percutaneous Peripheral Nerve Stimulation for Pain Reduction and Improvements in Functional Outcomes in Chronic Low Back Pain.

Chronic low back pain represents one of the most common sources of disability and a significant healthcare burden for the U.S. military. Present treatments for chronic back pain are often ineffective, poorly tolerated, invasive, destructive, and/or associated with complications and lead to the progression to invasive surgical procedures. There have been multiple calls for the development of a minimally invasive system that is effective without the risks or complications of existing surgical therapies, which could prevent the need for surgery and the recurrence of pain. The goal of this study was to evaluate a novel, minimally invasive approach using a percutaneous peripheral nerve stimulation (PNS) system designed to provide pain relief without surgery, to reduce complications, and provide a less-invasive treatment option. In nine subjects, percutaneous PNS improved participants' function, as evidenced by clinically and statistically significant reductions in pain, disability, and pain interference. Subjects also experienced reductions in opioid and non-opioid analgesic medication usage and reported improvements in quality of life with treatment. There were no serious or unanticipated adverse events. These results demonstrate the potential of percutaneous PNS as a non-surgical therapy to treat chronic back pain without opioids.

An Exploratory Analysis of Gender as a Potential Modifier of Treatment Effect Among Patients in a Randomized Controlled Trial of Integrative Acupuncture and Spinal Manipulation for Low Back Pain

ObjectiveTo identify the potential association of self-reported gender on pain and disability among patients in a randomized controlled trial of integrative acupuncture and spinal manipulation therapy (SMT) for low back pain (LBP). MethodsIn the original study, 100 participants with LBP were randomized to receive acupuncture, SMT, or both combined. Eighty completed treatment and were followed for 60 days. Primary outcome measures were the Roland-Morris Disability Questionnaire and numeric pain scales. This study was a secondary analysis and used regression models to estimate and test for gender-specific differences in outcomes from baseline through end of treatment. ResultsWomen assigned to acupuncture averaged a 3.8-point reduction in highest LBP vs 2.0 points for SMT, whereas men assigned to SMT averaged a 3.5-point reduction vs 1.8 points for acupuncture (P for interaction = .04). There was a trend toward the same for disability (P for interaction = .12). For women, acupuncture alone led to better outcomes without SMT, and for men, SMT alone led to better outcomes without acupuncture. Women who received acupuncture were more likely to experience 50% or greater reductions in disability and pain, whereas men who received SMT were more likely to experience 50% or greater reductions in disability and pain. ConclusionAn association was found between self-reported gender and response to LBP treatment. Women demonstrated a greater reduction in pain and disability with acupuncture and men with SMT. Future clinical trials should consider sex as a potential determinant of treatment outcomes for LBP.

Global Consensus From Clinicians Regarding Low Back Pain Outcome Indicators for Older Adults: Pairwise Wiki Survey Using Crowdsourcing.

BackgroundLow back pain (LBP) is one of the most debilitating conditions among older adults. Unfortunately, existing LBP outcome questionnaires are not adapted for specific circumstances related to old age, which may make these measures less than ideal for evaluating LBP in older adults.ObjectiveTo explore the necessity of developing age-specific outcome measures, crowdsourcing was conducted to solicit opinions from clinicians globally.MethodsClinicians around the world voted and/or prioritized various LBP outcome indicators for older adults on a pairwise wiki survey website. Seven seed outcome indicators were posted for voting while respondents were encouraged to suggest new indicators for others to vote/prioritize. The website was promoted on the social media of various health care professional organizations. An established algorithm calculated the mean scores of all ideas. A score >50 points means that the idea has >50% probability of beating another randomly presented indicator.ResultsWithin 42 days, 128 respondents from 6 continents cast 2466 votes and proposed 14 ideas. Indicators pertinent to improvements of physical functioning and age-related social functioning scored >50 while self-perceived reduction of LBP scored 32.ConclusionsThis is the first crowdsourcing study to address LBP outcome indicators for older adults. The study noted that age-specific outcome indicators should be integrated into future LBP outcome measures for older adults. Future research should solicit opinions from older patients with LBP to develop age-specific back pain outcome measures that suit clinicians and patients alike.

Randomized controlled trial of a 12-week digital care program in improving low back pain

Low back pain (LBP) is the leading cause of disability throughout the world and is economically burdensome. The recommended first line treatment for non-specific LBP is non-invasive care. A digital care program (DCP) delivering evidence-based non-invasive treatment for LBP can aid self-management by engaging patients and scales personalized therapy for patient-specific needs. We assessed the efficacy of a 12-week DCP for LBP in a two-armed, pre-registered, randomized, controlled trial (RCT). Participants were included based on self-reported duration of LBP, but those with surgery or injury to the lower back in the previous three months were excluded. The treatment group (DCP) received the 12-week DCP, consisting of sensor-guided exercise therapy, education, cognitive behavioral therapy, team and individual behavioral coaching, activity tracking, and symptom tracking – all administered remotely via an app. The control group received three digital education articles only. All participants maintained access to treatment-as-usual. At 12 weeks, an intention-to-treat analysis showed each primary outcome—Oswestry Disability Index (p < 0.001), Korff Pain (p < 0.001) and Korff Disability (p < 0.001)—as well as each secondary outcome improved more for participants in the DCP group compared to control group. For participants who completed the DCP (per protocol), average improvement in pain outcomes ranged 52-64% (Korff: 48.8–23.4, VAS: 43.6–16.5, VAS impact on daily life: 37.3–13.4; p < 0.01 for all) and average improvement in disability outcomes ranged 31–55% (Korff: 33.1–15, ODI: 19.7–13.5; p < 0.01 for both). Surgical interest significantly reduced in the DCP group. Participants that completed the DCP had an average engagement, each week, of 90%. Future studies will further explore the effectiveness of the DCP for long-term outcomes beyond 12 weeks and for a LBP patient population with possibly greater baseline pain and disability. In conclusion, the DCP resulted in improved LBP outcomes compared to treatment-as-usual and has potential to scale personalized evidence-based non-invasive treatment for LBP patients.

Magnetic resonance spectroscopy (MRS) can identify painful lumbar discs and may facilitate improved clinical outcomes of lumbar surgeries for discogenic pain

PurposeThe goal of this study was to refine clinical MRS to optimize performance and then determine whether MRS-derived biomarkers reliably identify painful discs, quantify degeneration severity, and forecast surgical outcomes for chronic low back pain (CLBP) patients.MethodsWe performed an observational diagnostic development and accuracy study. Six hundred and twenty-three (623) discs in 139 patients were scanned using MRS, with 275 discs also receiving provocative discography (PD). MRS data were used to quantify spectral features related to disc structure (collagen and proteoglycan) and acidity (lactate, alanine, propionate). Ratios of acidity to structure were used to calculate pain potential. MRS-SCOREs were compared to PD and Pfirrmann grade. Clinical utility was judged by evaluating surgical success for 75 of the subjects who underwent lumbar surgery.ResultsTwo hundred and six (206) discs had both a successful MRS and independent pain diagnosis. When comparing to PD, MRS had a total accuracy of 85%, sensitivity of 82%, and specificity of 88%. These increased to 93%, 91%, and 93% respectively, in non-herniated discs. The MRS structure measures differed significantly between Pfirrmann grades, except grade I versus grade II. When all MRS positive discs were treated, surgical success was 97% versus 57% when the treated level was MRS negative, or 54% when the non-treated adjacent level was MRS positive.ConclusionMRS correlates with PD and may support improved surgical outcomes for CLBP patients. Noninvasive MRS is a potentially valuable approach to clarifying pain mechanisms and designing CLBP therapies that are customized to the patient.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Comparison of Core Stabilisation Exercise and Proprioceptive Neuromuscular Facilitation Training on Pain-related and Neuromuscular Response Outcomes for Chronic Low Back Pain: A Randomised Controlled Trial.

BackgroundExisting literature offers little guidance for therapists who provide core stabilisation exercise (CSE) and proprioceptive neuromuscular facilitation (PNF) training to treat chronic low back pain (CLBP). Studies conducting a head-to-head comparison of CSE and PNF training for CLBP are needed.ObjectiveTo compare the effects of CSE and PNF training on pain-related outcomes and trunk muscle activity in CLBP patients.MethodsForty-five CLBP patients, ranging from 18 to 50 years of age, were randomly divided and assigned to either a four-week CSE, four-week PNF training, or control group. Pain-related outcomes, including pain intensity, functional disability and patient satisfaction, as well as superficial and deep trunk muscle activity were assessed before and after the four-week intervention, and at a three-month follow-up.ResultsCompared to the control group, those in the CSE and PNF training groups showed significant improvements in all pain-related outcomes after the four-week intervention and at three-month follow-up (P < 0.01). Following the four-week intervention, both CSE and PNF training groups demonstrated significant improvement in deep trunk muscle activity, including the transversus abdominis (TrA) and superficial fibres of lumbar multifidus (LM), compared to the control group (P < 0.05).ConclusionFour-week CSE and PNF training provided short-term and long-term effects on pain-related outcomes, along with increased deep trunk muscle activity in CLBP patients.

Feasibility and impact of sit-stand workstations with and without exercise in office workers at risk of low back pain: A pilot comparative effectiveness trial

The aim of this study was to compare the feasibility and impact of sit-stand workstations plus advice, with or without exercise, on back pain and sitting time in office workers at risk of low back pain (LBP). Eligible participants (n = 29/169; 17% overall) were randomized to receive a sit-stand workstation and advice with (n = 16) or without (n = 13) progressive resistance exercise training for 4-weeks. Feasibility (recruitment, acceptability, adherence) and impact (LBP severity during a standardized standing task, workplace-sitting time) were assessed. Intervention acceptability (87.5% very satisfied) was good and adherence (60% completed all 12 exercise sessions) was satisfactory. Maximum LBP severity (mean difference of −1.3 (−2.0, −0.6) and workplace sitting time (82.7–99.3 min/8-hr workday reduction) were similarly reduced in both groups. The introduction of a sit-stand workstation with advice was feasible and achieved similar outcomes for LBP and workplace sitting time when administered with or without exercise.

Does the Surgical Timing and Decompression Alone or Fusion Surgery in Lumbar Stenosis Influence Outcome in Cauda Equina Syndrome?

Study DesignA retrospective comparative analysis of 64 patients with cauda equina syndrome (CES), who underwent either decompression alone (NF) or fusion (F) surgery.PurposeWe compared the outcomes and timing effects.Overview of LiteratureCES can cause loss of autonomic control of vesicular function and lower limb neurological deficits. Prompt diagnosis and emergency surgery markedly improve outcome. Although decompression only is a mainstream technique, there is guarded recovery of vesicular dysfunction. Decompression ventrally in a narrow window requires manipulation of neural tissue in an already jeopardised critical canal and may accentuate irreversible damages. In F surgery, the adequate exposure leads to a lower neural manipulation.MethodsUntil January 2008, we treated CES with decompression (laminectomy and/or discectomy). However, from that month forward, all our single-level CES patients have received a fusion operation. In this study, characteristic categorical variables and outcomes were analysed.ResultsIn a retrospective analysis of 64 patients, NF (n=37) and F (n=27) who received treatment, we found that both groups improved significantly on follow-up in all objective parameters. Although, the comparison of clinical and functional outcome data between the two groups was statistically insignificant, the average value of objective outcome such as vesicular function, low back pain (LBP), and complications was better for patients in F group compared with NF group. However, the patient satisfaction for the F group was also lower, in view of their residual symptoms and disabilities. Contrary to common perceptions, we found that the timing of surgery does not influence the recovery rate for either approach.ConclusionsAlthough both the techniques appear to be equally effective, the fusion approach overall showed a definite edge over non-fusion, with respect to reduced incidence of iatrogenic dural tears, LBP, and overall outcome, even despite the lower patient satisfaction.

Longitudinal analysis of inflammatory, psychological, and sleep-related factors following an acute low back pain episode: A potential factor in tissue effects in low back pain

Introduction: Systemic inflammation is observed in chronic low back pain (LBP) (Wang et al 2008) and may contribute to the transition from acute to persistent LBP (Klyne et al 2017). Lower back connective tissues are a possible source of this inflammation and can be modified by inflammation. Fibroblasts secrete inflammatory cytokines in response to stretch or injury of the connective tissues (Dodd et al 2006; Wilke et al 2017), which can “spill over” into the bloodstream, leading to widespread secondary tissue damage and activation of pain pathways in the central nervous system (Xin et al 2017). Whether an early increase in systemic cytokines is related to LBP outcome is unclear. This study aimed to determine whether systemic cytokines and C-reactive protein (CRP) during an acute episode of LBP differ between individuals who did and did not recover by 6 months and to identify subgroups based on patterns of inflammatory, psychological, and sleep features associated with recovery/non-recovery.

Validation of the Croatian version of the Oswestry Disability Index.

To translate, cross-culturally adapt, and validate the Croatian version of the Oswestry Disability Index (ODI). The original English-language ODI was cross-culturally adapted into Croatian and then evaluated in a group of 114 patients with chronic low back pain (LBP) at the Department of Neurosurgery, Zagreb University School of Medicine. Confirmatory factor analysis (CFA) was conducted with three models: two were theory driven (unidimensional and two dimensional-static and dynamic factors); the other was based on our exploratory factor analysis (EFA). Internal consistency and test-retest reliability were evaluated using Cronbach's α and the intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by evaluating the correlation between the ODI and Visual Analogue Scale (VAS), and between the ODI and 36-item short form survey (SF-36) scores. The EFA-derived two-dimensional structure explained 82.7% of the total variance and was significantly better than the other models (P < 0.001); however, none of the models had acceptable fit. Internal consistency (Cronbach α = 0.84) and test-retest reliability (ICC = 0.94) were satisfactory. The ODI was positively correlated with VAS (rs = 0.54, P < 0.001) and negatively correlated with all of the SF-36 sections (rs = - 0.35 to - 0.64, P < 0.001, all), apart from the role-physical (rs = - 0.02, P = 0.767). The Croatian version of the ODI has acceptable psychometric properties. It appears to be suitable for assessment of LBP and treatment outcomes in Croatian-speaking patients. Overall, there was no evidence to reject the original unidimensional structure in favor of a two-factor solution. As such, the unidimensional structure should continue to be used in future studies. These slides can be retrieved under Electronic Supplementary Material.

Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care.

A multifaceted workplace intervention consisting of participatory ergonomics, physical training, and cognitive-behavioural training (CBT) has shown effectiveness for reducing low back pain (LBP). However, the mechanisms of action underlying these intervention components are not well understood. This was a mediation analysis of a cluster-randomised controlled trial of a multifaceted intervention in 420 workers in elderly care. Mediation analysis was carried out via structural equation modelling. Potential mediators investigated were: fear-avoidance beliefs, perceived muscle strength, use of assistive devices at work and perceived physical exertion at work. LBP outcomes assessed were: days with LBP, LBP intensity and days with bothersome LBP. There were no significant indirect effects of the intervention on LBP outcomes. There were significant effects of the intervention on both fear-avoidance measures [β=- 0.63, 95% CI (1.23, 0.03); β=- 1.03, 95% CI (- 1.70, - 0.34)] and the use of assistive devices [β=- 0.55, 95% CI (- 1.04, - 0.05)], but not on perceived muscle strength [β=- 0.18, 95% CI (- 0.50, 0.13)] or physical exertion [β=- 0.05, 95% CI (- 0.40, 0.31)]. The only potential mediator with a significant effect on LBP outcomes was physical exertion, which had a significant effect on LBP intensity [β = 0.14, 95% CI (0.04, 0.23)]. A multifaceted intervention consisting of participatory ergonomics, physical training, and CBT was able to decrease fear-avoidance beliefs and increase use of assistive devices in the workplace. However, these changes did not explain the effect of any of the intervention components on days with LBP, LBP intensity and days with bothersome LBP.

Friday, September 28, 2018 8:00 AM–9:00 AM interdisciplinary spine forum: abstract presentations: 142. Integrating multidisciplinary knowledge of low back pain through collaborative modeling: results from the NASS think tank workshop

BACKGROUND CONTEXT Low back pain (LBP) is a very complex problem with numerous bio-psycho-social factors interacting to impact pain, disability, and quality of life. To understand the dynamics of such a complex problem, it needs to be studied in its entirety (systems approach). Although this concept is accepted by the scientific and clinical communities, much research to date is conducted by specialized teams focusing on isolated factors related to LBP. Such a reductionist approach may be useful in some circumstances, but it also creates barriers for integrating knowledge between disciplines and ultimately precludes the understanding of the dynamics of the entire LBP problem. To leverage the knowledge shared among various stakeholders, an innovative process called collaborative modeling was developed within the field of systems science specifically for enhancing the understanding of complex, multifactorial systems dynamics. This study assessed the feasibility of using this approach for integrating multidisciplinary knowledge of LBP. METHODS Participants (n=29), who have contributed significant knowledge to the area of LBP (eg publications, contributions to societies, etc.), were selectively recruited for this study and represented diverse disciplines: Basic Science (n=7), Chiropractic (n=4), Spine Surgery (n=2), Physical Medicine & Rehabilitation (n=2), Physical or Exercise Therapy (n=12), and Psychology (n=2). Each participant underwent a structured one-on-one interview to construct a fuzzy-logic cognitive map (FCM) (Mental Modeler software, www.mentalmodeler.org ) representing his or her understanding of how factors related to LBP interact and affect patient outcomes (pain, disability and quality of life). All individual FCMs were then converted to adjacency matrices and integrated into one meta-model (Gephi software, www.gephi.org ). To demonstrate the integrated meta-model's potential, various intervention strategies listed in all FCMs were simulated and their relative effects on pain, disability, and quality of life were investigated. RESULTS The meta-model, that integrated the understanding of LBP of all participants, consisted of 272 factors and 1,429 connections representing interactions among these factors. Simulations of individual treatment interventions predicted that combined aerobic exercise, counseling, and education are likely to be the most effective intervention to reduce pain. Meditation, followed by cognitive behavioral therapy, had the greatest impact on reducing disability and improving quality of life. CONCLUSIONS The integration of 29 FCMs, representing diverse participants’ views of LBP dynamics, resulted in a model that was extremely complex, but still feasible to produce meaningful interpretations. The simulations provided outcomes that broadly agreed with data in the literature, which suggests that aerobic exercise, counseling, education, meditation, and cognitive behavioral therapy are effective LBP interventions. Although the selection of participants and the relatively small sample size may influence the results, the findings suggest that it is possible to integrate multidisciplinary knowledge of LBP into one meta-model. This approach could provide the framework for a larger, community-wide platform for further development and refinement of this meta-model. Such a meta-model could then be used to simulate other “what if” scenarios, to identify gaps in knowledge, and to inform new essential research directions to ultimately improve patient care and outcomes for LBP.

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.

Yellow flags as predictors of rehabilitation outcome in chronic low back pain.

While it is agreed that yellow flags (prognostic psychosocial factors for poor recovery in low back pain) predict pain-related outcomes, uncertainty remains regarding which constructs are the central ones, particularly as there is considerable conceptual overlap between constructs. Therefore, the aim of our study was to analyze the distinctiveness of different psychological factors in predicting rehabilitation outcomes in a sample of patients with chronic low back pain (CLBP) in a rehabilitation setting. Research Method/Design: We conducted a longitudinal study using multivariable modeling taking into account a broad set of psychological variables as potential predictors. Rehabilitation outcome was assessed via health related quality of life (HRQL) and disease-specific functioning at the end of rehabilitation and six months later. The sample comprised N = 214 patients. When considered separately, a range of psychological factors were significant predictors of HRQL and functioning at the end of rehabilitation and at six months follow-up, even if baseline values of outcome variables, sociodemographic variables, and baseline pain intensity are controlled. When considered in combination, a better work prognosis, self-efficacy and intensity of depressive symptoms were verified as independently significant predictors of HRQL. None of the psychological constructs remained significant predictors for disease-specific functioning. The incremental variance explained by the psychological constructs varied between 3 and 24%. The contribution of psychological factors may be different depending on the sample (acute vs. chronic) and the outcome domain. Future research should validate these results with respect to other patient-centered outcomes and in other CLBP samples. (PsycINFO Database Record

Pharmacological target therapy of neuropathic pain and patient-reported outcomes in patients with chronic low back pain in Korea: Results from the NLBP Outcomes Research.

A number of studies have demonstrated an association of neuropathic pain and chronic low back pain (CLBP), but the outcome difference in each medical management is poorly understood. This study is aimed to investigate treatment patterns of neuropathic pain in CLBP patients and to explore patient-reported outcomes (PROs) including quality of life (QoL) and functional disability by treatment patterns.Data were extracted from the neuropathic low back pain (NLBP) outcomes research. It was a multicenter and cross-sectional study in which 1200 patients were enrolled at 27 general hospitals, from 2014 to 2015. Of total, 478 patients classified as neuropathic pain were used for this subgroup analysis. The patients were divided into 2 groups according to treatment patterns (with vs. without the targeted therapy [TT] of neuropathic pain). Demographic and clinical features were collected by chart reviews and PROs were measured by patient's survey. QoL was assessed by EuroQoL 5-dimension (EQ-5D) questionnaire. Functional disability was measured by the Quebec Back Pain Disability Scale (QBPDS). Multiple linear regression analyses were conducted to compare the PROs between TT group and non-targeted therapy (nTT) group.Among the NLBP patients (mean age 63years, female 62%), EQ-5D index, EuroQoL-Visual Analog Scale (EQ-VAS), and QBPDS Scores (mean ± standard deviation) were 0.40 ± 0.28, 54.98 ± 19.98, and 46.03 ± 21.24, respectively. Only 142 (29.7%) patients had pharmacological TT of neuropathic pain. Univariate analyses revealed no significant mean differences between TT group and nTT group in the EQ-5D index (0.41 ± 0.27 and 0.39 ± 0.28), EQ-VAS (56.43 ± 18.17 and 54.37 ± 20.69), and QBPDS (45.31 ± 21.32 and 46.31 ± 21.24). After adjustment with covariates, TT group had higher scores of EQ-5D index (β = 0.07; P < 0.01) and EQ-VAS (β = 4.59; P < 0.05) than the nTT group. The TT group's QBPDS score was lower than the nTT group, although its statistical significance still has not been reached (β = −4.13; P = 0.07).We found that considerable proportion of the NLBP patients remains untreated or undertreated. Although TT group had significantly better QoL than nTT group, only 29.7% of NLBP patients had pharmacological TT. Therefore, clinicians should consider using TT for better QoL of neuropathic pain patients.