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Findings From Current Research

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Flexion Mobilizations with Movement Techniques: The Immediate Effects on Range of Movement and Pain in Subjects with Low Back Pain.

Authors: Konstantinou K, Foster N, Rushton A, Baxter D, Wright C, Breen A.

Spinal Physiotherapy Specialist/Research Physiotherapist, Haywood Hospital/ Primary Care Sciences Research Centre, Keele University, UK. k.konstantinou@cphc.keele.ac.uk

OBJECTIVE: This study investigates the immediate effects of flexion mobilizations with movement techniques (MWMs) on spinal range of movement in individuals with low back pain and also their impact on pain. A preliminary attempt has been made to describe the clinical profiles of subjects who were thought to benefit from MWMs. METHOD: A small-scale explanatory study was conducted using a crossover design, placebo-controlled, with subjects and assessors blinded. After assessment by physiotherapists, 26 subjects with low back pain with pain on lumbar flexion, thought to be appropriate for treatment with MWMs, participated. Subjects received an MWM intervention and a placebo intervention in a randomized order. Lumbar spinal flexion and extension and pain during flexion were recorded immediately before and after each intervention, using double inclinometry and visual analogue scales. RESULTS: Mean spinal range of movement increased significantly with the MWM intervention, as compared with the placebo (true flexion: MWMs 49.2 degrees [SD 16.4], placebo 45.3 degrees [SD 14.1], P = .005; total flexion: MWMs 76.7 degrees [SD 22.4], placebo 69.7 degrees [SD 21.5], P = .005). Mean pain scores did not change. CONCLUSIONS: The MWMs produced statistically significant, but small, immediate spinal mobility increases but no pain reduction when compared with placebo. By introducing clinical judgment into the subject selection process for the trial, 19 (73%) of 26 subjects benefited from MWMs techniques in terms of range of movement and/or pain intensity, whereas 9 (35%) subjects showed such changes with the placebo intervention.

Journal: J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):178-85.
Adapted from PubMed; click here to access full journal article.

Three-Dimensional Kinetics of the Lumbar Spine and Hips in Low Back Pain Patients During Sit-to-Stand and Stand-to-Sit.

Authors: Shum GL, Crosbie J, Lee RY.

School of Physiotherapy, the University of Sydney, Sydney, Australia.

STUDY DESIGN: Experimental, biomechanical study to determine the kinetics of the lumbar spine and hips during sit-to-stand and stand-to-sit. OBJECTIVE: To investigate the effects of back pain, with and without limitation in straight leg raise, on the joint moment and power of the lumbar and hips during sit-to-stand and stand-to-sit. SUMMARY OF BACKGROUND DATA: Movements of the lumbar spine and hips, and their coordination have been reported to be affected by the presence of low back pain (LBP), especially in those with a positive straight leg raise. However, the literature has no information concerning moment and power characteristics of the lumbar spine and hips during sit-to-stand and stand-to-sit in such patients. METHODS: Twenty asymptomatic subjects, 20 LBP patients, and 20 patients with LBP and a positive straight leg raise sign were requested to perform the sit-to-stand and stand-to-sit activities. Electromagnetic sensors were attached to the body segments to measure their kinematics while 2 nonconductive force plates gathered ground reaction force data. Biomechanical models were used to determine the muscle moments and power at the lumbosacral (L5/S1) joint and hips. RESULTS: Muscle moments acting at the lumbar spine and hip in the sagittal plane were found to decrease in subjects with LBP, but there were significant increases in moments in other planes of motion. The power patterns of the spine and hips were also significantly altered, particularly in subjects with a positive straight leg raise sign. CONCLUSIONS: Back pain subjects exhibit compensatory movements and altered load sharing strategies during the sit-to-stand and stand-to-sit activities. Exercise therapy should take account of these changes so that the normal kinematic and kinetic characteristics of the spine and hips can be restored.

Journal: Spine. 2007 Apr 1;32(7):E211-9.
Adapted from PubMed; click here to access full journal article.

Prevalence of Facet Joint Pain in Chronic Low Back Pain in Postsurgical Patients by Controlled Comparative Local Anesthetic Blocks.

Authors: Manchikanti L, Manchukonda R, Pampati V, Damron KS, McManus CD.

Pain Management Center of Paducah, Paducah, KY.

Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. OBJECTIVE: To evaluate the prevalence of facet joint pain in patients with chronic low back pain (CLBP) after surgical intervention(s). DESIGN: A prospective, nonrandomized, consecutive study. SETTING: An ambulatory interventional pain management setting. PARTICIPANTS: The prevalence of facet joint pain was evaluated in patients with CLBP after various surgical intervention(s) referred to an interventional pain management practice. The sample was derived from 282 patients with persistent CLBP after various surgical intervention(s). Of these, 242 patients consented to undergo interventional techniques. A total of 117 consecutive patients with chronic, nonspecific low back pain, after lumbar surgical intervention(s) were evaluated with controlled, comparative local anesthetic blocks. INTERVENTIONS: Controlled, comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by .25% bupivacaine) under fluoroscopic visualization using 0.5mL to block each facet joint nerve. MAIN OUTCOME MEASURES: A positive response was defined as at least 80% reduction of pain with ability to perform previously painful movements. A positive response was considered to be pain relief from the lidocaine block lasting at least 1 hour or at least 2 hours or greater than duration of relief with lidocaine when bupivacaine was used. Controlled, comparative local anesthetic blocks were used to eliminate false-positive results. Valid information is only obtained by performing controlled blocks in the form of comparative local anesthetic blocks, in which, on 2 separate occasions, the same joint is anesthetized by using local anesthetics with different durations of action. If patients obtained appropriate response with both blocks, they were considered a positive. If they obtained appropriate response with lidocaine but not with bupivacaine, they were considered false-positive, whereas if the response was negative with lidocaine, they were considered negative. RESULTS: The prevalence of lumbar facet joint pain in patients with recurrent pain after various surgical intervention(s) was 16% (95% confidence interval, 9%-23%). The false-positive rate with a single block with lidocaine was 49%. CONCLUSIONS: Facet joints are clinically important pain generators in a small but significant proportion of patients with recurrent CLBP after various surgical intervention(s).

Journal: Arch Phys Med Rehabil. 2007 Apr;88(4):449-55.
Adapted from PubMed; click here to access full journal article.

Office Management of Chronic Pain in the Elderly.

Authors: Weiner DK.

Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Penn, USA. dweiner@pitt.edu

Chronic pain plagues older adults more than any other age group; thus, practitioners must be able to approach this problem with confidence and skill. This article reviews the assessment and treatment of the most common chronic nonmalignant pain conditions that affect older adults--myofascial pain, generalized osteoarthritis, chronic low back pain (CLBP), fibromyalgia syndrome, and peripheral neuropathy. Specific topics include essential components of the physical examination; how and when to use basic and advanced imaging in older adults with CLBP; a stepped care approach to treating older adults with generalized osteoarthritis and CLBP, including noninvasive and invasive management techniques; how to diagnose and treat myofascial pain; strategies to identify the older adult with fibromyalgia syndrome and avoid unnecessary "diagnostic" testing; pharmacological treatment for the older adult with peripheral neuropathy; identification and treatment of other factors such as dementia and depression that may significantly influence response to pain treatment; and when to refer the patient to a pain specialist. While common, chronic pain is not a normal part of aging, and it should be treated with an emphasis on improved physical function and quality of life.

Journal: Am J Med. 2007 Apr;120(4):306-15.
Adapted from PubMed; click here to access full journal article.

Advice for the Management of Low Back Pain: A Systematic Review of Randomized Controlled Trials.

Authors: Dianne Liddle S, Gracey JH, David Baxter G.

Health and Rehabilitation Sciences Research Institute, University of Ulster at Jordanstown, Shore Road, Newtownabbey Co. Antrim, BT37 OQB, Northern Ireland.

To synthesize the evidence relating to the effectiveness of advice, the relevance of its content and frequency, and to compare the advice being offered to acute, subacute and chronic low back pain (LBP) patients. A systematic review of Randomized Controlled Trials (RCTs) using advice, either alone or with another intervention. The QUOROM guidelines and the Cochrane Collaboration Back Review Group Guidelines for Systematic Reviews were followed throughout: methodological assessment identified RCTs of 'high' or 'medium' methodological quality, based on their inclusion of at least 50% of the specified internal validity criteria. Outcome measures were analyzed based on five recommended core outcome domains; pain, work disability, back-specific function, generic health status and satisfaction with care. Relevant RCTs (n=56) were scored for methodological quality; 39 RCTs involving 7347 patients qualified for inclusion, based upon their methodological quality. Advice as an adjunct to exercise was most effective for improving pain, back-specific function and work disability in chronic LBP but, for acute LBP, was no more effective for improving these outcomes than simple advice to stay active. Advice as part of a back school was most effective for improving back-specific function in subacute LBP; these trials generally demonstrated long-term positive results. Advice as an adjunct to exercise was the most common form of treatment for acute and chronic LBP; advice as part of a back school was most commonly used for subacute LBP. Fifteen percent of acute LBP trials had a positive outcome, compared to 86% and 74% of subacute and chronic LBP trials respectively. A wide variety of outcome measures were used, making valid comparisons between treatment outcomes difficult. The advice provided to patients with LBP within RCTs varied considerably depending on symptom duration. The findings of this review have important implications for clinical practice, and for the design of further clinical trials in this area. Advice to stay active is sufficient for acute LBP; however, it appears that RCTs do not commonly reflect these recommendations. No conclusions could be drawn as to the content and frequency of advice that is most effective for subacute LBP, due to the limited number and poor quality of RCTs in this area: this review provides preliminary support for advice as part of a back school approach. Given that the effectiveness of treatment for subacute symptoms will directly influence the development of chronicity, these results would suggest that education and awareness of the causes and consequences of back pain may be a valuable treatment component for this patient subgroup. For chronic LBP there is strong evidence to support the use of advice to remain active in addition to specific advice relating to the most appropriate exercise, and/or functional activities to promote active self-management. More investigation is needed into the role of follow-up advice for chronic LBP patients.

Journal: Man Ther. 2007 Mar 27;
Adapted from PubMed; click here to access full journal article.

Psychosocial Factors and Their Predictive Value in Chiropractic Patients with Low Back Pain: A Prospective Inception Cohort Study.

Authors: Langworthy JM, Breen AC.

ABSTRACT: BACKGROUND: Being able to estimate the likelihood of poor recovery from episodes of back pain is important for care. Studies of psychosocial factors in inception cohorts in general practice and occupational populations have begun to make inroads to these problems. However, no studies have yet investigated this in chiropractic patients. METHODS: A prospective inception cohort study of patients presenting to a UK chiropractic practice for new episodes of non-specific low back pain (LBP) was conducted. Baseline questionnaires asked about age, gender, occupation, work status, duration of current episode, chronicity, aggravating features and bothersomeness using Deyo's 'Core Set'. Psychological factors (fear-avoidance beliefs, inevitability, anxiety/distress, coping and co-morbidity were also assessed at baseline. Satisfaction with care, number of attendances and pain impact were determined at 6 weeks. Predictors of poor outcome were sought by the calculation of relative risk ratios. RESULTS: Most patients presented within 4 weeks of onset. Of 158 eligible and willing patients, 130 completed both baseline and 6 week follow-up questionnaires. Greatest improvements at 6 weeks were in interference with normal work (ES 1.12) and LBP bothersomeness (ES 1.37). Although most patients began with moderate-high back pain bothersomeness scores, few had high psychometric ones. Co-morbidity was a risk for high-moderate interference with normal work at 6 weeks (RR 2.37; 95% C.I. 1.15-4.74). An episode duration of >4 weeks was associated with moderate to high bothersomeness at 6 weeks (RR 2.07; 95% C.I. 1.19-3.38) and negative outlook (inevitability) with moderate to high interference with normal work (RR 2.56; 95% C.I. 1.08-5.08). CONCLUSION: Patients attending a private UK chiropractic clinic for new episodes of non-specific LBP exhibited few psychosocial predictors of poor outcome, unlike other patient populations that have been studied. Despite considerable bothersomeness at baseline, scores were low at follow-up. In this independent health sector back pain population, general health and duration of episode before consulting appeared more important to outcome than psychosocial factors.

Journal: Chiropr Osteopat. 2007 Mar 29;15(1):5
Adapted from PubMed; click here to access full journal article.

A Brief Pain Management Program Compared with Physical Therapy for Low Back Pain: Results from an Economic Analysis Alongside a Randomized Clinical Trial.

Authors: Whitehurst DG, Lewis M, Yao GL, Bryan S, Raftery JP, Mullis R, Hay EM.br>
Primary Care Musculoskeletal Research Centre, Keele University, Staffordshire, UK.

OBJECTIVE: Guidelines for the management of acute low back pain in primary care recommend early intervention to address psychosocial risk factors associated with long-term disability. We assessed the cost utility and cost effectiveness of a brief pain management program (BPM) targeting psychosocial factors compared with physical therapy (PT) for primary care patients with low back pain of <12 weeks' duration. METHODS: A total of 402 patients were randomly assigned to BPM or PT. We adopted a health care perspective, examining the direct health care costs of low back pain. Outcome measures were quality-adjusted life years (QALYs) and 12-month change scores on the Roland and Morris disability questionnaire. Resource use data related to back pain were collected at 12-month followup. Cost effectiveness was expressed as incremental ratios, with uncertainty assessed using cost-effectiveness planes and acceptability curves. RESULTS: There were no statistically significant differences in mean health care costs or outcomes between treatments. PT had marginally greater effectiveness at 12 months, albeit with greater health care costs (BPM pound142, PT pound195). The incremental cost-per-QALY ratio was pound2,362. If the UK National Health Service were willing to pay pound10,000 per additional QALY, there is only a 17% chance that BPM provides the best value for money. CONCLUSION: PT is a cost-effective primary care management strategy for low back pain. However, the absence of a clinically superior treatment program raises the possibility that BPM could provide an additional primary care approach, administered in fewer sessions, allowing patient and doctor preferences to be considered.

Journal: Arthritis Rheum. 2007 Mar 29;57(3):466-473
Adapted from PubMed; click here to access full journal article.




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