Recurrent Low Back Pain Research Articles

Therapeutic guidelines in chronic low back pain

Chronic low back pain is a heterogeneous group of disorders with recurrent low back pain over 3 months. The high incidence of lumbago is an important phenomenon in our industrial society. Patients with chronic low back pain often receive multidisciplinary treatment. The bio approach, the psycho-approach, and the social approach optimally reduce the risk of chronicity by providing rehabilitation for patients with persistent pain after the initial acute phase. Damage to the structures of the spinal cord and the occurrence of low back pain as a result of evolutionary, social and medical causes disrupt the rhythm of life and cause less or greater disability. Recovery of patients with low back pain is not limited only to influencing the pain syndrome but requires the implementation of programs to eliminate the complaints that this pathology generates in personal, family and socio-professional terms. This paper aims to familiarize the audience with the medication used, and the programs for active recovery in patients suffering from chronic low back pain.

Reliability and construct validity of the modified Finnish version of the 9-item patient health questionnaire and its associations within the biopsychosocial framework among female health-care workers with sub-acute or recurrent low back pain

BackgroundHealth-care workers have an increased risk for chronic low back pain (LBP) leading to reduced workability. Depression, a highly prevalent, costly and disabling condition, is commonly seen in patients with sub-acute LBP. This study investigated the psychometric properties and construct-validity of a modified 9-item Patient Health Questionnaire (PHQ-9-mFIN) in female health-care workers with sub-acute LBP.MethodsReliability (internal consistency, test-retest repeatability) was assessed using standard methods. Construct validity of the PHQ-9-mFIN was assessed as level of depressive symptoms (PHQ-9-mFIN: 0–4 none, 5–9 mild, ≥10 at least moderate) against the RAND 36 Health Survey, a valid measure of health-related quality of life (HRQoL). Additionally, the strength of the association between the levels of PHQ-9-mFIN and selected biopsychosocial factors was determined.ResultsThe internal consistency of the PHQ-9-mFIN was high (Cronbach’s α = 0.82) and the test-retest repeatability scores (n = 64) were moderate: Pearson’s correlation was 0.73 and Intraclass Correlation Coefficient (ICC) 0.73 (95% CI: 0.58 to 0.82). Construct validity (Spearman correlation) against the Physical and Mental component items and their summary scales of the RAND 36 were much higher for the Mental (range, − 0.40 to − 0.67 and − 0.64) than for the Physical (range, − 0.08 to − 0.43 and − 0.22). There was a clear stepwise association (p < 0.001) between the levels of depressive symptoms and General health (physical component, range, 59.1 to 78.8). The associations with all items of the Mental components were strong and graded (p < 0.001). All participants had low scores for Bodily pain, regardless of the level of depressive symptoms. There was a strong association (p ≤ 0.003) between the levels of PHQ-9-mFIN and multisite pain, lumbar exertion and recovery after workdays, neuromuscular fitness in modified push-ups, workability, and fear of pain related to work.ConclusionsThe PHQ-9-mFIN showed adequate reliability and excellent construct validity among female health-care workers with recurrent LBP and physically strenuous work.Trial registrationNCT01465698.

Medical exercise and physiotherapy modes and frequency as predictors for a recurrence of chronic non-specific low back pain.

A considerable part of patients with non-specific low back pain (LBP) suffer from a recurrence of symptoms after therapy cessation. The aim of this cohort study was to evaluate the predictive value of active and passive treatments and treatment modalities on a recurrence of low back pain after cessation of medically prescribed therapy. Patients with non-specific LBP from a health- and therapy-center were included. Treatments were monitored and categorized as active or passive. During one year after therapy cessation, patients were monitored to retrieve information about recurrence of symptoms. Patients were dichotomized (recurrence versus no recurrence). An ROC-Analysis was used to determine optimal cut-offs for relevant treatment characteristics' (passive versus active; frequency) impact on recurrence risk. The relative risk for a recurrence was calculated based on Chi2-test. Data from 96 participants (56 females, 40 males, mean age 49 years, standard deviation 11 years) were analysed. A total of 34 participants had recurring LBP. The frequency of active treatment differed significantly between groups with or without recurrence (p< 0.05). A therapy frequency of 1.45 active treatments/week was a sensitive cut-off (sensitivity: 0.73) to discriminate the recurrence groups. Participants with an active therapy frequency of less than 1.45 treatments per week showed an 82% increased relative recurrence risk (RR: 1.824 (95%-CI: 1.077-3.087)). The results empathize the importance of active treatments (i.e. exercise) in the therapy and (secondary) prevention of non-specific LBP. Less than 1.45 active treatment sessions/week increases the 1-year-risk of a recurrence by 82%. Performing at least two treatments sessions per week is therefore recommended.

Effect of low back pain on the muscles controlling the sitting posture.

[Purpose] The purpose of the current study was to reveal the association between posture control and muscle activity by measuring the trunk and hip joint muscle activities in the upright and slump sitting positions in both the healthy participants and patients with recurrent lower back pain. [Participants and Methods] We recruited eleven patients of recurrent lower back pain and ten healthy participants. During the maintenance of the two types of posture, upright and slump, we collected the surface electromyography data. We assessed the following muscles: rectus abdominis, external oblique, thoracic erector spinae, lumbar erector spinae, internal oblique, lumbar multifidus, iliacus, serratus anterior, rectus femoris, tensor fascia latae, and gluteus maximus. We studied the differences in spinal–pelvic curvature and muscle activity between the upright and slump positions in each group. [Results] In the healthy group, comparison of the muscle activity in upright and slump positions for both the trunk (external oblique, internal oblique, lumbar erector spinae, and lumbar multifidus), and the hip muscles (iliacus and gluteus maximus) showed a significant decrease in activity in the slump position. In the group with recurrent lower back pain, although the external oblique, lumbar erector spinae and lumbar multifidus showed reduced activity in slump position, these values were smaller when compared to those in the healthy group. [Conclusion] This study aimed to clarify the relationship between posture (upright and slump) and the activity of the trunk and hip joint muscles in the healthy participants and the patients with recurrent lower back pain. The results indicated that postural changes caused by recurrent lower back pain significantly affected the activity of the muscles involved in controlling the posture.

People considering exercise to prevent low back pain recurrence prefer exercise programs that differ from programs known to be effective: a discrete choice experiment.

Do program and participant characteristics influence people's willingness to undertake exercise programs to prevent recurrence of low back pain? Discrete choice experiment. Six hundred and forty-seven people with a recent history of low back pain. Recruitment and participation occurred online. Participants were randomised to a block of 10 choice tasks, where the characteristics of the exercise program varied systematically. The characteristics that were presented for each exercise program were mode of exercise delivery, mode of supervision, setting, duration, weekly frequency, travel time, risk of recurrence, and costs. For each choice task, participants chose between no program or an exercise program with the characteristics as presented. Choices were analysed using mixed logit models. Latent class models examined preference heterogeneity and identified participant-level characteristics predictive of preferences. There appeared to be an underlying preference for exercise compared with no exercise, all else being equal. Preferences for programs were significantly influenced by the characteristics of the programs. Participants were less likely to choose exercise when programs were of a longer duration (OR 0.92, 95% CI 0.89 to 0.96 per extra month), but more likely to prefer programs offering greater reduction in the risk of recurrence of low back pain (OR 3.91, 95% CI 3.20 to 4.79 per 10% reduction in risk of recurrence). Preferences for engaging in exercise programs to prevent recurrent of low back pain were influenced by the characteristics of the programs themselves. However, there was mismatch between the preferred characteristics of exercise programs and the characteristics of known effective programs. People who have had low back pain should be advised explicitly about which exercise programs reduce recurrence. Understanding low back pain patients' preferences can help inform the implementation of existing prevention programs and guide the design of new prevention programs.

Effectiveness and cost-effectiveness of a progressive, individualised walking and education programme for prevention of low back pain recurrence in adults: study protocol for the WalkBack randomised controlled trial

IntroductionLow back pain (LBP) is recognised globally as a prevalent, costly and disabling condition. Recurrences are common and contribute to much of the burden of LBP. Current evidence favours exercise...

Trunk stiffness decreases and trunk damping increases with experimental low back pain

Movement adaptations to low back pain (LBP) are believed to protect the painful area. Increased trunk stiffness and decreased trunk damping have been shown in people with recurrent LBP. However, no study has examined these properties using external force perturbations to the trunk during acute LBP when protective adaptations might be expected to have most relevance.Adaptations to an acute painful stimulus via unilateral injection of hypertonic saline into the right longissimus muscle were assessed using a trunk force perturbation paradigm and a mass-spring-damper model to describe effective trunk dynamical properties. Equal weights (15% body weight) were connected to the front and back of the trunk via a cable. Either one was dropped at random to perturb the trunk. Effective trunk dynamical properties were estimated in fourteen males (mean (standard deviation) age 25 (6) years) assuming that trunk movement can be modelled as a second order linear system. Effective trunk dynamical properties were compared before, during and after the experimentally induced painful period.Estimates of effective trunk stiffness (K) decreased and damping (B) increased during pain compared to both before ([mean contrast, 95% CI] K: −403 [−651 to −155] Nm−1, B: 28 [9–50] Nms−1) and after (K: −324 [−58 to −591] Nm−1, B: 20 [4–33] Nms−1) the experimentally induced painful period. We interpret our results to show that, when challenged by a step force perturbation, a healthy system adapts to noxious input by controlling trunk velocity rather than trunk displacement, in contrast to observations during remission from recurrent clinical LBP.

A prospective study of low back pain in a general population. I. Occurrence, recurrence and aetiology

A general population of 928 men and women aged 30, 40, 50, and 60 years underwent a lower back examination as part of a general health survey. A 12 month follow-up questionnaire was completed by 99% of them. At the end of the follow-up year, the life time prevalence rates for low back pain (LBP) were 68-70% for men and rose with increasing age from 62% to 81% among women. The one year incidence of first attacks of LBP was 11% among the 30-year-olds and decreased in the older age-groups. Recurrences of LBP in the follow-up year were more frequent among those who had more recently and frequently experienced LBP before. Among those who had experienced LBP on some occasion, 23-31% had such symptoms daily or at least once a week. Heavy lifting, twisting and trauma were the most commonly stated causes of LBP, which 52-60% of the participants claimed to be work-related. A gradual onset and exacerbation of the LBP were of some prognostic value in the follow-up year, while the alleged cause of previous LBP was not.

Pain Catastrophizing, Self-reported Disability, and Temporal Summation of Pain Predict Self-reported Pain in Low Back Pain Patients 12 Weeks After General Practitioner Consultation: A Prospective Cohort Study.

Patients with low back pain (LBP) often demonstrate pain sensitization, high degree of pain catastrophizing, and psychological distress. This study investigated whether pain sensitization mechanisms, the Pain Catastrophizing Scale (PCS), and Start Back Screening Tool were associated with pain in recurrent LBP patients 12 weeks after consulting their general practitioner (GP). In 45 LBP patients, pressure pain thresholds, temporal summation of pain (TSP), conditioned pain modulation (CPM), the Roland Morris Disability Questionnaire (RMDQ), and the PCS were assessed before consultation. Patients were classified into low to medium or high risk of poor prognosis on the basis of the Start Back Screening Tool. Worst pain within the last 24 hours was assessed on a visual analogue scale (VAS) at inclusion and 12 weeks after GP consultation. VAS scores were reduced after 12 weeks in the low-to-medium (N=30, P<0.05), but not the high-risk group (N=15, P=0.40). RMDQ was reduced after 12 weeks (P<0.001), but with no difference between the groups. PCS was reduced in the low-to-medium and the high-risk group (P<0.05). TSP was significantly higher at follow-up in the high-risk group compared with the low-to-medium-risk group (P<0.05). A linear regression model explained 54.9% of the variance in VAS scores at follow-up utilizing baseline assessments of TSP, RMDQ, and PCS. This study indicate that patients with LBP and high self-reported disability, high pain catastrophizing, and facilitated TSP assessed when consulting the GP might predictive poor pain progression 12 weeks after the consultation.

Using neuromuscular electrical stimulation in conjunction with ultrasound imaging technique to investigate lumbar multifidus muscle activation deficit

Lumbar multifidus muscle (LM) activation deficit has been proposed as a potential underlying mechanism responsible for recurrence episode of low back pain (LBP). The quantification of voluntary LM activation can provide a better understanding of the role of muscle activation deficit in LBP. The objective of this technical report is to propose a new approach using neuromuscular electrical stimulation (NMES) in combination with the ultrasound imaging technique (USI) to investigate the ability of individual to voluntarily activate the LM. We recruited ten participants with a recurrent LBP (rLBP) and twelve participants with no history of LBP (NoLBP). Theoretically, the superimposition of NMES on the LM during maximum voluntary isometric contraction (MVIC) should activate all motor units available in the LM. The percentage of LM activation (%LM) can be calculated by the changes of LM thickness during MVIC, divided by the changes of LM thickness during the combination of MVIC and NMES. This %LM was used to compare between groups. The individuals with rLBP had significantly lower %LM (p < 0.05) compared with the NoLBP counterpart (%LM = 72.4 and 92.9, respectively). Results demonstrate that this new approach can potentially differentiate %LM among individuals with rLBP and NoLBP. This new approach can be potentially used to 1) determine the extent of LM activation deficit, 2) identify the existence of muscle activation deficit in the LM, and 3) objectively measure the effect of the intervention designed to address the LM activation deficit.

Is intrinsic lumbar spine shape associated with lumbar disc degeneration? An exploratory study

BackgroundLumbar disc degeneration (LDD) is a condition associated with recurrent low back pain (LBP). Knowledge regarding effective management is limited. As a step towards the identification of risk, prognostic or potentially modifiable factors in LDD patients, the aim of this study was to explore the hypothesis that intrinsic lumbar spine shape is associated with LDD and clinical outcomes in symptomatic adults.Methods3 T MRI was used to acquire T2-weighted sagittal images (L1-S1) from 70 healthy controls and LDD patients (mean age 49 years, SD 11, range 31–71 years). Statistical Shape Modelling (SSM) was used to describe lumbar spine shape. SSM identified variations in lumbar shape as ‘modes’ of variation and quantified deviation from the mean. Intrinsic shape differences were determined between LDD groups using analysis of variance with post-hoc comparisons. The relationship between intrinsic shape and self-reported function, mental health and quality of life were also examined.ResultsThe first 7 modes of variation explained 91% of variance in lumbar shape. Higher LDD sum scores correlated with a larger lumbar lordosis (Mode 1 (55% variance), P = 0.02), even lumbar curve distribution (Mode 2 (12% variance), P = 0.05), larger anterior-posterior (A-P) vertebral diameter (Mode 3 (10% variance), P = 0.007) and smaller L4-S1 disc spaces (Mode 7 (2% variance), P ≤ 0.001). In the presence of recurrent LBP, LDD was associated with a larger A-P vertebral diameter (Mode 3) and a more even lumbar curvature with smaller L5/S1 disc spaces (Mode 4), which was significantly associated with patient quality of life (P = 0.002–0.04, rp = 0.43–0.61)).ConclusionsThis exploratory study provides new evidence that intrinsic shape phenotypes are associated with LDD and quality of life in patients. Longitudinal studies are required to establish the potential role of these risk or prognostic shape phenotypes.

An individualised self-management exercise and education program did not prevent recurrence of low back pain but may reduce care seeking: a randomised trial.

What is the effect of a McKenzie-based self-management exercise and education program on the risk of recurrence of low back pain (LBP) and on the impact of LBP? Randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. 262 adults recently recovered from an episode of LBP. The experimental group received a McKenzie-based self-management exercise and education program delivered over two individual sessions of 30 to 45 minutes with a physiotherapist, approximately 2 weeks apart. The control group received a single advice session over the phone. The primary outcome was time to first recurrence of an episode of activity-limiting LBP. Secondary outcomes included time to recurrence of any LBP, time to a recurrence causing care seeking and a composite measure of pain and function ('impact of LBP'). Participants were followed-up monthly for ≥ 12 months. The estimated effect of the experimental intervention on the risk of recurrence of an episode of: activity-limiting LBP was HR 1.11 (95% CI 0.80 to 1.54), any LBP was HR 0.95 (95% CI 0.72 to 1.26), and LBP for which care was sought was HR 0.69 (95% CI 0.46 to 1.04). The quarterly estimates of the experimental intervention's effect on impact of LBP and their 95% CIs were all within 4 points above or below 0 (no effect) on this scale from 8 to50. This study's best estimate is that a McKenzie-based self-management exercise and education program does not produce a worthwhile reduction in the risk of an activity-limiting episode of LBP; however, modestly reduced or moderately increased risk cannot be ruled out. It may markedly reduce the risk of an episode of LBP resulting in care seeking, but does not have any worthwhile effect on the impact of LBP over 12 months. ACTRN12616000926437.

Cohort profile: the AUstralian Twin BACK pain and physical activity study (AUTBACK study)

PurposeDespite the growing evidence that physical activity and familial factors play a role in low back pain (LBP), there is a lack of robust longitudinal studies that (1) investigate the...

Differences in psychological factors, disability and fatigue according to the grade of chronification in non-specific low back pain patients: A cross-sectional study.

Differences in pain processing, muscle structure and function have been reported in patients with low back pain (LBP) with different grades of pain chronicity. The present study aims to examine differences in psychological factors, disability and subjective fatigue between subgroups of LBP based on their chronification grade. Twenty-one healthy controls (HC) and 54 LBP patients (categorized based on the grades of chronicity into recurrent LBP (RLBP), non-continuous chronic LBP (CLBP), or continuous (CLBP)) filled out a set of self-reporting questionnaires. The Hospital Anxiety and Depression Scale (HADS) and Multidimensional Pain Inventory (MPI) scores indicated that anxiety, pain severity, pain interference and affective distress were lower in HC and RLBP compared to non-continuous CLBP. Anxiety scores were higher in non-continuous CLBP compared to RLBP, continuous CLBP and HC. The Pain Catastrophizing Scale for Helplessness (PSCH) was higher in non-continuous CLBP compared to HC. The Survey of Pain Attitudes (SOPA) showed no differences in adaptive and maladaptive behaviors across the groups. The Pain Disability Index (PDI) measured a higher disability in both CLBP groups compared to HC. Moreover, the Rolland Morris Disability Questionnaire (RMDQ) showed higher levels of disability in continuous CLBP compared to non-continuous CLBP, RLBP and HC. The Checklist Individual Strength (CIS) revealed that patients with non-continuous CLBP were affected to a higher extent by severe fatigue compared to continuous CLBP, RLBP and HC (subjective fatigue, concentration and physical activity). For all tests, a significance level of 0.05 was used. RLBP patients are more disabled than HC, but have a tendency towards a general positive psychological state of mind. Non-continuous CLBP patients would most likely present a negative psychological mindset, become more disabled and have prolonged fatigue complaints. Finally, the continuous CLBP patients are characterized by more negative attitudes and believes on pain, enhanced disability and interference of pain in their daily lives.

A Controlled Study on the Outcome of Inpatient and Outpatient Treatment of Low Back Pain. Part II. Effects on Physical Measurements Three Months After Treatment

Inpatient and outpatient treatments were compared with a control intervention in 288 men and 168 women, aged 35-54, who were at work, but suffered from chronic or recurrent low back pain. Physical measurements and back pain assessments were carried out before the intervention and at a 3-month follow-up. Physical fitness improved most in the inpatients, but the outpatients did not differ from the controls. Correlations between back pain and physical measurements indicated that increase of lumbar and hip mobility was more important than increase of trunk strength for subjective progress in these patients. Increased trunk extension strength correlated significantly with subjective progress in women, who also had higher correlations between improved physical fitness and progress than men.

TOPS – a randomized controlled trial of exercise and education to prevent recurrence of low back pain: statistical analysis plan

BackgroundThis a priori statistical analysis plan describes the methods of analysis for the Trial Of Prevention Strategies for low back pain (TOPS). ObjectivesTOPS aimed to investigate the effectiveness and cost-effectiveness of exercise and education classes compared with a minimal intervention control in preventing recurrence of low back pain (LBP) in people who have recently recovered from an episode of LBP. MethodsTOPS is a superiority, pragmatic, parallel-group randomized controlled trial with allocation concealment, blinded outcome assessors, and intention-to-treat analysis. Participants were randomized to a physical therapist-led exercise and education program for 12 weeks or minimal intervention. The primary outcome was days to recurrence of an episode of LBP. The three key secondary outcomes were days to recurrence of an episode of LBP resulting in (1) activity limitation, (2) care seeking for LBP; and (3) work absence of at least 1 day. Differences in survival curves for the primary (days to recurrence) and secondary outcome (days to LBP with activity limitation, days to care seeking due to LBP, and days to work absence due to LBP) will be compared using Cox regression. Hazard ratios (HRs) and median survival times with 95% confidence intervals (CI) will be calculated. The number of adverse events, including serious adverse events will be reported and the proportion of adverse events between groups will be compared using a Chi-squared test. DiscussionThis paper will provide a detailed description of the planned analyses for the TOPS trial. Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12615000939594).

Prevalence of Low Back Pain and Relationship to Mental Health Symptoms and Quality of Life After a Deployment-related Lower Limb Amputation

Retrospective, cross-sectional study. To assess the prevalence and association of low back pain (LBP) with psychosocial factors in Service members with amputations. LBP is a common secondary health condition after amputation with important implications related to function and quality of life. A growing body of evidence suggests that psychosocial factors influence LBP in patients without amputation. However, there is a dearth of information regarding the association of psychosocial factors and LBP after amputation. Seventy-nine individuals with lower limb amputations who were a part of the Wounded Warrior Recovery Project were included in the analysis. Data on posttraumatic stress disorder (PTSD), depression, and quality of life (QOL) were collected from the Wounded Warrior Recovery Project, while data on LBP and LBP chronicity were extracted from the Military Health System Data Repository. General linear models were utilized to analyze associations between LBP and psychosocial factors, while controlling for injury severity and time since amputation. In individuals with amputations, 19.0% had acute LBP and 49.4% had recurrent LBP. Individuals with amputations and recurrent LBP reported higher PTSD symptom severity compared with those without LBP (B = 9.213, P < 0.05). More severe depression symptoms were observed in those with amputations and recurrent LBP compared with those without LBP (B = 5.626, P < 0.05). Among individuals with amputations, those with recurrent LBP reported lower QOL compared with those without LBP (B = -0.058, P < 0.05). There were no differences in PTSD, depression or QOL in those with amputations with and without acute LBP. Presence of recurrent LBP after amputation appears to be associated with more severe PTSD and depression symptoms as well as lower QOL. Further research is needed to assess the efficacy of addressing psychosocial factors for improving pain and function in service members with amputations and LBP. 3.

Fear-avoidance beliefs are associated with exercise adherence: secondary analysis of a randomised controlled trial (RCT) among female healthcare workers with recurrent low back pain

BackgroundExercise is recommended for the treatment and management of low back pain (LBP) and the prevention of chronicity. Exercise adherence has been only modest in intervention studies among people with musculoskeletal pain. Fear-avoidance beliefs (FABs) are known to affect exercise adherence.The purpose was twofold: to examine which bio-psycho-social factors contributed to exercise adherence during a 6-month neuromuscular exercise intervention among female healthcare workers with recurrent LBP, and to investigate how exercising affects FABs at 6 and 12 months’ follow-up.MethodsSome 219 healthcare workers aged 30–55 years with mild-to-moderate re-current non-specific LBP were originally allocated into: 1) exercise, 2) counselling, 3) combined exercise and counselling, and 4) control groups. In the present secondary analysis, groups 1 and 3 (exercise only and exercise+counselling) were merged to be exercisers and groups 2 and 4 were merged to be non-exercisers. Baseline variables of the exercise compliers (≥24 times over 24 weeks; n = 58) were compared to those of the non-compliers (< 1 time/week, 0–23 times; n = 52). The effects of the exercise programme on FABs were analysed by a generalised linear mixed model according to the intention-to-treat principle (exercisers; n = 110 vs non-exercisers; n = 109) at three measurement points (baseline, 6, and 12 months). A per-protocol analysis compared the more exercised to the less exercised and non-exercisers.ResultsA low education level (p = 0.026), shift work (p = 0.023), low aerobic (p = 0.048) and musculoskeletal (p = 0.043) fitness, and high baseline physical activity-related FABs (p = 0.019) were related to low exercise adherence. The exercise programme reduced levels of both physical activity- and work-related FABs, and there was a dose response: FABs reduced more in persons who exercised ≥24 times compared to those who exercised 0–23 times.ConclusionHealthcare workers who had lower education and fitness levels, worked shifts, and had high physical activity-related FABs had a lower adherence to the 6-month neuromuscular exercise programme. Exercising with good adherence reduced levels of FABs, which have been shown to be linked with prolonged LBP. Motivational strategies should be targeted at persons with low education and fitness levels and high FABs in order to achieve better exercise adherence.

The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial

BackgroundA recent study showed that chiropractic patients had fewer days with bothersome (activity-limiting) low back pain (LBP) when receiving care at regular pre-planned intervals regardless of symptoms (‘maintenance care’, MC) compared to receiving treatment only with a new episode of LBP. Benefit varied across psychological subgroups. The aims of this study were to investigate 1) pain trajectories around treatments, 2) recurrence of new episodes of LBP, and 3) length of consecutive pain-free periods and total number of pain-free weeks, for all study participants as well as for each psychological subgroup.MethodsA secondary analysis of data from a randomized controlled trial of patients (n = 319) seeking chiropractic care for recurrent or persistent LBP used 52 weekly estimates of days with bothersome (activity-limiting) LBP. First, a generalized estimating equations analysis was used to compare the pain trajectory before and after the initial treatment in every new treatment period. Thereafter, a time-to-event analysis (using Cox regression) estimated time to/risk of a new LBP episode. The analyses were performed on i) all study participants and ii) separately for each psychological sub-group (named adaptive copers, interpersonally distressed and dysfunctional) classified by the West Haven-Yale Multidimensional Pain Inventory.ResultsPatients receiving MC had flat pain trajectories around each new treatment period and reported fewer days with pain compared to patients receiving the control intervention. The entire effect was attributed to the dysfunctional subgroup who reported fewer days with activity limiting pain within each new LBP episode as well as longer total pain-free periods between episodes with a difference of 9.8 weeks (CI 95% 3.3, 16.3) compared to the control group. There were no differences in the time to/risk of a new episode of LBP in either of the subgroups.ConclusionData support the use of MC in a stratified care model targeting dysfunctional patients for MC. For a carefully selected group of patients with recurrent and persistent LBP the clinical course becomes more stable and the number of pain-free weeks between episodes increases when receiving MC. Understanding how subgroups of patients are likely to be affected by MC may help align patients’ and clinicians’ expectations based on realistic outcomes.Trial registrationClinical trials.gov; NCT01539863; February 22, 2012.

Effect of increased relative stiffness of the lumbar spine on hamstring muscle stretching in individuals with a history of low back pain suspected to have a clinical lumbar instability: A randomized crossover design

BackgroundTheoretically, lumbopelvic stabilization techniques during hamstring muscle stretching could increase lumbar stiffness relative to hamstring muscle in individuals with a history of low back pain and suspected clinical lumbar instability. However, evidence to support this theory is limited. This study aimed to 1) determine changes in lumbopelvic, lumbar, and hip motions, and hamstring muscle length after stretching exercises with lumbopelvic stiffening or relaxing techniques, and 2) compare those changes between techniques. MethodsThis study used a randomized crossover design. Thirty-two participants with a history of low back pain and bilateral hamstring muscle tightness were recruited. The order of the first technique was randomly assigned. After a 2-day washout, participants were crossed over to the second technique. Motion data during active forward trunk bending and bilateral hamstring muscle length during passive knee extension were collected pre- and post-intervention. FindingsSignificant increases (P < 0.05) were found in bilateral hamstring muscle length for both techniques. However, stiffening technique demonstrated a significant decrease in lumbar motion (P < 0.05) and increase in hip motion (P < 0.05), while relaxing technique demonstrated trends showing increases in lumbar and hip motions (P = 0.134 and 0.115, respectively). The findings showed significantly greater improvement (P < 0.05) in lumbar and hip motions with stiffening technique. InterpretationThe findings suggest increased relative stiffness of the lumbar spine during hamstring muscle stretching can specifically lengthen bilateral hamstring muscle and decrease excessive lumbar motion. This stiffening technique may prevent excessive movement of the lumbar spine, thereby reducing the risk of recurrent low back pain.