Back Pain Research: 2002-2006
     
J Emerg Med. 2006 Nov;31(4):365-70.
Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain.
Friedman BW, Holden L, Esses D, Bijur PE, Choi HK, Solorzano C, Paternoster J, Gallagher EJ.
Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York.

Although not recommended for low back pain, the efficacy of systemic corticosteroids has never been evaluated in a general low back pain population. To test the efficacy of systemic corticosteroids for Emergency Department (ED) patients with low back pain, a randomized, double-blind, placebo-controlled trial of long-acting methylprednisolone was conducted with follow-up assessment 1 month after ED discharge. Patients with non-traumatic low back pain were included if their straight leg raise test was negative. The primary outcome was a comparison of the change in a numerical rating scale (NRS) 1 month after discharge. Of 87 subjects randomized, 86 were successfully followed to the 1-month endpoint. The change in NRS between discharge and 1 month differed between the two groups by 0.6 (95% confidence interval -1.0 to 2.2), a clinically and statistically insignificant difference. Disability, medication use, and healthcare resources utilized were comparable in both groups. Corticosteroids do not seem to benefit patients with acute non-radicular low back pain.

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Rheumatology (Oxford). 2006 Oct 24; [Epub ahead of print]
Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: 'McKenzie' vs brief physiotherapy pain management.
Klaber Moffett J, Jackson DA, Gardiner ED, Torgerson DJ, Coulton S, Eaton S, Mooney MP, Pickering C, Green AJ, Walker LG, May S, Young S.
Institute of Rehabilitation, University of Hull, Hull, UK.

Objectives. Interventions that take psychosocial factors into account are recommended for patients with persistent back or neck pain. We compared the effectiveness of a brief physiotherapy pain management approach using cognitive-behavioural principles (Solution-Finding Approach--SFA) with a commonly used method of physical therapy (McKenzie Approach--McK). Methods. Eligible patients referred by GPs to physiotherapy departments with neck or back pain lasting at least 2 weeks were randomized to McK (n = 161) or to SFA (n = 154). They were further randomized to receive an educational booklet or not. The primary outcome was the Tampa Scale of Kinesiophobia (TSK) (Activity-Avoidance scale used as a proxy for coping) at 6 weeks, and 6 and 12 months. Results. Of 649 patients assessed for eligibility, 315 were recruited (219 with back pain, 96 with neck pain). There were no statistically significant differences in outcomes between the groups, except that at any time point SFA patients supported by a booklet reported less reliance on health professionals (Multidimensional Health Locus of Control Powerful Others Scale), while at 6 months McK patients showed slightly more improvement on activity-avoidance (TSK). At 6 weeks, patient satisfaction was greater for McK (median 90% compared with 70% for SFA). Both interventions resulted in modest but clinically important improvements over time on the Roland Disability Questionnaire Scores and Northwick Park Neck Pain Scores. Conclusions. The McK approach resulted in higher patient satisfaction overall but the SFA could be more cost-effective, as fewer (three vs four) sessions were needed.

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Spine. 2006 Oct 1;31(21):2409-14.
Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up.
Osterman H, Seitsalo S, Karppinen J, Malmivaara A.
Orton Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland. heikki.osterman@kolumbus.fi

STUDY DESIGN: Prospective randomized controlled trial. OBJECTIVE: To assess effectiveness of microdiscectomy in lumbar disc herniation patients with 6 to 12 weeks of symptoms but no absolute indication for surgery. SUMMARY OF BACKGROUND DATA: There is limited evidence in favor of discectomy for prolonged symptoms of lumbar disc herniation. However, only one randomized trial has directly compared discectomy with conservative treatment. METHODS: Fifty-six patients (age range, 20-50 years) with a lumbar disc herniation, clinical findings of nerve root compression, and radicular pain lasting 6 to 12 weeks were randomized to microdiscectomy or conservative management. Fifty patients (89%) were available at the 2-year follow-up. Leg pain intensity was the primary outcome measure. RESULTS: There were no clinically significant differences between the groups in leg or back pain intensity, subjective disability, or health-related quality of life over the 2-year follow-up, although discectomy seemed to be associated with a more rapid initial recovery. In a subgroup analysis, discectomy was superior to conservative treatment when the herniation was at L4-L5. CONCLUSIONS: Lumbar microdiscectomy offered only modest short-term benefits in patients with sciatica due to disc extrusion or sequester. Spinal level of the herniation may be an important factor modifying effectiveness of surgery, but this hypothesis needs verification.

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Arch Phys Med Rehabil. 2006 Oct;87(10):1310-7.
Continuous low-level heat wrap therapy for the prevention and early phase treatment of delayed-onset muscle soreness of the low back: a randomized controlled trial.
Mayer JM, Mooney V, Matheson LN, Erasala GN, Verna JL, Udermann BE, Leggett S.
U.S. Spine & Sport Foundation, San Diego, CA 92123, USA. jmayer2@san.rr.com

OBJECTIVE: To evaluate the effects of continuous low-level heat wrap therapy for the prevention and early phase treatment (ie, 0-48 h postexercise) of delayed-onset muscle soreness (DOMS) of the low back. DESIGN: Two prospective randomized controlled trials. SETTING: Outpatient medical facility. PARTICIPANTS: Sixty-seven subjects asymptomatic of back pain and in good general health (mean age, 23.5+/-6.6 y). INTERVENTIONS: Participants performed vigorous eccentric exercise to experimentally induce low back DOMS. Participants were assigned to 1 of 2 substudies (prevention and treatment) and randomized to 1 of 2 treatment groups within each substudy: prevention study (heat wrap, n=17; control [nontarget muscle stretch], n=18) and treatment study (heat wrap, n=16; cold pack, n=16). Interventions were administered 4 hours before and 4 hours after exercise in the prevention study and between hours 18 to 42 postexercise in the treatment study. MAIN OUTCOME MEASURES: To coincide with the expected occurrence of peak symptoms related to exercise-induced low back DOMS, hour 24 postexercise was considered primary. Pain intensity (prevention) and pain relief (treatment) were primary measures, and self-reported physical function and disability were secondary measures. RESULTS: In the prevention study, at hour 24 postexercise, pain intensity, disability, and deficits in self-reported physical function in subjects with the heat wrap were reduced by 47% (P<.001), 52.3% (P=.029), and 45% (P=.013), respectively, compared with the control group. At hour 24 in the treatment study, postexercise, pain relief with the heat wrap was 138% greater (P=.026) than with the cold pack; there were no differences between the groups in changes in self-reported physical function and disability. CONCLUSIONS: In this small study, continuous low-level heat wrap therapy was of significant benefit in the prevention and early phase treatment of low back DOMS.

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Scand J Rheumatol. 2006 Sep-Oct;35(5):363-7.
Therapy outcome after multidisciplinary treatment for chronic neck and chronic low back pain: a prospective clinical study in 365 patients.
Buchner M, Zahlten-Hinguranage A, Schiltenwolf M, Neubauer E.
Department of Orthopaedic Surgery, University of Heidelberg, Germany.

Objectives: This prospective longitudinal clinical study analyses the therapy outcome of 365 patients with either chronic neck (n = 134) or low back (n = 231) pain treated with a multidisciplinary biopsychosocial therapy approach.Methods: Patients with chronic neck pain (NP) or low back pain (LBP) for 3 months or longer, corresponding sick leave for longer than 6 weeks, and clearly defined inclusion and exclusion criteria underwent a 3-week standardized inpatient multidisciplinary biopsychosocial therapy. Baseline sociodemographic, occupational, functional, and psychological data at entry into the study (T0) were comparable in both groups. At the 6-month follow-up (T1), five different therapy outcomes were analysed in both groups: back-to-work status, generic health status (the 36-item Short Form Health Survey, SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy.Results: Both treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up there were no significant differences between the group with chronic NP and the group with chronic LBP in the outcome criteria back-to-work status, improvement of health status and functional capacity, satisfaction with therapy, and reduction of pain.Conclusion: Evaluation of the main results of this study suggests that patients with chronic NP also derive significant benefit from a multidisciplinary treatment strategy, demonstrated in the literature so far mainly for patients with chronic LBP.

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Pain Med. 2006 Sep-Oct;7(5):435-9.
Pulsed radiofrequency treatment of the lumbar medial branch for facet pain: a retrospective analysis.
Lindner R, Sluijter ME, Schleinzer W.
Department of Anesthesiology, Intensive Care and Pain Treatment, The Swiss Paraplegic Center, Nottwil, Switzerland.

BACKGROUND: The use of pulsed radiofrequency (PRF) for treatment of the medial branch is controversial. STUDY DESIGN: A retrospective study of the results of PRF treatment of the medial branch in 48 patients with chronic low back pain was carried out. Patients who did not respond were offered treatment with conventional radiofrequency heat lesions. PATIENT MATERIAL: Patients were included who had low back pain and >50% pain relief following a diagnostic medial branch block. The mean age was 53.1 +/- 13.5 years, the mean duration of pain was 11.4 +/- 10.9 years (range 2-50). Nineteen patients had undergone surgery. METHODS: Pain scores on a numeric rating scale of 1-10 were noted before and after the diagnostic nerve block, before the procedure, and at 1-month and 4-month follow-up. PRF was applied for 2 minutes at a setting of 2 x 20 ms/s and 45 V at a minimum of two levels using a 22G electrode with a 5 mm active tip. Heat lesions were made at 80 degrees C for 1 minute. OUTCOME DEFINITION: A successful outcome was defined as a >60% improvement on the numeric rating scale at 4-month follow-up. RESULTS: In 21/29 nonoperated patients and 5/19 operated patients, the outcome was successful. In the unsuccessful patients who were subsequently treated with heat lesions, the success rate was 1/6. CONCLUSION: The setup of our study does not permit a comparison with the results of continuous radiofrequency (CRF) for the same procedure, other than the detection of an obvious trend. When comparing our results with various studies on CRF of the medial branch such a trend could not be found. Based on these retrospective data, prospective and randomized trials, for example, radiofrequency vs PRF are justified.

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J Rheumatol Suppl. 2006 Sep;78:24-31.
Treatment of ankylosing spondylitis.
Clegg DO.
Rheumatology Section, Salt Lake City Veterans Health Care System, University of Utah School of Medicine, USA. daniel.clegg@hsc.utah.edu

Ankylosing spondylitis (AS) is a condition characterized by inflammatory back pain and associated with considerable disability and diminished quality of life in affected individuals. The condition is undertreated in part due to a delay in diagnosis and limited therapeutic interventions. Although traditional treatment approaches (physical therapy, exercise, patient education, nonsteroidal antiinflammatory drugs) remain important components of the management of AS, the demonstrated efficacy of tumor necrosis factor-a (TNF-a) antagonists such as etanercept and infliximab have allowed clinicians to more effectively manage this condition. These targeted therapies have demonstrated rapid and consistent effectiveness in reducing the axial and peripheral symptoms of AS, slowing disease progression, and improving patient function and quality of life. Appropriate and timely use of TNF-a antagonists offers additional options for patients with active AS who are inadequately controlled with conventional treatment.

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Pediatr Rehabil. 2006 Jul-Sep;9(3):174-84.
The role of rehabilitation in juvenile low back disorders.
Ippolito E, Versari P, Lezzerini S.
Department of Orthopaedic Surgery, University of Rome Tor Vergata, Roma, Italy. ippolito@med.uniroma2.it

Both children and adolescents are frequently affected by low back pain--mainly when they are involved in sporting activities--but they rarely ask for medical help, because their symptoms are often mild and self-resolving. However, in the young patients who seek orthopaedic evaluation, especially in referral centres, there is a high incidence of organic causes of their back pain. Mechanical, developmental, inflammatory and tumoural or tumour-like disorders are the most frequent aetiologic factors. A diagnosis of psychosomatic back pain should be made only when all the other possible organic causes have been excluded. Rehabilitation is part of the treatment of low back disorders in children and adolescents. Postural low back pain is likely to be resolved by physical therapy alone. In other disorders that initially require medical, orthotic or surgical treatment, rehabilitation plays an important role either in combination with them or as a subsequent treatment.

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Clin J Pain. 2006 Jul-Aug;22(6):526-31.
Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study.
Muehlbacher M, Nickel MK, Kettler C, Tritt K, Lahmann C, Leiberich PK, Nickel C, Krawczyk J, Mitterlehner FO, Rother WK, Loew TH, Kaplan P.
University Clinic for Psychiatry 1, PMU, Salzburg, Austria.

OBJECTIVE: Chronic low back pain (CLBP) is a widespread ailment. The aim of this study was to assess the efficacy of topiramate in the treatment of CLBP and the changes in anger status and processing, body weight, subjective pain-related disability and health-related quality of life during the course of treatment. METHODS: We conducted a 10-week, randomized, double-blind, placebo-controlled study of topiramate in 96 (36 women) patients with CLBP. The subjects were randomly assigned to topiramate (n=48) or placebo (n=48). Primary outcome measures were changes on the McGill Pain Questionnaire, State-Trait Anger Expression Inventory, Oswestry Low Back Pain Disability Questionnaire and SF-36 Health Survey scales, and in body weight. RESULTS: In comparison with the placebo group (according to the intent-to-treat principle), significant changes on the pain rating index of McGill Pain Questionnaire (Ps<0.001), State-Trait Anger Expression Inventory Scales (all Ps<0.001), Oswestry Low Back Pain Disability Questionnaire (P<0.001), and SF-36 Health Survey scales (all P<0.001, except on the role-emotional scale) were observed after 10 weeks in the patients treated with topiramate. Weight loss was also observed and was significantly more pronounced in the group treated with topiramate than in those treated with placebo (P<0.001). Most patients tolerated topiramate relatively well but 2 patients dropped out because of side effects. DISCUSSION: Topiramate seems to be a relatively safe and effective agent in the treatment of CLBP. Significantly positive changes in pain sensitivity, anger status and processing, subjective disability, health-related quality of life, and loss of weight were observed.

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Clin J Pain. 2006 Jul-Aug;22(6):505-11.
Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial.
Nordeman L, Nilsson B, Moller M, Gunnarsson R.
Physiotherapy Unit, Primary Health Care, Alingsas Municipality, Sweden. lena.nordeman@vgregion.se

OBJECTIVES: To evaluate the effects of early access (EA) to physical therapy treatment for patients with subacute low back pain compared to access with a 4-week waiting list. DESIGN: A prospective, randomized clinical trial. SETTING: Primary health care. PATIENTS: Sixty consecutive patients with subacute low back pain. INTERVENTIONS: Patients were randomized either to EA within 2 days for physical examination and individualized physical therapy treatment (n=32) or a control group with a 4-week waiting list (n=28). OUTCOME MEASURES: Self-administrated questionnaires were used for assessment at inclusion, at discharge, and at 6 months. Primary outcome measure was pain intensity assessed by Borg category scale for ratings of perceived pain. Secondary outcomes included the Orebro musculoskeletal pain screening questionnaire, the Roland and Morris disability questionnaire, sick-leave, visits to health care, and physical therapy. RESULTS: The results showed no significant differences in pain between the groups at discharge. At 6 months, the reduction of pain was significantly greater in the EA group compared to the control group (P=0.025). Changes in secondary outcome measures were not significantly different between groups. CONCLUSIONS: This study indicated that EA to physical therapy resulted in greater improvement in perceived pain at 6 months compared to later access. In this study, EA to physical therapy could be introduced by reorganization without additional resources.

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Eur Spine J. 2006 Jul 27; [Epub ahead of print]
Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain.
Soegaard R, Christensen FB, Christiansen T, Bunger C.
Spine Unit, Orthopaedic Research Lab., University Hospital of Aarhus, Aarhus, Denmark, rikke.sogaard@ki.au.dk.

Although cost-effectiveness is becoming the foremost evaluative criterion within health service management of spine surgery, scientific knowledge about cost-patterns and cost-effectiveness is limited. The aims of this study were (1) to establish an activity-based method for costing at the patient-level, (2) to investigate the correlation between costs and effects, (3) to investigate the influence of selected patient characteristics on cost-effectiveness and, (4) to investigate the incremental cost-effectiveness ratio of (a) posterior instrumentation and (b) intervertebral anterior support in lumbar spinal fusion. We hypothesized a positive correlation between costs and effects, that determinants of effects would also determine cost-effectiveness, and that posterolateral instrumentation and anterior intervertebral support are cost-effective adjuncts in posterolateral lumbar fusion. A cohort of 136 consecutive patients with chronic low back pain, who were surgically treated from January 2001 through January 2003, was followed until 2 years postoperatively. Operations took place at University Hospital of Aarhus and all patients had either (1) non-instrumented posterolateral lumbar spinal fusion, (2) instrumented posterolateral lumbar spinal fusion, or (3) instrumented posterolateral lumbar spinal fusion + anterior intervertebral support. Analysis of costs was performed at the patient-level, from an administrator's perspective, by means of Activity-Based-Costing. Clinical effects were measured by means of the Dallas Pain Questionnaire and the Low Back Pain Rating Scale at baseline and 2 years postoperatively. Regression models were used to reveal determinants for costs and effects. Costs and effects were analyzed as a net-benefit measure to reveal determinants for cost-effectiveness, and finally, adjusted analysis (for non-random allocation of patients) was performed in order to reveal the incremental cost-effectiveness ratios of (a) posterior instrumentation and (b) anterior support. The costs of non-instrumented posterolateral spinal fusion were estimated at DKK 88,285(95% CI 81,369;95,546), instrumented posterolateral spinal fusion at DKK 94,396(95% CI 89,865;99,574) and instrumented posterolateral lumbar spinal fusion + anterior intervertebral support at DKK 120,759(95% CI 111,981;133,738). The net-benefit of the regimens was significantly affected by smoking and functional disability in psychosocial life areas. Multi-level fusion and surgical technique significantly affected the net-benefit as well. Surprisingly, no correlation was found between treatment costs and treatment effects. Incremental analysis suggested that the probability of posterior instrumentation being cost-effective was limited, whereas the probability of anterior intervertebral support being cost-effective escalates as willingness-to-pay per effect unit increases. This study reveals useful and hitherto unknown information both about cost-patterns at the patient-level and determinants of cost-effectiveness. The overall conclusion of the present investigation is a recommendation to focus further on determinants of cost-effectiveness. For example, patient characteristics that are modifiable at a relatively low expense may have greater influence on cost-effectiveness than the surgical technique itself-at least from an administrator's perspective.

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Occup Environ Med. 2006 Jul 17; [Epub ahead of print]
The effectiveness of graded activity for low back pain in occupational healthcare.
Steenstra IA, Anema H, Bongers PM, De Vet HC, Knol DL, Mechelen WV.
Coronel Institute, Netherlands.

Context. Low back pain is a common medical and social problem associated with disability and absence from work. Knowledge on effective return to work (RTW) interventions is scarce. Objective. To determine the effectiveness of graded activity as part of a multi stage RTW program. Design. Randomized controlled trial. Setting. Occupational health care. Subjects. 112 workers absent from work for more than 8 weeks due to low back pain, were randomized to either graded activity (n=55) or usual care (n=57). Intervention. Graded activity, a physical exercise program aiming at RTW based on operant-conditioning behavioral principles. Main outcome measures. The number of days off work until first RTW for more then 28 days, total number of days on sick leave during follow up, functional status and severity of pain. Follow up was 26 weeks. Results. Graded activity prolonged RTW. Median time until RTW was equal to the total number of days on sick leave and was 139 (IQR=69) days in the graded activity group and 111 (IQR=76) days in the usual care group (hazard ratio= 0.52 (95% CI=[0.32-0.86]). An interaction between a prior workplace intervention and graded activity, together with a delay in the start of the graded activity intervention, explained most of the delay in RTW (hazard ratio= 0.86, 95% CI= [0.40-1.84] without prior intervention and 0.39, 95% CI=[0.19- 0.81] with prior intervention). Graded activity did neither improve pain nor functional status clinically significantly. Conclusions. Graded activity was not effective on any of the outcome measures. Different interventions combined can lead to a delay in RTW. Delay in referral to graded activity delays RTW. In implementing graded activity special attention should be paid to structure and process of care.

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Spine. 2006 Jul 15;31(16):1761-9.
Prevention of low back pain in female eldercare workers: randomized controlled work site trial.
Jensen LD, Gonge H, Jors E, Ryom P, Foldspang A, Christensen M, Vesterdorf A, Bonde JP.
Department of Occupational Medicine, University Hospital of Aarhus, Aarhus, Denmark. lodj@ofir.dk

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To evaluate the effectiveness of an ergonomic and psychosocial intervention in reducing low back pain (LBP) among health care workers. SUMMARY OF BACKGROUND DATA: LBP and injuries are reported frequently among health care workers worldwide. Improvement of person-transfer techniques is the preferred tool in the prevention of both. Although popular, to our knowledge, any effect has not been documented in controlled trials. METHODS: Study participants were eldercare workers from 19 eldercare groups randomly assigned to the transfer technique, stress management, or reference arm. A total of 163 individuals (79% of the source population) participated in both baseline and follow-up after 2 years. Outcome was intra-individual change in rating of LBP during the past 3 and 12 months. RESULTS: We found no difference in LBP in any of the intervention arms over the study period. CONCLUSION: The study showed no effect of a transfer technique or stress management program targeting LBP. Thus, there is a need for discussing other priorities in the prevention of LBP among health care workers.

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Man Ther. 2006 Jul 11; [Epub ahead of print]
A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain.
Childs JD, Flynn TW, Fritz JM.
US Army-Baylor University Doctoral Program in Physical Therapy, 3151 Scott Rd., Rm 2307, Fort Sam Houston, TX 78234, USA.

The purpose of this study was to determine if patients who do not receive manipulation for their low back pain (LBP) are at an increased risk for worsening disability compared to patients receiving an exercise intervention without manipulation. One hundred and thirty-one consecutive patients with LBP were randomly assigned to receive manipulation and an exercise intervention (n=70) or an exercise intervention without manipulation (n=61). Patients were classified as to whether they had experienced a worsening in disability upon follow-up. Relative risk and number needed to treat (NNT) statistics and associated 95% confidence intervals (CI) were calculated. Patients who completed the exercise intervention without manipulation were eight (95% CI: 1.1, 63.5) times more likely to experience a worsening in disability than patients who received manipulation. The NNT with manipulation to prevent one additional patient from experiencing a worsening in disability was 9.9 (95% CI: 4.9, 65.3) and 4 weeks with manipulation was 11.6 (95% CI: 5.2, 219.2). The results of this study offer an additional perspective for considering the risks and benefits of spinal manipulation and help to inform the integration of current evidence for spinal manipulation into healthcare policy.

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Am J Epidemiol. 2006 Jun 23; [Epub ahead of print]
Pragmatic Randomized Trial Evaluating the Clinical and Economic Effectiveness of Acupuncture for Chronic Low Back Pain.
Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, Liecker B, Linde K, Wegscheider K, Willich SN.
Institute for Social Medicine, Epidemiology, and Health Economics, Charite University Medical Center, Berlin, Germany.

In a randomized controlled trial plus a nonrandomized cohort, the authors investigated the effectiveness and costs of acupuncture in addition to routine care in the treatment of chronic low back pain and assessed whether the effects of acupuncture differed in randomized and nonrandomized patients. In 2001, German patients with chronic low back pain were allocated to an acupuncture group or a no-acupuncture control group. Persons who did not consent to randomization were included in a nonrandomized acupuncture group. All patients were allowed to receive routine medical care in addition to study treatment. Back function (Hannover Functional Ability Questionnaire), pain, and quality of life were assessed at baseline and after 3 and 6 months, and cost-effectiveness was analyzed. Of 11,630 patients (mean age = 52.9 years (standard deviation, 13.7); 59% female), 1,549 were randomized to the acupuncture group and 1,544 to the control group; 8,537 were included in the nonrandomized acupuncture group. At 3 months, back function improved by 12.1 (standard error (SE), 0.4) to 74.5 (SE, 0.4) points in the acupuncture group and by 2.7 (SE, 0.4) to 65.1 (SE, 0.4) points among controls (difference = 9.4 points (95% confidence interval 8.3, 10.5); p < 0.001). Nonrandomized patients had more severe symptoms at baseline and showed improvements in back function similar to those seen in randomized patients. The incremental cost-effectiveness ratio was {euro}10,526 (euros) per quality-adjusted life year. Acupuncture plus routine care was associated with marked clinical improvements in these patients and was relatively cost-effective.

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Z Orthop Ihre Grenzgeb. 2006 May-Jun;144(3):255-66.
[Multidisciplinary orthopedic rehabilitation program in patients with chronic back pain and need for changing job situation - long-term effects of a multimodal, multidisciplinary program with activation and job development.]
[Article in German]
Greitemann B, Dibbelt S, Buschel C.
Klinik fur orthopadisch-rheumatologische Erkrankungen, Klinik Munsterland, Bad Rothenfelde.

BACKGROUND: According to a recent review by Huppe and Raspe effects of multidisciplinary treatment programs for patients with chronic low back pain in Germany seem to be rather weak and not to have persisting effects . Factors which could counteract possible benefits of treatment are, among others, psychic and job-related stresses and strains persisting after treatment. A multidisciplinary, in-patient treatment program for patients with chronic low back pain, therefore, was amended by multidisciplinary diagnosis and assignment and measures to support vocational solutions. METHOD: To evaluate the effects of the multidisciplinary program in comparison to a control group with the usual care, a prospective longitudinal study was conducted. 307 patients were assigned to the multidisciplinary in-patient treatment program, whereas 176 patients with comparable complaints had the standard rehabilitation program. Besides the full sample, we analyzed a subgroup of patients with chronic low back pain. RESULTS: We found positive moderate and strong effects in the intervention group concerning function, pain, psychic strains as well as the number of sick days and return to work rates 10 months after discharge. Effects in the intervention group exceeded the effects achieved in the control group. Beside the full sample, we analyzed a subgroup of patients with chronic low back pain, who received an intense activating group treatment. Also in this subgroup we found moderate and strong effects of treatment superior to those in the control group for function, psychic strains and sick days. CONCLUSION: We attribute these persisting and superior effects in the treatment group to an efficient treatment of occupational and psychic problems as well as to more homogeneous treatment groups attained by a multidisciplinary diagnosis and team-based assignment. They also show the significance of in-patient-treatment which is effective, when - based on multidisciplinary diagnosis - differential treatment groups can be formed.

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Surg Neurol. 2006 Apr;65(4):326-31.
Omega-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain.
Maroon JC, Bost JW.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

BACKGROUND: The use of NSAID medications is a well-established effective therapy for both acute and chronic nonspecific neck and back pain. Extreme complications, including gastric ulcers, bleeding, myocardial infarction, and even deaths, are associated with their use. An alternative treatment with fewer side effects that also reduces the inflammatory response and thereby reduces pain is believed to be omega-3 EFAs found in fish oil. We report our experience in a neurosurgical practice using fish oil supplements for pain relief. METHODS: From March to June 2004, 250 patients who had been seen by a neurosurgeon and were found to have nonsurgical neck or back pain were asked to take a total of 1200 mg per day of omega-3 EFAs (eicosapentaenoic acid and decosahexaenoic acid) found in fish oil supplements. A questionnaire was sent approximately 1 month after starting the supplement. RESULTS: Of the 250 patients, 125 returned the questionnaire at an average of 75 days on fish oil. Seventy-eight percent were taking 1200 mg and 22% were taking 2400 mg of EFAs. Fifty-nine percent discontinued to take their prescription NSAID medications for pain. Sixty percent stated that their overall pain was improved, and 60% stated that their joint pain had improved. Eighty percent stated they were satisfied with their improvement, and 88% stated they would continue to take the fish oil. There were no significant side effects reported. CONCLUSIONS: Our results mirror other controlled studies that compared ibuprofen and omega-3 EFAs demonstrating equivalent effect in reducing arthritic pain. omega-3 EFA fish oil supplements appear to be a safer alternative to NSAIDs for treatment of nonsurgical neck or back pain in this selective group.

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Disabil Rehabil. 2006 Apr;28(7):437-46.
Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up.
Westman A, Linton SJ, Theorell T, Ohrvik J, Wahlen P, Leppert J.
Department of Occupational and Environmental Medicine, Orebro University Hospital, Orebro.

Purpose. There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.Method. The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.Results. Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.Conclusions. These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.

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Spine J. 2006 Mar-Apr;6(2):131-7. Epub 2006 Feb 3.
Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.
Santilli V, Beghi E, Finucci S.
Direttore Cattedra Medicina Fisica e Riabilitativa, Universita di Roma "La Sapienza", P.le Aldo Moro 5, Roma, 00185, Italy.

BACKGROUND CONTEXT: Acute back pain and sciatica are major sources of disability. Many medical interventions are available, including manipulations, with conflicting results. PURPOSE: To assess the short- and long-term effects of spinal manipulations on acute back pain and sciatica with disc protrusion. STUDY DESIGN/SETTING: Randomized double-blind trial comparing active and simulated manipulations in rehabilitation medical centers in Rome and suburbs. PATIENT SAMPLE: 102 ambulatory patients with at least moderate pain on a visual analog scale for local pain (VAS1) and/or radiating pain (VAS2). OUTCOME MEASURES: Pain-free patients at end of treatment; treatment failure (proportion of patients stopping the assigned treatment for lack of effect on pain); number of days with no, mild, moderate, or severe pain; quality of life; number of days on nonsteroidal anti-inflammatory drugs; number of drug prescriptions; VAS1 and VAS2 scores; quality of life and psychosocial findings; and reduction of disc protrusion on magnetic resonance imaging. METHODS: Manipulations or simulated manipulations were done 5 days per week by experienced chiropractors, with a number of sessions which depended on pain relief or up to a maximum of 20, using a rapid thrust technique. Patients were assessed at admission and at 15, 30, 45, 90, and 180 days. At each visit, all indicators of pain relief were used. RESULTS: A total of 64 men and 38 women aged 19-63 years were randomized to manipulations (53) or simulated manipulations (49). Manipulations appeared more effective on the basis of the percentage of pain-free cases (local pain 28 vs. 6%; p<.005; radiating pain 55 vs. 20%; p<.0001), number of days with pain (23.6 vs. 27.4; p<.005), and number of days with moderate or severe pain (13.9 vs. 17.9; p<.05). Patients receiving manipulations had lower mean VAS1 (p<.0001) and VAS2 scores (p<.001). A significant interaction was found between therapeutic arm and time. There were no significant differences in quality of life and psychosocial scores. There were only two treatment failures (manipulation 1; simulated manipulation 1) and no adverse events. CONCLUSIONS: Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.

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Spine. 2006 Mar 15;31(6):653-7.
A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect.
Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S.
Division of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA. carragee@stanford.edu

STUDY DESIGN: Prospective observational study with historical control. The prospective study population consisted of 30 patients undergoing a posterior lumbar subtotal discectomy for lumbar disc herniation. This group was compared to a historical cohort of 46 patients treated with limited discectomy alone. OBJECTIVE: To compare clinical outcomes after limited versus subtotal discectomy for lumbar disc herniations. SUMMARY OF BACKGROUND DATA: Large posterior anular defects found at posterior discectomy have been associated with more frequent reherniation when treated with limited discectomy (i.e., removing only extruded or loose intervertebral fragments). A trial of more aggressive discectomy (subtotal) was undertaken to determine if the rate of reherniation could be decreased with this technique. METHODS: A total of 30 patients undergoing a posterior lumbar discectomy for lumbar disc herniation were treated with an aggressive (subtotal) resection of intervertebral disc material after removal of the extruded or protruded fragments. This group was compared against a historical cohort of 46 patients treated with limited discectomy alone. Reherniation rates and clinical outcomes were determined by independent evaluation at 6, 12, and 24 months after surgery. RESULTS: The reherniation rate in the limited discectomy group was 18% versus 9% in the subtotal discectomy group at follow-up (P = 0.1). However, the back pain (visual analog scale) (P = 0.02) and Oswestry scores (P = 0.06) were worse in the subtotal discectomy group at 12-month follow-up. Time to return to work was longer, and pain medication usage was higher in the subtotal discectomy group at 12-month follow-up. Despite a trend toward a higher reherniation rate, the patient satisfaction at 2-year follow-up was higher in the limited discectomy group. CONCLUSIONS: The more aggressive removal of remaining intervertebral disc material may decrease the risk of reherniation, but the overall outcome was less satisfactory, especially during the first year after surgery.

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Spine. 2006 Mar 15;31(6):611-21; discussion 622.
A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study.
Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM.
Department of Epidemiology, UCLA School of Public Health, Los Angeles, CA, USA. ehurwitz@hawaii.edu

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care. SUMMARY OF BACKGROUND DATA: Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking. METHODS: A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms. RESULTS: Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months. CONCLUSIONS: Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

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J Fam Pract. 2006 Mar;55(3):235-6.
Does psychiatric treatment help patients with intractable chronic pain?
Kerns JW, White A, Nashelsky J, Sherman S.
Department of Family Medicine, Virginia Commonwealth University, Winchester, VA USA.

Tricyclic antidepressants and intensive multidisciplinary programs are moderately effective for reducing chronic back pain; tricyclics are also effective for diabetic neuropathy and irritable bowel syndrome (strength of recommendation [SOR]: A, meta-analyses and multiple small randomized controlled trials). Cognitive therapies are modestly effective for reducing pain in the following: chronic back pain, other chronic musculoskeletal disorders including rheumatoid arthritis (SOR: B, multiple meta-analyses with significant heterogeneity), and for chronic cancer pain (SOR: B, 1 meta-analysis of various quality studies).

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Patient Educ Couns. 2006 Mar 13; [Epub ahead of print]
Preventing chronic back pain: Evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain.
Gohner W, Schlicht W.
University of Freiburg, Department of Sport and Sport Sciences, Schwarzwaldstr. 175, 79117 Freiburg, Germany.

OBJECTIVE: For long-term treatment effects, patients with subacute back pain need to adhere to treatment recommendations beyond the prescribed exercise treatment. Adherence rates are as low as 30%, so we developed a cognitive-behavioural training programme to enhance patients' self-efficacy, maximise severity perceptions and reduce barrier perceptions. METHOD: A 2x4 (groupxtime) repeated measurement design was applied. Forty-seven patients with non-specific, subacute back pain were randomly assigned to a training group (exercise treatment plus cognitive-behavioural training programme) or a control group (exercise treatment only). RESULTS: Repeated measures ANOVA revealed significant main and interaction effects; the training group reported enhanced self-efficacy and severity perceptions, reduced barrier perceptions, and self-reported that they exercised more often than the control group over time. However, no group differences regarding pain intensity emerged. CONCLUSION: Our findings demonstrate that a short and inexpensive cognitive-behavioural training programme is an effective tool to enable back pain patients to follow treatment recommendations on a regular basis. PRACTICE IMPLICATIONS: The short and simple intervention can easily be conducted by personnel, other than psychologists, i.e., physiotherapists.

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Neurosurgery. 2006 Mar;58(3):481-96; discussion 481-96.
Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience.
Kumar K, Hunter G, Demeria D.
Section of Neurosurgery, Department of Surgery, University of Saskatchewan, Regina General Hospital, Regina, Canada. krishna.kumar@rqhealth.ca

OBJECTIVE: To present an in-depth analysis of clinical predictors of outcome including age, sex, etiology of pain, type of electrodes used, duration of pain, duration of treatment, development of tolerance, employment status, activities of daily living, psychological status, and quality of life. Suggestions for treatment of low back pain with a predominant axial component are addressed. We analyzed the complications and proposed remedial measures to improve the effectiveness of this modality. METHODS: Study group consists of 410 patients (252 men, 58 women) with a mean age of 54 years and a mean follow-up period of 97.6 months. All patients were gated through a multidisciplinary pain clinic. The study was conducted over 22 years. RESULTS: The early success rate was 80% (328 patients), whereas the long-term success rate of internalized patients was 74.1% (243 patients) after the mean follow-up period of 97.6 months. Hardware-related complications included displaced or fractured electrodes, infection, and hardware malfunction. Etiologies demonstrating efficacy included failed back syndrome, peripheral vascular disease, angina pain, complex regional pain syndrome I and II, peripheral neuropathy, lower limb pain caused by multiple sclerosis. Age, sex, laterality of pain or number of surgeries before implant did not play a role in predicting outcome. The percentage of pain relief was inversely related to the time interval between pain onset and time of implantation. Radicular pain with axial component responded better to dual Pisces electrode or Specify-Lead implantation. CONCLUSION: Spinal cord stimulation can provide significant long-term pain relief with improved quality of life and employment. Results of this study will be effective in better defining prognostic factors and reducing complications leading to higher success rates with spinal cord stimulation.

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Phytother Res. 2006 Mar 6;20(3):232-234 [Epub ahead of print]
Pycnogenol((R)) alleviates pain associated with pregnancy.
Kohama T, Inoue M.
Department of Obstetrics and Gynecology, Keiju Medical Center, Tomioka-chou 94, Nanao City, Ishikawa Pref., Japan.

The effect of Pycnogenol((R)) was studied in women in the third trimester of pregnancy, complaining of lower back pain, hip joint pain, pelvic pain (pain in the inguinal region), pain due to varices or calf cramps. The women were supplemented with Pycnogenol((R)) at a dose of 30 mg/day without any other therapy. Alleviation of pain was evaluated by pain scores until delivery. A significant reduction of pain could be obtained compared with the control group, where no decrease in pain scores in any symptoms was reported. No unwanted effects were observed in the Pycnogenol((R)) group. These results indicate the potential of Pycnogenol((R)) to reduce pain associated with pregnancy. Copyright (c) 2006 John Wiley & Sons, Ltd.

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Stem Cells Dev. 2006 Feb;15(1):136-7.
Intradiscal injection of hematopoietic stem cells in an attempt to rejuvenate the intervertebral discs.
Haufe SM, Mork AR.
MicroSpine Center, DeFuniak Springs, FL 32435.

This study is a prospective analysis of 10 patients who underwent intradiscal injection of hematopoietic precursor stem cells (HSCs) obtained from their pelvic bone marrow in an attempt to rejuvenate the disc. Several studies in animals express the ability to regrow disc tissue with possible regenerative effects. No human studies have been done to date. Patients were randomly offered the option of this study, and ten patients with confirmed disc pain via provocative discograms underwent intradiscal HSC injections. After the intradiscal injection of HSCs, all of the patients underwent a 2-week course of hyperbaric oxygen therapy. These patients were followed up at 6- and 12- month intervals to determine their degree of pain relief from this procedure. Of the 10 patients, none achieved any improvement of their discogenic low back pain after 1 year. In conclusion, although animal studies suggest possible regeneration of disc via HSC injections, living human studies reveal that this effect does not correlate with reduced pain, and thus intradiscal HSC injection appears to be of little value.

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J Neurosurg Spine. 2006 Feb;4(2):85-90.
Lumbar total disc arthroplasty in patients older than 60 years of age: a prospective study of the ProDisc prosthesis with 2-year minimum follow-up period.
Bertagnoli R, Yue JJ, Nanieva R, Fenk-Mayer A, Husted DS, Shah RV, Emerson JW.
Department of Orthopaedic Surgery, Spine Center, St. Elizabeth Klinikum, Straubing, Germany.

OBJECT: The authors conducted a prospective longitudinal study to obtain outcome (minimum follow-up period 2 years) regarding the safety and efficacy of single-level lumbar disc (ProDisc prosthesis) replacement in patients 60 years of age or older. METHODS: This prospective analysis involved 22 patients treated in whom the lumbar ProDisc prosthesis was used for total disc arthroplasty. All patients presented with disabling discogenic low-back pain (LBP) with or without radicular pain. The involved segments ranged from L-2 to S-1. Patients in whom there was no evidence of radiographic circumferential spinal stenosis and with minimal or no facet joint degeneration were included. Patients were assessed preoperatively and outcome was evaluated postoperatively at 3, 6, 12, and 24 months by administration of standardized tests (the visual analog scale [VAS], Oswestry Disability Index [ODI], and patient satisfaction). Secondary parameters included analysis of pre- and postoperative radiographic results of disc height at the affected level, adjacent-level disc height and motion, and complications. Twenty-two (100%) fulfilled all follow-up criteria. The median age of all patients was 63 years (range 61-71 years). There were 17 single-level cases, four two-level cases, and one three-level case. Statistical improvements in VAS, ODI, and patient satisfaction scores were observed at 3 months postoperatively. These improvements were maintained at 24-month follow-up examination. Patient satisfaction rates were 94% at 24 months (compared with 95% reported in a previously reported ProDisc study). Radicular pain also decreased significantly. Patients in whom bone mineral density was decreased underwent same-session vertebroplasty following implantation of the ProDisc device(s). There were two cases involving neurological deterioration: unilateral foot drop and loss of proprioception and vibration in one patient and unilateral foot drop in another patient. Both deficits occurred in patients in whom there was evidence preoperatively of circumferential spinal stenosis. There were two cases of implant subsidence and no thromboembolic phenomena. CONCLUSIONS: Significant improvements in patient satisfaction and ODI scores were observed by 3 months postoperatively and these improvements were maintained at the 2-year follow-up examination. Although the authors' early results indicate that the use of ProDisc lumbar total disc arthroplasty in patients older than 60 years of age reduces chronic LBP and improves clinical functional outcomes, they recommend the judicious use of artificial disc replacement in this age group. Until further findings are reported, the authors cautiously recommend the use of artificial disc replacement in the treatment of chronic discogenic LBP in patients older than age 60 years in whom bone quality is adequate in the absence of circumferential spinal stenosis.

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J Occup Rehabil. 2005 Dec;15(4):491-505.
Physical exercise interventions to improve disability and return to work in low back pain: current insights and opportunities for improvement.
Staal JB, Rainville J, Fritz J, van Mechelen W, Pransky G.
Department of Epidemiology, Maastricht University, 6200 MD, PO Box 616, Maastricht, The Netherlands, Bart.Staal@epid.unimaas.nl.

Introduction: There is a body of literature that indicates that physical exercise interventions, with a primary focus on improvement of functioning instead of pain relief, might be effective to stimulate return to work and improve function in workers who are absent from work due to low back pain (LBP). Successful application and implementation of these interventions however, depends on multiple factors that need to be addressed carefully in clinical practice as well as research. Methods: Descriptive literature review, to identify an overview of current knowledge with respect to the safety, content- and context-related aspects of physical exercise interventions, issues relating to timing, the influence of treatment confidence and patient expectations, and the process of changing provider and employer behavior. Results: Physical exercises are not associated with an increased risk for recurrences. The effects of interventions may vary depending on content-related factors (i.e., type of exercises, dosage, frequency, skills of the healthcare providers, etc.) and contextual factors (i.e., treatment setting, compensation system, etc.). Treatment confidence and patients' expectations also significantly influence outcomes of physical exercise interventions. Timing is also important; interventions targeting return to work, applied during the acute phase of work absenteeism, compete with a high rate of spontaneous recovery and may therefore be inefficient. Conclusions: Despite numerous studies, more quantitative and qualitative investigations are needed to further clarify the requirements for a successful application and implementation of physical exercise interventions for disabled workers with low back pain.

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Clin J Pain. 2005 Nov-Dec;21(6):463-70.
A randomized, controlled trial of manual therapy and specific adjuvant exercise for chronic low back pain.
Geisser ME, Wiggert EA, Haig AJ, Colwell MO.
The Spine Program, Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor, MI 48108, USA. mgeisser@umich.edu

OBJECTIVE: This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating chronic low back pain and disability. METHODS: A single blind, randomized, controlled trial was employed. Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning. In addition, patients received manual therapy or sham manual therapy. Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily. RESULTS: Seventy-two out of 100 patients completed the study. Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction (P = 0.04 and P = 0.05, respectively), indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received. When controlling for pretreatment scores, patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain. No change in perceived disability was observed, with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment. DISCUSSION: Manual therapy with specific adjuvant exercise appears to be beneficial in treating chronic low back pain. Despite changes in pain, perceived function did not improve. It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability. Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population.

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Phys Ther. 2005 Nov;85(11):1168-81.
Management of work-related low back pain: a population-based survey of physical therapists.
Poitras S, Blais R, Swaine B, Rossignol M.
Groupe de Recherche Interdisciplinaire en Sante, Universite de Montreal, CP 6128, Succursale Centre-ville, Montreal, Quebec, Canada H3C 3J7. stephane.poitras@mcgill.ca.

BACKGROUND AND PURPOSE: Physical therapy often is used in the management of work-related low back pain (LBP). Little information, however, is known about the types of interventions used by physical therapists in the management of this condition. The objective of this study was to describe the interventions used by physical therapists in the treatment of workers with acute or subacute LBP, with or without radiating pain below the knee. SUBJECTS: Clinical management questionnaires for workers without and with radiating pain were returned by 190 and 139 physical therapists, respectively. METHODS: For each treatment session, therapists recorded treatment objectives, interventions, and education provided to 2 workers with LBP, 1 with radiating pain and 1 without radiating pain. RESULTS: The majority of physical therapists used stretching and strengthening exercises, spinal mobilizations, soft tissue mobilizations and massage, manual traction, posture correction, interferential current, ultrasound, heat, and functional activities education. With radiating pain, the majority of the therapists also used cold and the McKenzie approach. Treatment objectives pursued by the majority of the therapists were decrease of pain, increase of range of motion, increase of muscle strength (force-generating capacity of muscle), decrease of muscle tension, and worker education. DISCUSSION AND CONCLUSION: Physical therapists use an array of interventions with workers with LBP. The effectiveness of most interventions reported has not been well studied.

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BMC Musculoskelet Disord. 2005 Nov 4;6(1):54 [Epub ahead of print]
The effect of motor control exercise versus placebo in patients with chronic low back pain [ACTRN012605000262606].
Maher CG, Latimer J, Hodges PW, Refshauge KM, Moseley LG, Herbert RD, Costa LO, McAuley J.

BACKGROUND: While one in ten Australians suffer from chronic low back pain this condition remains extremely difficult to treat. Many contemporary treatments are of unknown value. One potentially useful therapy is the use of motor control exercise. This therapy has a biologically plausible effect, is readily available in primary care and it is of modest cost. However, to date, the efficacy of motor control exercise has not been established. METHODS: This paper describes the protocol for a clinical trial comparing the effects of motor control exercise versus placebo in the treatment of chronic non-specific low back pain. One hundred and fifty-four participants will be randomly allocated to receive an 8-week program of motor control exercise or placebo (detuned short wave and detuned ultrasound). Measures of outcomes will be obtained at follow-up appointments at 2, 6 and 12 months after randomisation. The primary outcomes are: pain, global perceived effect and patient-generated measure of disability at 2 months and recurrence at 12 months. This trial will be the first placebo-controlled trial of motor control exercise. The results will inform best practice for treating chronic low back pain and prevent its occurrence.

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Spine. 2005 Nov 1;30(21):2369-77; discussion 2378.
A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain.
Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC.
Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia. brian.freeman@qmc.nhs.uk

STUDY DESIGN: A prospective, randomized, double-blind, placebo-controlled trial of intradiscal electrothermal therapy (IDET) for the treatment of chronic discogenic low back pain (CDLBP). OBJECTIVES: To test the safety and efficacy of IDET compared with a sham treatment (placebo). SUMMARY OF BACKGROUND DATA: In North America alone, more than 40,000 intradiscal catheters have been used to treat CDLBP. The evidence for efficacy of IDET is weak coming from retrospective and prospective cohort studies providing only Class II and Class III evidence. There is one study published with Class I evidence. This demonstrates statistically significant improvements following IDET; however, the clinical significance of these improvements is questionable. METHODS: Patients with CDLBP who failed to improve following conservative therapy were considered for this study. Inclusion criteria included the presence of one- or two-level symptomatic disc degeneration with posterior or posterolateral anular tears as determined by provocative computed tomography (CT) discography. Patients were excluded if there was greater than 50% loss of disc height or previous spinal surgery. Fifty-seven patients were randomized with a 2:1 ratio: 38 to IDET and 19 to sham procedure (placebo). In all cases, the IDET catheter was positioned to cover at least 75% of the annular tear as defined by the CT discography. An independent technician connected the catheter to the generator and then either delivered electrothermal energy (active group) or did not (sham group). Surgeon, patient, and independent outcome assessor were all blinded to the treatment. All patients followed a standard postprocedural rehabilitation program. Independent statistical analysis was performed. OUTCOME MEASURES: Low Back Outcome Score (LBOS), Oswestry Disability Index (ODI), Short Form 36 questionnaire (SF-36), Zung Depression Index (ZDI), and Modified Somatic Perceptions Questionnaire (MSPQ) were measured at baseline and 6 months. Successful outcome was defined as: no neurologic deficit, improvement in LBOS of greater then 7 points, and improvement in SF-36 subsets (physical function and bodily pain) of greater than 1 standard deviation. RESULTS: Baseline demographic data, initial LBOS, ODI, SF-36, ZDI, and MSPQ were similar for both groups. No neurologic deficits occurred. No subject in either arm showed improvement of greater than 7 points in LBOS or greater than 1 standard deviation in the specified domains of the SF-36. Mean ODI was 41.42 at baseline and 39.77 at 6 months for the IDET group, compared with 40.74 at baseline and 41.58 at 6 months for the placebo group. There was no significant change in ZDI or MSPQ scores for either group. CONCLUSIONS: The IDET procedure appeared safe with no permanent complications. No subject in either arm met criteria for successful outcome. Further detailed analyses showed no significant change in outcome measures in either group at 6 months. This study demonstrates no significant benefit from IDET over placebo.

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J Neurosurg Spine. 2005 Oct;3(4):296-301.
Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures.
Gerszten PC, Germanwala A, Burton SA, Welch WC, Ozhasoglu C, Vogel WJ.
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. gersztenpc@upmc.edu

OBJECT: Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and irradiation for the underlying malignant process. The authors evaluated a treatment paradigm of closed fracture reduction and fixation involving kyphoplasty and subsequent spinal radiosurgery. METHODS: Twenty-six patients (six men and 20 women, mean age 72 years) with pathological compression fractures (16 thoracic and 10 lumbar) were prospectively evaluated. Histological diagnoses included 11 lung, nine breast, four renal, one cholangiocarcioma, and one ocular melanoma. Seven lesions had received prior external-beam radiation therapy. All patients underwent kyphoplasty that involved the percutaneous transpedicular technique. Fiducial markers allowing for image guidance during CyberKnife treatment were placed, at time of the kyphoplasty, in the pedicles at adjacent levels. Patients underwent single-fraction radiosurgery (mean time after kyphoplasty 12 days) in an outpatient setting. The tumor dose was maintained at 16 to 20 Gy (mean 18 Gy) to the 80% isodose line. The treated tumor volume ranged from 12.7 to 37.1 cm3. No acute radiation-induced toxicity or new neurological deficit occurred during the follow-up period (range 11-24 months, median 16 months). Axial pain improved in 24 (92%) of 26 patients. CONCLUSIONS: The combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be clinically effective in patients with pathological fractures; there was no significant spinal canal compromise. In this technique two minimally invasive surgical procedures are combined to avoid the morbidity associated with open surgery while providing both immediate fracture fixation and administering a single-fraction tumoricidal radiation dose.

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Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001352.
Surgery for degenerative lumbar spondylosis.
Gibson J, Waddell G, Gibson JA.

BACKGROUND: Surgical investigations and interventions account for large health care utilisation and costs, but the scientific evidence for most procedures is still limited. OBJECTIVES: Degenerative conditions affecting the lumbar spine are variously described as lumbar spondylosis or degenerative disc disease (which we regarded as one entity) and may be associated with back pain and associated leg symptoms, instability, spinal stenosis and/or degenerative spondylolisthesis. The objective of this review was to assess current scientific evidence on the effectiveness of surgical interventions for degenerative lumbar spondylosis. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, PubMed, Spine and ISSLS abstracts, with citation tracking from the retrieved articles. We also corresponded with experts. All data found up to 31 March 2005 are included. SELECTION CRITERIA: Randomised (RCTs) or quasi-randomised trials of surgical treatment of lumbar spondylosis. DATA COLLECTION AND ANALYSIS: Two authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary. MAIN RESULTS: Thirty-one published RCTs of all forms of surgical treatment for degenerative lumbar spondylosis were identified. The trials varied in quality: only the more recent trials used appropriate methods of randomization, blinding and independent assessment of outcome. Most of the earlier published results were of technical surgical outcomes with some crude ratings of clinical outcome. More of the recent trials also reported patient-centered outcomes of pain or disability, but there is still very little information on occupational outcomes. There was a particular lack of long term outcomes beyond two to three years. Seven heterogeneous trials on spondylolisthesis, spinal stenosis and nerve compression permitted limited conclusions. Two new trials on the effectiveness of fusion showed conflicting results. One showed that fusion gave better clinical outcomes than conventional physiotherapy, while the other showed that fusion was no better than a modern exercise and rehabilitation programme. Eight trials showed that instrumented fusion produced a higher fusion rate (though that needs to be qualified by the difficulty of assessing fusion in the presence of metal-work), but any improvement in clinical outcomes is probably marginal, while there is other evidence that it may be associated with higher complication rates. Three trials with conflicting results did not permit any conclusions about the relative effectiveness of anterior, posterior or circumferential fusion. Preliminary results of two small trials of intra-discal electrotherapy showed conflicting results. Preliminary data from three trials of disc arthroplasty did not permit any firm conclusions. AUTHORS' CONCLUSIONS: Limited evidence is now available to support some aspects of surgical practice. Surgeons should be encouraged to perform further RCTs in this field.

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Clin J Pain. 2005 Sep-Oct;21(5):446-55.
Sacroiliac joint dysfunction: evaluation and management.
Zelle BA, Gruen GS, Brown S, George S.
>From the Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, University of Pittsburgh Medical Center, Pittsburgh, PA.

Sacroiliac joint dysfunction is believed to be a significant source of low back and posterior pelvic pain. METHODS:: To assess the clinical presentation, diagnostic testing, and treatment options for sacroiliac joint dysfunction, a systematic literature review was performed using MEDLINE. RESULTS:: Presently, there are no widely accepted guidelines in the literature for the diagnosis and treatment of sacroiliac instability. Establishing management guidelines for this disorder has been complicated by the large spectrum of different etiologic factors, the variability of patient history and clinical symptoms, limited availability of objective testing, and incomplete understanding of the biomechanics of the sacroiliac joint. CONCLUSIONS:: A reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be pain relief following a radiologically guided injection of a local anaesthetic into the sacroiliac joint. Most patients respond to non-operative treatment. Patients who do not respond to non-operative treatment should be considered for operative sacroiliac joint stabilization.

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Clin J Pain. 2005 September/October;21(5):406-411.
A Comparison of Physician and Nonphysician Acupuncture Treatment For Chronic Low Back Pain.
Kalauokalani D, Cherkin DC, Sherman KJ.
>From the *Department of Anesthesia and Pain Medicine, University of California, Davis Medical Center, Sacramento, California, daggerDepartment of Health Services, University of Washington, Seattle, Washington, double daggerCenter for Health Studies, Group Health Cooperative, Seattle, Washington, section signDepartment of Family Medicine, University of Washington, Seattle, Washington, parallelNorthwest Institute of Acupuncture and Oriental Medicine, Seattle, Washington, and paragraph signDepartment of Epidemiology, University of Washington, Seattle, Washington.

BACKGROUND:: Although up to a third of the 10,000 acupuncturists in the United States are medical doctors, little is known about the acupuncture techniques they use or how their practices compare with those of nonphysician licensed acupuncturists. This is the first study providing descriptive data on physician acupuncture and comparison to nonphysician acupuncture. PURPOSE:: This study describes how a random sample of physician acupuncturists in the United States diagnose and treat chronic low back pain and contrasts their practices with those of nonphysician licensed acupuncturists. METHODS:: A total of 464 questionnaires were mailed to physician acupuncturists randomly sampled from 3 sources: web-based Yellow Pages, American Academy of Medical Acupuncturists (AAMA) membership, and Pain Clinics associated with American College of Graduate Medical Education-approved fellowship programs. Responses (n = 137, 30%) were analyzed using descriptive statistics. The results of this survey were compared with data published from a similar survey of nonphysician licensed acupuncturists in Washington State. RESULTS:: Physicians who perform acupuncture use a mixture of styles and emphasize neuroanatomic approaches to needle placement. Most physicians received training in French Energetic acupuncture. In contrast, most nonphysician licensed acupuncturists use a traditional Chinese medicine approach to needle placement. Despite this apparent difference in their predominant styles of acupuncture, there was a high correlation between physician and nonphysician licensed acupuncturist acupoint selection to treat low back pain. In addition to acupuncture needling, physicians use other medical treatments, whereas nonphysician licensed acupuncturists' employ a variety of traditional Chinese medicine adjuncts to needling. CONCLUSION:: This study provides new information about the nature of physician acupuncture practice in the United States and how it compares to acupuncture provided by nonphysician licensed acupuncturists. Further research is necessary to determine if the different types of acupuncture provided by physicians and nonphysician acupuncturists affect treatment outcomes and costs for patients with chronic low back pain.

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Spine. 2005 Aug 15;30(16 Suppl):S33-43.
Current treatment strategies for the painful lumbar motion segment: posterolateral fusion versus interbody fusion.
Wang JC, Mummaneni PV, Haid RW.
Atlanta Brain and Spine Care, Atlanta, GA 30309, USA. jwang@atlantabrainandspine.com

STUDY DESIGN: Review of the literature. OBJECTIVES: We discuss the indications and contraindications for posterolateral lumbar fusion and posterior approaches to lumbar interbody fusion. We also review the advances in minimal access surgical techniques, graft materials, and osteobiologics. SUMMARY OF BACKGROUND DATA: Previously published data and our own surgical experience form the basis of this report. METHODS: A Pub Med online internet search for the keywords was performed. The pertinent articles were then cited. RESULTS: Posterior interbody fusion techniques have theoretical and demonstrable advantages over posterolateral fusion, but the former is also associated with greater morbidity. There are several approaches one may use to perform posterior interbody fusion, as well as multiple minimally invasive techniques and interbody spacer graft options. Bone morphogenetic protein offers an attractive alternative for achieving fusion. CONCLUSION: Fusion of painful motion segments is widely used to treat patients with degenerative low back pain. Successful arthrodesis may be achieved using either posterolateral fusion with pedicle screw fixation or posterior interbody fusion, depending on the patient's situation. These techniques may be accomplished with a variety of minimal access strategies and various graft and spacer technologies. The modern spine surgeon should be proficient in using all these options to treat the painful lumbar motion segment.

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J Rheumatol. 2005 Aug;32(8):1556-62.
Longterm reduction of back pain risk in women with osteoporosis treated with teriparatide compared with alendronate.
Miller PD, Shergy WJ, Body JJ, Chen P, Rohe ME, Krege JH.
Colorado Center for Bone Research, Lakewood, 80227, USA. millerccbr@aol.com

OBJECTIVE: To compare the effects on back pain of teriparatide versus alendronate, we analyzed the reporting of back pain in a head to head comparator trial and a followup study. METHODS: In the comparator trial, women were randomized to receive either daily self-injected teriparatide 40 microg plus an oral placebo (n = 73), or daily oral alendronate 10 mg plus self-injected placebo (n = 73). Treatment was for a median 14 months. After completion of the comparator trial, 72% of these patients enrolled in a nontreatment followup study. Adverse events were recorded at each comparator trial visit and followup study visit, and the incidence of new or worsening back pain in each group was compared. RESULTS: During the comparator trial, compared with women randomized to alendronate 10 mg, women randomized to teriparatide 40 microg had reduced risk for any back pain (relative risk 0.27, 95% CI 0.09-0.82) and moderate or severe back pain (relative risk 0.19, 95% CI 0.04-0.86). The differences in the reporting of back pain between the teriparatide treated women and the alendronate treated women were sustained during an interval including the comparator trial plus 18 additional months. During an interval including the comparator trial plus 30 additional months, teriparatide treated patients had numerically fewer occurrences of back pain and moderate or severe back pain. CONCLUSION: Compared with women randomized to alendronate 10 mg, women randomized to teriparatide 40 microg had reduced risk of back pain during the trial and 2.5 years of followup.

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Disabil Rehabil. 2005 Aug 19;27(16):929-37.
A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in
a severely deprived area.
Carr JL, Klaber Moffett JA, Howarth E, Richmond SJ, Torgerson DJ, Jackson DA, Metcalfe CJ.
Institute of Rehabilitation, University of Hull, UK.

PURPOSE: To compare a group exercise programme known as the Back to Fitness programme with individual physiotherapy for patients with non-specific low back pain from a materially deprived area. METHOD: This was a randomized controlled trial including 237 physiotherapy patients with back pain lasting more than six weeks. Participants were allocated to either the Back to Fitness programme or to individual physiotherapy, and followed up at three months and 12 months after randomization. The main outcome measure was the Roland Disability Questionnaire. Secondary measures were: SF12, EQ5D, Pain Self-Efficacy Scale. Health care diaries recording patients' use of health care resources were also collected over a 12-month period. RESULTS: There were no statistically significant differences in change scores between groups on the primary outcome measure at three months (CI - 2.24 to 0.49) and at 12 months (CI - 1.68 to 1.39). Only minor improvements in disability scores were observed in the Back to Fitness group at three months and 12 months respectively (mean change scores; - 0.89, - 0.77) and in the individual physiotherapy arm (mean change scores; - 0.02, - 0.63). Further analysis showed that patients from the most severely deprived areas were marginally worse at three month follow-up whereas those from more affluent areas tended to improve (CI 0.43 to 3.15).

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Health Technol Assess. 2005 Aug;9(32):1-126.
Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain.
Thomas KJ, Macpherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, Fitter M, Roman M, Walters S, Nicholl JP.
School of Health and Related Research (ScHARR), University of Sheffield, UK.

OBJECTIVES: To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested. DESIGN: A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested. SETTING: Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK. PARTICIPANTS: Patients aged 18--65 years with non-specific low back pain of 4--52 weeks' duration, assessed as suitable for primary care management by their general practitioner. INTERVENTIONS: The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need. MAIN OUTCOME MEASURES: The Short Form 36 (SF-36) Bodily Pain dimension (range 0--100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care. RESULTS: A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was pound4241 (95% CI pound191 to pound28,026) using the SF-6D scoring algorithm based on responses to the SF-36, and pound3598 (95% CI pound189 to pound22,035) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset. CONCLUSIONS: Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols.

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Am J Sports Med. 2005 Aug 10; [Epub ahead of print]
Lumbar Spondylolysis in Pediatric and Adolescent Soccer Players.
El Rassi G, Takemitsu M, Woratanarat P, Shah SA.
Department of Orthopaedics, Alfred I. duPont Hospital for Children, Nemours Children's Clinic, Wilmington, Delaware.

BACKGROUND: Lumbar spondylolysis in young soccer players has not been studied extensively. PURPOSE: The purpose of this study was to review lumbar spondylolysis in young soccer players, describe the causes, and report the results of nonoperative treatment emphasizing the cessation of activity for 3 months. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors reviewed 57 child and adolescent soccer players (35 boys and 22 girls) with lumbar spondylolysis who came to their outpatient clinic for back pain evaluation. These patients received different modalities of nonoperative treatment, including cessation of sports and wearing a thoracolumbosacral orthosis. Soccer skills, field position, side of dominant leg, age, initiating event of low back pain, duration of symptoms, and nonoperative treatment were reviewed. Clinical outcome of treatment was assessed by the Steiner-Micheli criteria at the most recent follow-up (minimum 2 years). The Fisher exact test was used to compare all the data. RESULTS: Of the patients, 43% noticed that pain started after a high-velocity kick. Thirty-three (58%) of 57 patients had excellent results with no pain during sports, 20 (35%) good, 3 (5%) fair, and 1 (2%) poor. Subjects who ceased playing soccer for 3 months had better results than those who did not comply with this restriction. CONCLUSION: The authors recommend stopping sports for at least 3 months in cases of lumbar spondylolysis in young soccer players who hope to return to their previous level of play without back pain.

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AJNR Am J Neuroradiol. 2005 Aug;26(7):1629-33.
Vertebroplasty in the inpatient population.
Trout AT, Gray LA, Kallmes DF.
Mayo Clinic College of Medicine, Rochester, MN 55901, USA.

BACKGROUND AND PURPOSE: Vertebroplasty is frequently offered to patients hospitalized for refractory pain due to vertebral fractures, because it is assumed that the procedure will facilitate resolution of pain and a rapid hospital discharge. We report our experience with inpatient vertebroplasty, with attention to rapidity of discharge and relevant clinical parameters. METHODS: We retrospectively reviewed the duration of hospitalization in patients admitted with primary diagnoses of back pain or vertebral fracture who were treated with vertebroplasty. We cataloged outcomes in the form of verbal pain scales (graded 0-10), in-hospital medication use (graded 0-6), and posthospitalization medication use. Outcomes were assessed at baseline and at 1 week, 1 month, 6 months, 1 year, and 2 years postvertebroplasty. RESULTS: We identified 66 such patients who had a median total hospital stay of 6.0 days (range, 1-26 days). Median length of stay before and after vertebroplasty were 4.0 (range, 1-24 days) and 1.5 days (range, 0-7 days), respectively. Ten (15%) patients were discharged the day of vertebroplasty. By days 2 and 3, 33 (50%) and 48 (72.7%) of the 66 patients had been discharged. Patients who received vertebroplasty earlier in the course of hospitalization demonstrated greater decreases in medication strength by discharge (P = .045). There was significant improvement in all outcome measures by 1 week, with continued improvement at 1 and 6 months. CONCLUSION: This study confirms that vertebroplasty facilitates a rapid hospital discharge as well as long-term improvement in patients admitted for refractory pain. Vertebroplasty administered earlier in hospitalization also leads to greater decreases in analgesic requirements.

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Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2005 Aug;48(8):841-7.
[Exercise therapy as a therapeutic concept.]
[Article in German]
Reer R, Ziegler M, Braumann KM.
Universitat Hamburg, Hamburg.

Lack of exercise is a primary cause for today's level of morbidity and mortality in the Western world. Thus, exercise as a therapeutic modality has an important role. Beneficial effects of exercise have been extensively documented, specifically in primary and secondary prevention of coronary heart disease (CHD), diabetes mellitus, hypertension, disorders of fat metabolism, heart insufficiency, cancer, etc. A regular (at least 3x per week) en durance training program of 30- 40 min duration at an in tensity of 65-70% of VO(2)max involving large muscle groups is recommended. The specific exercise activity can also positively affect individuals with orthopedic disease patterns, i.e., osteoporosis, back pain, postoperative rehabilitation, etc. Endurance strength training in the form of sequential training in volving approx. 8-10 different exercises for the most important muscle groups 2x per week is a suitable exercise therapy. One to three sets with 8-12 repetitions per exercise should be performed until volitional exhaustion of the trained muscle groups among healthy adults and 15-20 repetitions among older and cardiac patients. Apart from a positive effect on the locomotor system, this type of strength training has positive effects on CHD, diabetes mellitus, and cancer.

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BMC Musculoskelet Disord. 2005 Aug 4;6(1):43 [Epub ahead of print]
Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials.
Licciardone JC, Brimhall AK, King LN.

BACKGROUND: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain. METHODS: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses. RESULTS: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up. CONCLUSIONS: OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

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Pain Med. 2005 Jul;6(4):287-96.
A narrative review of intra-articular corticosteroid injections for low back pain.
Bogduk N.
Department of Clinical Research, University of Newcastle, Royal Newcastle Hospital, Newcastle, New South Wales, Australia.

Objective. To summarize and to analyze the available literature on the efficacy of intra-articular injections of corticosteroids for low back pain. Design. Publications, in English, French, and German, were obtained that reported the proportions of patients who obtained complete relief of pain following intra-articular steroids, and that provided any form of follow-up. These publications were analyzed to determine the rationale, indications, and outcomes of the treatment. Results. The only rationale for intra-articular steroids appears to be the expectation that they should work. The most commonly used indication has been back pain, for which no specific diagnosis has been made. When the results of observational studies are pooled, they paint a picture of impressive immediate responses, but a rapid decay of outcomes by three and six months. Initial responses, however, are dissonant with the literature from controlled studies of the prevalence of lumbar zygapophysial joint pain. Moreover, controlled trials have shown that there is no attributable effect to the injection of steroids. Conclusion. The apparent efficacy of lumbar intra-articular steroids is no greater than that of a sham injection. There is no justification for the continued use of this intervention. Better outcomes can be achieved with deliberate placebo therapy.

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Spine J. 2005 May-Jun;5(3):256-61.
A factor analysis of lumbar intradiscal electrothermal annuloplasty outcomes.
Derby R, Seo KS, Kazala K, Chen YC, Lee SH, Kim BJ.
Spinal Diagnostics and Treatment Center, 901 Campus Drive, Suite 310, Daly City, CA 94015, USA.

BACKGROUND CONTEXT: Intradiscal electrothermal annuloplasty (IDET) is a minimally invasive procedure for managing chronic discogenic low back pain (LBP). Although there have been numerous reports of IDET outcome rates, few have dissected the detailed factors affecting those outcomes. PURPOSE: To evaluate how heating variables and the number of catheters used affect the outcomes and pain flare-up in LBP patients treated with IDET. STUDY DESIGN/SETTING: Retrospective analysis. PATIENT SAMPLE: Data were gathered on the basis of chart records from January 6, 1999 to January 6, 2000. Twenty-five cases treated at a single level with disc protrusion </=2 mm, nonfocal neurological abnormalities, and positive discogram with annular tear were studied. Six patients were unavailable for follow-up at 16 months. OUTCOME MEASURES: All assessments were incorporated into our own evaluation sheet, completed before the procedure and at follow-up. Assessments included the following: 1) Visual Analog Scale (VAS) and 2) Back Pain Improvement Scales (BPI) preoperatively and at 8 and 16 months post-procedure. Post-procedure flare-up of the pain was defined as the pain aggravation after the IDET procedure from the pre-procedure baseline pain. It was evaluated by a 10-point numeric rating scale, ranging from no aggravated pain "0" to the worst aggravated pain "10". METHODS: Patients were partitioned into a single-catheter group and a double-catheter group. In these two groups, statistical analyses were done to compare the outcomes and flare-up duration and intensity. In each catheter group, the correlation coefficients were analyzed between heating variables such as heating duration/temperature and two outcome scales. Then, two outcome scales relative to intensity and duration of post-IDET flare-up were analyzed with Pearson's correlation. Also the combined effect of the heating duration and temperature was evaluated as a thermal dosage, which is the total amount of heat developed during the procedure. It was calculated by multiplying the temperature and its heating duration above a starting temperature of 65 degrees C. RESULTS: Comparing the single- and double-catheter groups, patients placed in the single-catheter group showed significantly shorter flare-up duration (11.00+/-19.17 vs. 24.89+/-20.84 days, p<.05). In the single-catheter group, the flare-up duration manifested moderate linear correlation with heating variables (0.580 with temperature, 0.519 with thermal dosage, p<.05). Also, the improvements of pain with VAS displayed moderate reverse correlation with heating variables at 8 months (-.436 with temperature, -0.439 with thermal dosage, p<.1). In the double-catheter group, the Back Pain Improvement% had strong reverse correlations with temperature and thermal dosage at 8 months (-.735 and -.729, p<.05). The correlation between the improvement of VAS and temperature yielded a moderate reverse relationship (-.619, p<0.1). These correlations were not, however, observed at 16 months in either the single- or double-catheter groups. CONCLUSIONS: Higher temperatures and larger total heating doses during IDET procedures with catheters placed in the outer annulus may increase the duration of post-procedure pain flare-ups and lead to less favorable outcomes at 8 months follow-up. The long-term outcomes at 16 months may, however, not be affected by these heating variables.

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Spine J. 2005 May-Jun;5(3):310-28.
Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature.
Dagenais S, Haldeman S, Wooley JR.
Department of Environmental Health, Science, and Policy, University of California, Irvine, CA 92697, USA; CAM Research Institute, 2102 Business Center Drive, Irvine, CA 92612, USA.

BACKGROUND CONTEXT: The injection of various solutions aimed at producing a sclerosing effect has been used to treat soft tissues injuries (eg, inguinal hernia) for more than 100 years. In the 1930s, this treatment approach was applied to injured joints in an attempt to stimulate connective tissue repair. Although several studies have been published about this method of treatment for various orthopedic and spinal indications (termed prolotherapy), its use remains controversial. PURPOSE: To conduct a critical review of the literature on prolotherapy for spinal pain. STUDY DESIGN/SETTING: Critical review of the literature. METHODS: Computerized medical literature databases (Medline, CINAHL, Mantis, Cochrane Central Register of Controlled Trials) were searched to uncover all published information about the use of sclerosing injections in humans with spinal pain disorders. Search results were reviewed for relevance, and information was abstracted from full-text articles. RESULTS: Our search uncovered almost 200 reference materials in various media related to prolotherapy, including 31 clinical studies related to spinal pain. There were 26 observational cohorts and 5 randomized clinical trials (RCTs). Indications in these studies were low back pain (22), neck pain (3), cervical headaches (3) and dorsal or thoracic pain (3). A total of 20 sclerosing solutions were used in these studies; the most common was a mixture of dextrose 12.5%, glycerin 12.5%, phenol 1.25% and lidocaine 0.25%. Wide variations were found in treatment protocols, such as dose, number of treatments and use of adjunct therapies. Most cohort studies were only of moderate quality and varied greatly in the substances injected and the use of co-interventions. Most clinical studies reported positive results such as decreased pain or disability, although differences between treatment and control groups did not always reach statistical significance. Commonly reported adverse reactions to this treatment include temporary postinjection pain and stiffness. A handful of more serious adverse events were reported in the 1950s and 1960s with stronger or unknown solutions. CONCLUSION: Prolotherapy describes a variety of treatment approaches rather than a specific protocol. Results from clinical studies published to date indicate that it may be effective at reducing spinal pain. Great variation was found in the injection and treatment protocols used in these studies that preclude definite conclusions. Future research should focus on those solutions and protocols that are most commonly used in clinical practice and have been used in trials reporting effectiveness to help determine which patients, if any, are most likely to benefit from this treatment.

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J Manipulative Physiol Ther. 2005 May;28(4):245-52.
Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic
low back pain.
Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S.
Department of Health Services, University of California Los Angeles, School of Public Health, Los Angeles, California, USA.

OBJECTIVES: To measure changes in pain and disability for chronic low-back pain patients receiving treatment with medication-assisted manipulation (MAM) and to compare these to changes in a group only receiving spinal manipulation. STUDY DESIGN: Prospective cohort study of 68 chronic low-back pain patients. METHODS: Outcomes were measured using the 1998 Version 2.0 American Association of Orthopaedic Surgeons/Council of Musculoskeletal Specialty Societies/Council of Spine Societies Outcomes Data Collection Instruments. The primary outcome variable was change in pain and disability. All patients received an initial 4- to 6-week trial of spinal manipulation therapy (SMT), after which 42 patients received supplemental intervention with MAM and the remaining 26 patients continued with SMT. RESULTS: Low back pain and disability measures favored the MAM group over the SMT-only group at 3 months (adjusted mean difference of 4.4 points on a 100-point scale, 95% confidence interval [CI] -2.2 to 11.0). This difference attenuated at 1 year (adjusted mean difference of 0.3 points, 95% CI -8.6 to 9.2). The relative odds of experiencing a 10-point improvement in pain and disability favored the MAM group at 3 months (odds ratio 4.1, 95% CI 1.3-13.6) and at 1 year (odds ratio 1.9, 95% CI 0.6-6.5). CONCLUSION: Medication-assisted manipulation appears to offer some patients increased improvement in low back pain and disability. Further investigation of these apparent benefits in a randomized clinical trial is warranted.

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Ann Intern Med. 2005 May 3;142(9):765-75.
Meta-analysis: exercise therapy for nonspecific low back pain.
Hayden JA, van Tulder MW, Malmivaara AV, Koes BW.
Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada. jhayden@iwh.on.ca

BACKGROUND: Exercise therapy is widely used as an intervention in low back pain. OBJECTIVE: To evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute, and chronic low back pain versus no treatment and other conservative treatments. DATA SOURCES: MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews. STUDY SELECTION: Randomized, controlled trials evaluating exercise therapy for adult nonspecific low back pain and measuring pain, function, return to work or absenteeism, and global improvement outcomes. DATA EXTRACTION: Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short-, intermediate-, and long-term follow-up. DATA SYNTHESIS: 61 randomized, controlled trials (6390 participants) met inclusion criteria: acute (11 trials), subacute (6 trials), and chronic (43 trials) low back pain (1 trial was unclear). Evidence suggests that exercise therapy is effective in chronic back pain relative to comparisons at all follow-up periods. Pooled mean improvement (of 100 points) was 7.3 points (95% CI, 3.7 to 10.9 points) for pain and 2.5 points (CI, 1.0 to 3.9 points) for function at earliest follow-up. In studies investigating patients (people seeking care for back pain), mean improvement was 13.3 points (CI, 5.5 to 21.1 points) for pain and 6.9 points (CI, 2.2 to 11.7 points) for function, compared with studies where some participants had been recruited from a general population (for example, with advertisements). Some evidence suggests effectiveness of a graded-activity exercise program in subacute low back pain in occupational settings, although the evidence for other types of exercise therapy in other populations is inconsistent. In acute low back pain, exercise therapy and other programs were equally effective (pain, 0.03 point [CI, -1.3 to 1.4 points]). LIMITATIONS: Limitations of the literature, including low-quality studies with heterogeneous outcome measures inconsistent and poor reporting, and possibility of publication bias. CONCLUSIONS: Exercise therapy seems to be slightly effective at decreasing pain and improving function in adults with chronic low back pain, particularly in health care populations. In subacute low back pain populations, some evidence suggests that a graded-activity program improves absenteeism outcomes, although evidence for other types of exercise is unclear. In acute low back pain populations, exercise therapy is as effective as either no treatment or other conservative treatments.

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J Am Geriatr Soc. 2005 May;53(5):785-92.
The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years.
Chang Y, Singer DE, Wu YA, Keller RB, Atlas SJ.
General Medicine Division and the Clinical Epidemiology Unit, Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Objectives: To assess the relative effect of initial surgical and nonsurgical treatment on longitudinal outcomes of patients with lumbar spinal stenosis over a 10-year follow-up period. Design: A prospective observational cohort study. Setting: Enrollment from community-based specialist practices throughout Maine. Participants: One hundred forty-four patients with lumbar spinal stenosis who had at least one follow-up: 77 initially treated surgically and 67 initially treated nonsurgically. Intervention: Initial surgical or nonsurgical treatment. Measurements: Clinical data were obtained at baseline and outcomes followed at regular intervals over 10 years with mailed questionnaires including patient-reported symptoms of back pain, leg symptoms, back-specific functional status, and satisfaction. Longitudinal data were analyzed using general linear mixed models. In addition to treatment (initial surgical or nonsurgical care), time period, and the interaction between treatment and time, the models included baseline score, patient age and sex, and a time-varying general health status score. The effects of these covariates in explaining differences between treatment groups were also examined. The effect of subsequent surgical procedures was assessed using different analysis strategies. Results: The 10-year rate of subsequent surgical procedures was 23% and 38% for patients initially treated surgically and nonsurgically, respectively, and the overall 10-year survival rate was 69%. Patients undergoing initial surgical treatment had worse baseline symptoms and functional status than those initially treated nonsurgically. For all outcomes and at each time point, surgically treated patients reported greater improvement in symptoms and functional status and higher satisfaction scores, indicative of better outcomes, than nonsurgically treated patients. However, the relative magnitude of the benefit diminished over time such that the relative differences for low back pain and satisfaction were no longer significant over long-term follow-up (both P=.08 for treatment effect between 5 and 10 years after controlling for covariates). Regardless of initial treatment received, patients undergoing subsequent surgical procedures reported less improvement in outcomes over time than patients who did not undergo subsequent procedures, but the relative differences between treatment groups were similar in analyses that controlled for outcomes after subsequent procedures. Conclusion: After controlling for covariates, patients initially treated surgically demonstrated better outcomes on all measures than those initially treated nonsurgically. Although outcomes of initial surgical treatment remained superior over time, the relative benefit of surgery diminished in later years, especially for low back pain and satisfaction. Patients undergoing subsequent surgery had worse outcomes regardless of initial treatment received, but excluding them did not change overall treatment group comparisons. The analytical methods described may be helpful in the design and analysis of future studies comparing treatment outcomes for patients with lumbar spinal stenosis.

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Spine. 2005 May 1;30(9):995-1000.
Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain.
Friedrich M, Gittler G, Arendasy M, Friedrich KM.
Department of Orthopedic Pain Management, Orthopedic Hospital Speising, Vienna, Austria. martin.friedrich@oss.at

STUDY DESIGN: A prospective clinical randomized controlled trial. OBJECTIVES: To determine the long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic and recurrent low back pain (LBP). SUMMARY OF BACKGROUND DATA: There is agreement on the importance of exercise during the course of chronic LBP. However, it is well known that long-term adherence with exercises is particularly low. METHODS: A total of 93 patients with LBP were randomly assigned to the control group (standard exercise program) or the motivational group (combined exercise and motivational program). Follow-up assessments were performed at 3.5 weeks, 4 months, 12 months, and 5 years. Main outcome measures were disability scores, pain intensity, and working ability. In addition to classic statistics, the sophisticated linear partial credit model was used to test the effects of treatment on disability scores. RESULTS: In both groups, significant improvements in the disability scores were found at all points of follow-up assessment, however, the cumulative effect of the treatment in the motivational group was more than twice as much as in the control group. This result is in accordance with the increasing divergence in pain intensity between groups between 12 months and 5 years after intervention. A significant, positive long-term effect at the 5-year reassessment in working ability was only seen in the motivational group. All statistically significant results were confirmed by intention-to-treat analyses. CONCLUSIONS: Regarding long-term efficacy, the combined exercise and motivation program was superior to the standard exercise program. Five years after the supervised combined exercise and motivational program, patients had significant improvements in disability, pain intensity, and working ability.

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Ann Intern Med. 2005 Apr 19;142(8):651-63.
Meta-analysis: acupuncture for low back pain.
Manheimer E, White A, Berman B, Forys K, Ernst E.
University of Maryland School of Medicine, Center for Integrative Medicine, Baltimore, Maryland 21207, USA.

BACKGROUND: Low back pain limits activity and is the second most frequent reason for physician visits. Previous research shows widespread use of acupuncture for low back pain. PURPOSE: To assess acupuncture's effectiveness for treating low back pain. DATA SOURCES: Randomized, controlled trials were identified through searches of MEDLINE, Cochrane Central, EMBASE, AMED, CINAHL, CISCOM, and GERA databases through August 2004. Additional data sources included previous reviews and personal contacts with colleagues. STUDY SELECTION: Randomized, controlled trials comparing needle acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment for patients with low back pain. DATA EXTRACTION: Data were dually extracted for the outcomes of pain, functional status, overall improvement, return to work, and analgesic consumption. In addition, study quality was assessed. DATA SYNTHESIS: The 33 randomized, controlled trials that met inclusion criteria were subgrouped according to acute or chronic pain, style of acupuncture, and type of control group used. The principle measure of effect size was the standardized mean difference, since the trials assessed the same outcome but measured it in various ways. For the primary outcome of short-term relief of chronic pain, the meta-analyses showed that acupuncture is significantly more effective than sham treatment (standardized mean difference, 0.54 [95% CI, 0.35 to 0.73]; 7 trials) and no additional treatment (standardized mean difference, 0.69 [CI, 0.40 to 0.98]; 8 trials). For patients with acute low back pain, data are sparse and inconclusive. Data are also insufficient for drawing conclusions about acupuncture's short-term effectiveness compared with most other therapies. LIMITATIONS: The quantity and quality of the included trials varied. CONCLUSIONS: Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.

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Spine. 2005 Apr 15;30(8):944-63.
Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration.
Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B.
Institute for Work & Health, Toronto, Ontario, Canada. afurlan@iwh.on.ca

OBJECTIVES: To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain. BACKGROUND: Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed. SEARCH STRATEGY: We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. SELECTION CRITERIA: Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling. RESULTS: Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique. CONCLUSIONS: The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

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Int J Gynaecol Obstet. 2005 Mar;88(3):271-5. Epub 2005 Jan 16.
The effect of exercise on the intensity of low back pain in pregnant women.
Garshasbi A, Faghih Zadeh S.
Department of Obstetrics and Gynecology, Shahed University, Faculty of Medicine, 1481973411 Tehran, Iran.

OBJECTIVE: To investigate the effect of exercise during pregnancy on the intensity of low back pain and kinematics of spine. METHOD: A prospective randomized study was deigned. 107 women participated in an exercise program three times a week during second half of pregnancy for 12 weeks and 105 as control group. All filled a questionnaire between 17-22 weeks of gestation and 12 weeks later for assessment of their back pain intensity. Lordosis and flexibility of spine were measured by Flexible ruler and Side bending test, respectively, at the same times. Weight gain during pregnancy, Pregnancy length and neonatal weight were recorded. RESULT: Low back pain intensity was increased in the control group. The exercise group showed significant reduction in the intensity of low back pain after exercise (p<0.0001). Flexibility of spine decreased more in the exercise group (p<0.0001). Weight gain during pregnancy, pregnancy length and neonatal weight were not different between the two groups. CONCLUSION: Exercise during second half of the pregnancy significantly reduced the intensity of low back pain, had no detectable effect on Lordosis and had significant effect on flexibility of spine.

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Phys Ther. 2005 Mar;85(3):209-25.
Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain.
Koumantakis GA, Watson PJ, Oldham JA.
Drosopoulou 6, Kypseli, Athens, 112 57, Greece. gak4@otenet.gr.

BACKGROUND AND PURPOSE: The purpose of this randomized controlled trial was to examine the usefulness of the addition of specific stabilization exercises to a general back and abdominal muscle exercise approach for patients with subacute or chronic nonspecific back pain by comparing a specific muscle stabilization-enhanced general exercise approach with a general exercise-only approach. SUBJECTS: Fifty-five patients with recurrent, nonspecific back pain (stabilization-enhanced exercise group: n=29, general exercise-only group: n=26) and no clinical signs suggesting spinal instability were recruited. METHODS: Both groups received an 8-week exercise intervention and written advice (The Back Book). Outcome was based on self-reported pain (Short-Form McGill Pain Questionnaire), disability (Roland-Morris Disability Questionnaire), and cognitive status (Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, Pain Locus of Control Scale) measured immediately before and after intervention and 3 months after the end of the intervention period. RESULTS: Outcome measures for both groups improved. Furthermore, self-reported disability improved more in the general exercise-only group immediately after intervention but not at the 3-month follow-up. There were generally no differences between the 2 exercise approaches for any of the other outcomes. DISCUSSION AND CONCLUSION: A general exercise program reduced disability in the short term to a greater extent than a stabilization-enhanced exercise approach in patients with recurrent nonspecific low back pain. Stabilization exercises do not appear to provide additional benefit to patients with subacute or chronic low back pain who have no clinical signs suggesting the presence of spinal instability.

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J Health Psychol. 2005 Mar;10(2):233-43.
Effect of a Brief Cognitive Training Programme in Patients with Long-lasting Back Pain Evaluated as Unfit for Surgery.
Magnussen L, Rognsvag T, Tveito TH, Eriksen HR.
University of Bergen, Norway, Orthopedic University Clinic, Norway, University of Bergen, Norway, & University of Bergen, Norway.

The aim of the study was to evaluate the effect of cognitive intervention (information and physical exercise), on patients with long-lasting back pain referred for surgical evaluation at an orthopaedic hospital, but evaluated as unfit for surgery. One hundred and fifty-two patients were randomized to a five days intervention or control. The intervention had no significant effects on pain. At three-month follow-up, the patients in the intervention group used significantly more active strategies to cope with the back pain compared to the control group. This effect seemed to increase over time, being more pronounced at one-year follow-up evaluation.

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Am J Phys Med Rehabil. 2005 Mar;84(3 Suppl):S29-41.
Management of chronic low back pain.
Grabois M.
>From the Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.

Grabois M: Management of chronic low back pain. Am J Phys Med Rehabil 2005;84(suppl):S29-S41.Chronic low back pain is common. It presents a clinical challenge with widespread implications for resource utilization on a national scale. The causes of chronic low back pain may be mechanical or nonmechanical, nociceptive or neuropathic. Diagnosis is problematic because available tools lack both specificity and sensitivity. In rare instances, the cause of chronic low back pain can be attributed to an identified cause. Comprehensive pain management relies on the use of pharmacotherapy, physical therapy, and a multidisciplinary approach to treatment. Recent studies have shown a benefit for traditional adjunctive therapies and interdisciplinary treatment. Antidepressants and opioids have been and remain key elements for medical management, and some recently developed therapies have shown promising results in clinical trials. The following article presents an overview of evidence-based management for chronic low back pain, with an emphasis on pharmaceutical therapies.

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Eur Spine J. 2005 Feb 16; [Epub ahead of print]
Long-term effects of supervised physical training in secondary prevention of low back pain.
Maul I, Laubli T, Oliveri M, Krueger H.
Institute of Hygiene and Applied Physiology, Swiss Federal Institute of Technology, Zurich, Switzerland, Irina.Maul@web.de.

Background and objectives: In the last few years, several studies have focused on short-term treatment effects of exercise therapy. However, there is a lack of knowledge concerning the long-term treatment effects recorded after several years. Hence, this study was performed to investigate the short- and long-term effects of supervised physical training on functional ability, self-rated pain and disability in secondary prevention of low back pain. Methods: One hundred and eighty-three hospital employees with chronic low back pain were randomly assigned either to back school (comparison group), or three-months supervised physical training including a back school (exercise group). Various measurements of functional ability were performed and subjects completed questionnaires on self-rated pain, disability, and general well-being before treatment, immediately after intervention, and at six-months follow-up. At one-year and at ten-years follow-up participants evaluated treatment effectiveness. Results: Out of 183 employees, 148 completed the program. Participation at follow-ups ranged from 66 to 96%. Supervised physical training significantly improved muscular endurance and isokinetic strength during a six-months follow-up, and effectively decreased self-rated pain and disability during a one-year follow-up. At ten-years follow-up the subjects' assessment of the effectiveness of treatment was significantly better in the exercise group. Conclusions: Supervised physical training effectively improved functional capacity and decreased LBP and disability up to one-year follow-up. The subjects' positive evaluation of the treatment effect at ten-years follow-up suggests a long-term benefit of training.

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Osteoporos Int. 2005 Feb 9; [Epub ahead of print]
Both resistance and agility training reduce back pain and improve health-related quality of life in older women with low bone mass.
Liu-Ambrose TY, Khan KM, Eng JJ, Lord SR, Lentle B, McKay HA.
UBC Bone Health Research Group: BC Women's Hospital and Health Centre Osteoporosis Program, Centre for Hip Health, and Faculty of Medicine, University of British Columbia, Suite 211-2150 Western Parkway, Vancouver, BC, V6T 1V6, Canada.

The purpose of the study was to compare the effects of three different types of group-based exercise programs (resistance training, agility training and general stretching) on back pain and health-related quality of life in older (aged 75-85 years) community-dwelling women with low bone mass (i.e., osteopenia or osteoporosis). The design was a 25-week randomized controlled trial. Participating were 98 community-dwelling women with low bone mass between the ages of 75 to 85 years old. We assessed back pain and its related disability and health-related quality of life. All three types of group-based exercise programs significantly reduced back pain and its related disabilities, but only resistance and agility training significantly improved health-related quality of life in community-dwelling older women with low bone mass. Baseline physical activity level and class attendance were significant predictors of change in health-related quality of life. Change in back pain and its related disabilities after 25 weeks of exercise intervention was significantly correlated with change in health-related quality of life and changes in the domains of pain and physical function. Resistance and agility training significantly enhanced health-related quality of life and may have done so by increasing social interactions and support, enhancing self-efficacy of physical abilities and modifying the experience of back pain. These data provide valuable insight into the specifics of exercise prescription for older women with low bone mass. Future studies may wish to use individualized quality of life measures to further delineate the effects of different types of exercise on quality of life in older adults with low bone mass.

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J Manipulative Physiol Ther. 2005 Jan;28(1):3-11.
Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes.
Muller R, Giles LG.
School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia.

OBJECTIVE: To assess the long-term benefits of medication, needle acupuncture, and spinal manipulation as exclusive and standardized treatment regimens in patients with chronic (>13 weeks) spinal pain syndromes. STUDY DESIGN: Extended follow-up (>1 year) of a randomized clinical trial was conducted at the multidisciplinary spinal pain unit of Townsville's General Hospital between February 1999 and October 2001. PATIENTS AND METHODS: Of the 115 patients originally randomized, 69 had exclusively been treated with the randomly allocated treatment during the 9-week treatment period (results at 9 weeks were reported earlier). These patients were followed up and assessed again 1 year after inception into the study reapplying the same instruments (ie, Oswestry Back Pain Index, Neck Disability Index, Short-Form-36, and Visual Analogue Scales). Questionnaires were obtained from 62 patients reflecting a retention proportion of 90%. The main analysis was restricted to 40 patients who had received exclusively the randomly allocated treatment for the whole observation period since randomization. RESULTS: Comparisons of initial and extended follow-up questionnaires to assess absolute efficacy showed that only the application of spinal manipulation revealed broad-based long-term benefit: 5 of the 7 main outcome measures showed significant improvements compared with only 1 item in each of the acupuncture and the medication groups. CONCLUSIONS: In patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.

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J Chin Med Assoc. 2004 Nov;67(11):575-8.
The results of posterolateral lumbar fusion with bone chips from laminectomy in patients with lumbar spondylolisthesis.
Kho VK, Chen WC.
Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan, ROC.

BACKGROUND: This study was undertaken to assess the radiologic outcome of spinal fusion, with bone chips from laminectomy in patients with lumbar spondylolisthesis. METHODS: From January 1993 to September 2001, 95 patients with lumbar spondylolisthesis were managed and followed up well at our Orthopedic Division. All patients presented with persistent low back pain, radiculopathy and claudication. The diagnosis of lumbar spondylolisthesis was confirmed by plain radiographs of the lumbar spine, with lumbar spine computed tomography scan (CT-scan) performed to identify other associated conditions. A near total posterior decompression laminectomy with foraminotomy and posterolateral lumbar fusion using bone chips from laminectomy as bone graft and reduction of the vertebral slip using transpedicle screws with Arbeitsgemeinschaft fur Osteosynthesefragen spinal fixators and Trifix Reduction Fixation spinal system implants, were instituted. Additional disectomies were performed in several patients with disc rupture as confirmed by CT-scan. Fusion was then assessed by plain lumbar radiographs done at 4, 8, and 24 months after operation. RESULTS: The outcome was good, with 88 (92.6%) cases attaining solid fusion, while failed fusion was noted in 7 (7.4%) cases. CONCLUSIONS: Proper decortication of the posterolateral vertebral gutter with removal of all soft tissues attached to the bone chips prior to the placement of bone graft were noted to be the most significant factors for spinal fusion. Fusion rate with bone chips from laminectomy was shown to be comparable to that of the iliac crest bone graft.

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Scand J Med Sci Sports. 2004 Dec;14(6):346-51.
Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment.
Iwamoto J, Takeda T, Wakano K.
Department of Sports Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.

The purpose of this study was to clarify the efficacy of conservative treatment in athletes with severe low back pain and spondylolysis, especially focusing on returning to original sporting activities. One hundred and four athletes (96 males and eight females), who consulted our sports medicine clinic during the 11-year period between September 1991 and October 2002 because of low back pain with an apparent defect of the pars interarticularis on plain radiographs, were subjected to conservative treatment. The mean age of the patients was 20.7 years. Of all the patients, 40 (38.5%) discontinued sporting activities due to severe low back pain, and were conservatively treated with activity restriction and antilordotic lumbosacral bracing, aimed at relieving low back pain by achieving stability of the fracture partly associated with fibrous union. After their low back pain was markedly reduced, the brace was removed and then individual training to return to the original sporting activities was started. Thirty-five patients (87.5%) could return to their original sporting activities in an average of 5.4 months (range: 1.0-11.5 months) after the onset of treatment, and could continue the activities for at least 6 months despite non-bony union. These results suggest that the outcome of conservative treatment with activity restriction and bracing appears to be satisfactory in controlling symptoms and returning to original sporting activities. Randomized controlled trials or comparative follow-up studies are needed to confirm our results.

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Spine J. 2004 Nov-Dec;4(6 Suppl):S177-81.
The indications for lumbar and cervical disc replacement.
McAfee PC.
St. Joseph Hospital, Scoliosis and Spine Center, O'Dea Medical Building 104, 7505 Osler Drive, Towson, MD 21204, USA.

Although cervical and lumbar disc replacements are in their spinal surgical infancy with regard to clinical application, the indications are already delineated. Lumbar disc arthroplasty is indicated for one- or two-level discogenic mechanical back pain primarily in the absence of radiculopathy. In contrast, cervical disc replacement can be readily applied in patients presenting with neurologic deficit, radiculopathy or myelopathy because the approach and anterior spinal cord decompression are identical for anterior cervical disc replacement and traditional Smith-Robinson cervical decompression. In addition, the application of more complex spinal osteotomies, revision of pseudarthroses and deformity correction are much more applicable to the cervical arthroplasty procedures. This is because even the most experienced vascular access surgeon has difficulty with the formidable revision through a repeat anterior lumbar procedure, whereas most experienced cervical spinal surgeons are familiar with repeat anterior cervical approaches. The end result is that surgeons will have more trepidation with multilevel lumbar arthroplasties, especially those presenting in conjunction with neurologic symptoms. At the current time radiculopathy is an exclusion criteria for the four prospective Investigational Device Exemption (IDE) Food and Drug Administration (FDA) studies on lumbar disc replacement, whereas cervical radiculopathy is an inclusion criteria for the major IDE FDA investigations of cervical arthroplasties.

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Spine J. 2004 Nov-Dec;4(6 Suppl):S260-7.
Lumbar spine arthroplasty using the ProDisc II.
Zigler JE.
Texas Back Institute, 6300 West Parker Road, Room 102, Plano, TX 75093, USA.

The ProDisc was developed by Thierry Marnay, a French orthopedic surgeon, in the late 1980s. Marnay and his associate implanted ProDiscs into 64 patients from 1990 to 1993. Demonstrating remarkable intellectual restraint, he let this cohort of patients "incubate" so he could see their progress before performing any additional implantations. In 1998, 61 of these patients were still alive, and 58 (95%) of them were available for a thorough follow-up evaluation. No device-related safety issues were identified during this review, and 93% of these patients were satisfied with their implants. This unique and strong data set led to an unusually rapid Food and Drug Administration (FDA) approval for an Investigational Device Exemption study in the United States, prospectively comparing implantation of a ProDisc with a 360-degree fusion, with both single- and double-level study arms. This article represents data on the first 78 patients with at least 6-month follow-up, with 54 of these patients also having 1-year follow-up, enrolled in a prospective randomized FDA study evaluating the safety and efficacy of ProDisc II versus control, a 360-degree lumbar spinal fusion. Data were collected preoperatively at 6 weeks, 3 months, 6 months and 1 year postoperatively. Visual analog scale (VAS), Oswestry Low Back Pain Disability Questionnaire (ODQ) and patient satisfaction rates were evaluated at these intervals, as well as range of motion, return to work, recreational status and ambulatory status. At 6-month follow-up, there were there were 55 ProDisc patients and 23 who underwent fusion. Twenty-five of these patients had two-level surgery. Estimated blood loss (ProDisc, 103 cc, vs fusion, 213 cc) and operative time (ProDisc, 90 minutes, vs fusion, 232 minutes) were significantly different (p<.01). Hospital stays were shorter (ProDisc, 2.24 days, vs fusion, 3.26 days [p<.01]) for ProDisc patients. There was a significant reduction in the ODQ scores from preoperative values in both ProDisc and fusion groups. Similarly, there was a significant reduction for both groups in VAS scores from before to after surgery. A trend was identified at 6 months in patient satisfaction rates favoring ProDisc versus fusion (p=.08), which became more pronounced (although still not statistically significant) at 1 year. Flexion and lateral bend range of motion was significantly improved in ProDisc patients compared with the fusion group (p=.02). Ambulatory status as well as recreational activity improved faster in the ProDisc group. The data suggest that total disc arthroplasty may be an attractive option to lumbar fusion for the surgical treatment of disabling mechanical low back pain secondary to lumbar disc disease.

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Spine J. 2004 Nov-Dec;4(6 Suppl):S151-7.
Why a mechanical disc?
Errico TJ.
Department of Orthopedic and Neurological Surgery, New York University School of Medicine, the Spine Service, Suite 8U, NYU-Hospital for Joint Diseases Department of Orthopedic Surgery, 530 First Avenue, New York, NY 10016, USA.

Low back pain secondary to degenerative disc disease is an overwhelming and growing problem in the United States and Western countries. Most degenerative disc disease can be treated nonoperatively. There are, however, substantial numbers of patients who have not benefited from exhaustive nonoperative treatments and subsequently seek surgical solutions to their incapacitating back pain. Lumbar fusion for back pain and/or leg pain associated with degenerative disc disease is considered the gold standard by which other treatments are judged. A challenge to spinal fusion for degenerative disc disease is now being offered in the form of the artificial disc. The implantation of an artificial lumbar disc allows for maintenance or restoration of physiologic movement at affected segments. A major long-term complication of spinal fusion is degeneration of a disc adjacent to the fused segments. Theoretically, the maintenance of motion could minimize development of adjacent disc degeneration as seen with spinal fusion. It is interesting to note that fusion of the hip or knee is not considered a primary procedure, but fusion is a primary procedure for the lumbar spine. Four artificial lumbar discs are discussed in this article. Early results are promising in terms of clinical results and movement, but long-term follow-up clinical trials must be done in order to gain an accurate comparison with spinal fusion. Trials are currently ongoing. The clinical results up to now and the potential for maintaining lumbar mobility throughout life warrant continuation of this surgical procedure.

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Acta Orthop Scand Suppl. 2004 Oct;75(313):2-43.
Lumbar spinal fusion. Outcome in relation to surgical methods, choice of implant and postoperative rehabilitation.
Christensen FB.
Faculty of Health Sciences, University of Aarhus, Spine Section, Orthopaedic Department, Orthopaedic Research Laboratory, Institute of Experimental Clinical Reaserch, Aarhus University Hospital, Denmark. f.b.christensen@dadlnet.dk

Chronic low back pain (CLBP) has become one of the most common causes of disability in adults under 45 years of age and is consequently one of the most common reasons for early retirement in industrialised societies. Accordingly, CLBP represents an expensive drain on society's resources and is a very challenging area for which a consensus for rational therapy is yet to be established. The spinal fusion procedure was introduced as a treatment option for CLBP more than 70 years ago. However, few areas of spinal surgery have caused so much controversy as spinal fusion. The literature reveals divergent opinions about when fusion is indicated and how it should be performed. Furthermore, the significance of the role of postoperative rehabilitation following spinal fusion may be underestimated. There exists no consensus on the design of a program specific for rehabilitation. Ideally, for any given surgical procedure, it should be possible to identify not only possible complications relative to a surgical procedure, but also what symptoms may be expected, and what pain behaviour may be expected of a particular patient. The overall aims of the current studies were: 1) to introduce patient-based functional outcome evaluation into spinal fusion treatment; 2) to evaluate radiological assessment of different spinal fusion procedures; 3) to investigate the effect of titanium versus stainless steel pedicle screws on mechanical fixation and bone ingrowth in lumbar spinal fusion; 4) to analyse the clinical and radiological outcome of different lumbar spinal fusion techniques; 5) to evaluate complications and re-operation rates following different surgical procedures; and 6) to analyse the effect of different rehabilitation strategies for lumbar spinal fusion patients. The present thesis comprises 9 studies: 2 clinical retrospective studies, 1 clinical prospective case/reference study, 5 clinical randomised prospective studies and 1 animal study (Mini-pigs). In total, 594 patients were included in the investigation from 1979 to 1999. Each had prior to inclusion at least 2 years of CLBP and had therefore been subjected to most of the conservative treatment leg pain, due to localized isthmic spondylolisthesis grades I-II or primary or secondary degeneration. PATIENT-BASED FUNCTIONAL OUTCOME: Patients' self-reported parameters should include the impact of CLBP on daily activity, work and leisure time activities, anxiety/depression, social interests and intensity of back and leg pain. Between 1993 and 2003 approximately 1400 lumbar spinal fusion patients completed the Dallas Pain Questionnaire under prospective design studies. In 1996, the Low Back Pain Rating scale was added to the standard questionnaire packet distributed among spinal fusion patients. In our experience, these tools are valid instruments for clinical assessment of candidates for spinal fusion procedures. RADIOLOGICAL ASSESSMENT: It is extremely difficult to interpret radiographs of both lumbar posterolateral fusion and anterior interbody fusion. Plain radiographs are clearly not the perfect media for analysis of spinal fusion, but until new and better diagnostic methods are available for clinical use, radiographs will remain the golden standard. Therefore, the development of a detailed reliable radiographic classification system is highly desirable. The classification used in the present thesis for the evaluation of posteroalteral spinal fusion, both with and without instrumentation, demonstrated good interobserver and intraobserver agreement. The classification showed acceptable reliability and may be one way to improve interstudy and intrastudy correlation of radiologic outcomes after posterolateral spinal fusion. Radiology-based evaluation of anterior lumbar interbody fusion is further complicated when cages are employed. The use of different cage designs and materials makes it almost impossible to establish a standard radiological classification system for anterior fusions. BONE-SCREW INTERFACE: Mechanical binding at the bone-screw interface was significantly greater for titanium pedicle screws than it was for stainless steel. This could be explained by the fact that the titanium screws had superior bone on-growth. There was no correlation between screw removal torques and pull-out strength. Clinically, the use of titanium and titanium-alloy pedicle screws may be preferable for osteoporotic patients and those with decreased osteogenesis. OUTCOME: The present series of studies observed significant long-term functional improvement for approximately 70% of patients who had undergone lumbar spinal fusion procedure. Solid fusion as determined from radiographs ranged from 52% to 92% depending on the choice of surgical procedure. The choice of surgical procedure should relate to the diagnosis, as patients with isthmic spondylolisthesis (Grades I and II) are best served with posterolateral fusion without instrumentation, and patients with disc degeneration seem to gain most from instrumented posterolateral fusion or circumferential fusion. COMPLICATIONS: The number of perioperative complications increased with the use of pedicle screw systems to support posterolateral fusions and increased further with the use of circumferential fusions. There was no significant association between outcome result and perioperative complications. The risk of reoperation within 2 years after the spinal fusion procedure was, however, significantly lower for those who had received circumferential fusion in comparison to posterolateral fusion with instrumentation. Furthermore, the risk of non-union was found to be significantly lower for patients who had received circumferential fusion as compared to posterolateral fusion with and without instrumentation. The complications of sexual dysfunction and fusion at non-intended levels were found to be significant but without influence on the overall outcome. REHABILITATION: The patients in the Back-cafe group performed a succession of many daily tasks significantly better and moreover had less pain compared with both the Video and Training groups 2 years after lumbar spinal fusion. The Video group had significantly greater treatment demands outside the hospital system. This study demonstrates the importance of the inclusion of coping schemes and questions the role of intensive exercises in a rehabilitation program for spinal fusion patients.

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J Manipulative Physiol Ther. 2004 Oct;27(8):509-14.
Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study.
Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N.
Laval University, Kinesiology Division and Quebec University in Trois-Rivieres, Chiropractic Department, Quebec, Canada. Martin_descarreaux@uqtr.ca <Martin_descarreaux@uqtr.ca>

OBJECTIVE: To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments. METHODS: Thirty patients with chronic nonspecific low-back pain were separated into 2 groups. The first group received 12 treatments in an intensive 1-month period but received no treatment in a subsequent 9-month period. For this group, a 4-week period preceding the initial phase of treatment was used as a control period to examine the sole effect of time on pain and disability levels. The second group received 12 treatments in an intensive 1-month period and also received maintenance spinal manipulation every 3 weeks for a 9-month follow-up period. Pain and disability levels were evaluated with a visual analog scale and a modified Oswestry questionnaire, respectively. RESULTS: The 1-month control period did not modify the pain and disability levels. For both groups, the pain and disability levels decreased after the intensive phase of treatments. Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels. CONCLUSIONS: Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.

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Drugs Today (Barc). 2004 Sep;40(9):765-72.
Pharmacotherapy in lower back pain.
Jackson KC 2nd.
Pain and Palliative Care, University Hospital and College of Pharmacy, University of Utah Health Sciences Center, Salt Lake City, Utah, USA. kenneth.jackson@hsc.utah.edu.

In the US, back pain is the second most common cause of disability and the leading cause among men, with approximately 45% of the adult population experiencing lower back pain annually and a direct cost for diagnosis and treatment reported to be higher than 23 billion US$ in 1990. However, despite the high prevalence of this condition, lower back pain diagnoses are commonly imprecise, and specific causes for lower back pain can only be determined in approximately 15% of patients. So, although for most patients with acute lower back pain, a simple cause-and-effect model can be described, often the result of a lumbar sprain or strain, clinicians must be alert to a variety of other conditions which may present in a similar fashion and require more emergent care. Pharmacotherapy and nondrug-related modalities have been shown to reduce pain and other related symptoms. Medication classes with known benefit include the nonsteroidal antiinflammatory drugs (NSAIDs), skeletal muscle relaxants, opioids, acetaminophen and the newer cyclooxygenase-2 (COX-2) inhibitors. This review analyzes the different drugs available for treating lower back pain in light of the most recent evidence coming from clinical studies. More critical research is needed to further define the roles of these medications in treating pain associated with lower back injury. (c) 2004 Prous Science. All rights reserved.

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Clin Ther. 2004 Sep;26(9):1355-67.
Commonly used muscle relaxant therapies for acute low back pain: a review of carisoprodol, cyclobenzaprine hydrochloride, and metaxalone.
Toth PP, Urtis J.
Department of Family and Community Medicine, University of Illinois School of Medicine, Peoria, USA.

BACKGROUND: Low back pain is a leading reason for primary care visits. Many treatment options are available, but some lack scientific support. OBJECTIVE: The aim of this review was to discuss the etiology of low back pain and the relative risks and benefits of muscle relaxants commonly prescribed for the management of back pain. METHODS: We searched Intercontinental Marketing Services data for January 2003 through January 2004 to determine the most commonly prescribed agents for the management of musculoskeletal pain. Carisoprodol, cyclobenzaprine hydrochloride, and metaxalone represented >45% of all such prescriptions. Cochrane Library, MEDLINE, and EMBASE databases were searched (time frame: 1960 through January 2004; search terms: back pain, carisoprodol, cyclobenzaprine, metaxalone, muscle relaxants, and pharmacotherapy) and reference lists of identified articles were hand-searched. RESULTS: Three trials of carisoprodol (N = 197) were located in the Cochrane Library database. Two double-blind, randomized, placebo-controlled trials evaluating the safety and efficacy of cyclobenzaprine hydrochloride (N = 1405) were identified in the literature. Three double-blind, placebo-controlled trials were identified for metaxalone (N = 428) in 2 reports. The types of adverse events seen with these agents involved the central nervous system, including drowsiness/sedation, fatigue, and dizziness. However, the efficacy of cyclobenzaprine hydrochloride was shown to be independent of its sedative effects, which were dose related. The potential for abuse with carisoprodol is of growing concern. CONCLUSIONS: Analgesic pain management for low back pain due to muscle spasm may be combined with a muscle relaxant. Cyclobenzaprine hydrochloride has the most recent and largest clinical trials demonstrating its benefit, but carisoprodol and metaxalone also appear to be effective. However, carisoprodol's usefulness is mitigated by its potential for abuse.

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Scand J Rheumatol Suppl. 2004;(119):76-8.
Treatment of chronic low back pain with tropisetron.
Stratz T, Muller W.
Hochrhein Institute of Rehabilitation Research, Department of Clinical Research, Bad Sackingen, Germany. mehrer@hri.de

BACKGROUND: Various pathophysiological processes can lead to chronic back pain, which necessitates a differentiated therapeutic approach. In addition, psychic and psychosocial processes may influence the clinical picture. METHOD: Twenty-five patients with chronic back pain were enrolled in the study. Patients suffering from psychosocial stresses and depressions were excluded from the study. The patients with painful tendinopathies and myofascial pain syndromes were treated with local injections of 5-10 mg tropisetron, and patients with degenerative processes were treated for 5 days with an intravenous (i.v.) bolus injection of 5 mg tropisetron (Navoban). Before treatment and 7 and 14 days later, the visual analog pain scale was filled in. The long-term drug therapy could be continued. RESULTS: There was a highly significant pain reduction with a very potent effect both in the locally treated group and in the intravenously treated group. Most of the patients could discontinue or reduce their long-term therapy with non-steroidal anti-inflammatory drugs or analgesics. CONCLUSION: A marked improvement in pain could be achieved in an open study by treating back pain of a primarily somatic nature with the 5-HT3 receptor antagonist tropisetron. A reduction in pain of > or =50% was reported by 76% of the patients. These results should be substantiated by the corresponding randomized, placebo-controlled, double blind studies that are needed to investigate the true benefit of treating back pain with 5-HT3 receptor antagonists.

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Clin J Pain. 2004 Sep-Oct;20(5):319-23.
Statistical reanalysis of four recent randomized trials of acupuncture for pain using analysis of covariance.
Vickers AJ.
Integrative Medicine Service, Biostatistics Service, Memorial Sloan-Kettering Cancer Center, New York, NY.

OBJECTIVES:: Acupuncture has been promoted for the treatment of chronic pain. Though many randomized trials have been conducted, these have been criticized for deficiencies of methodology, acupuncture technique, and sample size. Somewhat less emphasis has been placed on methods of statistical analysis. This paper describes 4 recent randomized trials of acupuncture for musculoskeletal or headache pain. Each trial used statistical methods that did not adjust for baseline pain scores and were thus of suboptimal power. The objective of this study is to reanalyze the trials using analysis of covariance (ANCOVA). METHODS:: Raw data for the 4 trials were obtained from the original authors. Data were reanalyzed by ANCOVA. RESULTS:: For 2 trials-acupuncture versus placebo for chronic headache and acupuncture versus transcutaneous electric nerve stimulation for back pain-reanalysis did not change the conclusion of no difference between groups, but showed that clinically significant differences between groups could not ruled out. Reanalysis of a trial of acupuncture versus placebo for shoulder pain slightly strengthened the evidence of acupuncture effectiveness. Reanalysis of the fourth trial, which compared acupuncture to placebo acupuncture and massage for neck pain, reversed the results of the original paper: reanalysis found acupuncture to be effective and that its effectiveness could not be ascribed to a placebo effect. DISCUSSION:: Future trials of acupuncture and other modalities for pain should use efficient statistical methods. ANCOVA is more efficient than unadjusted analysis where used appropriately.

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J Manipulative Physiol Ther. 2004 Jul-Aug;27(6):388-98.
A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.
Hoiriis KT, Pfleger B, McDuffie FC, Cotsonis G, Elsangak O, Hinson R, Verzosa GT.
College of Chiropractic, Chiropractic Sciences Division, Life University, Marietta, Ga 30060, USA. khoiriis@life.edu

BACKGROUND: The adult lifetime incidence for low back pain is 75% to 85% in the United States. Investigating appropriate care has proven difficult, since, in general, acute pain subsides spontaneously and chronic pain is resistant to intervention. Subacute back pain has been rarely studied. OBJECTIVE: To compare the relative efficacy of chiropractic adjustments with muscle relaxants and placebo/sham for subacute low back pain. DESIGN: A randomized, double-blind clinical trial. METHODS: Subjects (N = 192) experiencing low back pain of 2 to 6 weeks' duration were randomly allocated to 3 groups with interventions applied over 2 weeks. Interventions were either chiropractic adjustments with placebo medicine, muscle relaxants with sham adjustments, or placebo medicine with sham adjustments. Visual Analog Scale for Pain, Oswestry Disability Questionnaire, and Modified Zung Depression Scale were assessed at baseline, 2 weeks, and 4 weeks. Schober's flexibility test, acetaminophen usage, and Global Impression of Severity Scale (GIS), a physician's clinical impression used as a secondary outcome, were assessed at baseline and 2 weeks. RESULTS: Baseline values, except GIS, were similar for all groups. When all subjects completing the protocol were combined (N = 146), the data revealed pain, disability, depression, and GIS decreased significantly (P <.0001); lumbar flexibility did not change. Statistical differences across groups were seen for pain, a primary outcome, (chiropractic group improved more than control group) and GIS (chiropractic group improved more than other groups). No significant differences were seen for disability, depression, flexibility, or acetaminophen usage across groups. CONCLUSION: Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS.

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Prev Med. 2004 Jul;39(1):168-76.
A randomized controlled clinical trial for low back pain treated by acupressure and physical therapy.
Hsieh LL, Kuo CH, Yen MF, Chen TH.
Institute of Prevention Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.

BACKGROUND: Although acupressure has been reported to be effective in managing various types of pain, its efficacy in relieving pain associated with low back pain (LBP) remains unclear. The aim of this study is to compare the efficacy of acupressure with that of physical therapy in reducing low back pain. METHODS: A randomized controlled clinical trial in an orthopedic referral hospital in Taiwan was conducted between December 20, 2000, and March 2, 2001. A total of 146 participants with chronic low back pain were randomly assigned to the acupressure group (69) or the physical therapy group (77), each with a different treatment technique. Self-appraised pain scores were obtained before treatment as baseline and after treatment as outcomes using the Chinese version of Short-Form Pain Questionnaire (SF-PQ). RESULTS: There were no significant differences in baseline characteristics among patients randomized into the two groups. The mean of posttreatment pain score after a 4-week treatment (2.28, SD = 2.62) in the acupressure group was significantly lower than that in the physical therapy group (5.05, SD = 5.11) (P = 0.0002). At the 6-month follow-up assessment, the mean of pain score in the acupressure group (1.08, SD = 1.43) was still significantly lower than that in the physical therapy group (3.15, SD = 3.62) (P = 0.0004). CONCLUSIONS: Our results suggest that acupressure is another effective alternative medicine in reducing low back pain, although the standard operating procedures involved with acupressure treatment should be carefully assessed in the future. Copyright 2004 The Institute for Cancer Prevention and Elsevier Inc.

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J Pain Symptom Manage. 2004 Jul;28(1):72-95.
A comprehensive review of clinical trials on the efficacy and safety of drugs for the treatment of low back pain.
Schnitzer TJ, Ferraro A, Hunsche E, Kong SX.
Office of Clinical Research and Training, Northwestern University, Chicago, Illinois, USA.

A systematic review involving 50 randomized controlled trials (4,863 patients) published since 1980 was undertaken with the objective of assessing efficacy and safety of low back pain (LBP) medications. The methodological quality of each trial was evaluated based on a standardized system. Quality scores ranged from 26 to 82 points on a 100-point scale (from 0 to 100), indicating an overall moderate quality of the trials reviewed. Limited evidence was found regarding the effectiveness of drug treatments for LBP and current studies focused on short-term usage of the therapies. Available evidence supported the effectiveness of non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) in acute and chronic LBP, of muscle relaxants in acute LBP, and of antidepressants in chronic LBP; safety results were heterogeneous. More rigorously designed trials should be implemented to establish comparative efficacy and safety of drugs used to treat chronic and acute LBP.

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Curr Med Res Opin. 2004 Jul;20(7):1075-85.
Efficacy of etanercept delivered by perispinal administration for chronic back and/or neck disc-related pain: a study of clinical observations in 143 patients.
Tobinick E, Davoodifar S.
Institute Research Associates, A Medical Group, Inc, Los Angeles, CA, USA. etmd@ucla.edu

OBJECTIVE: Documentation of the clinical results obtained utilizing perispinal etanercept off-label for treatment-refractory back and neck pain in a clinical practice setting. RESEARCH DESIGN AND METHODS: The medical charts of all patients who were treated with etanercept for back or neck pain at a single private medical clinic in 2003 were reviewed retrospectively. Patients were treated if they had disc-related pain which was chronic, treatment-refractory, present every day for at least 8 h, and of moderate or severe intensity. Patients with active infection, demyelinating disease, uncontrolled diabetes, lymphoma or immunosuppression were excluded from treatment with etanercept. Etanercept 25 mg was administered by subcutaneous injection directly overlying the spine. Visual Analogue Scales (VAS, 0-10 cm) for intensity of pain, sensory disturbance, and weakness prior to and 20 min, 1 day, 1 week, 2 weeks, and 1 month after treatment were completed. Inclusion criteria for analysis required baseline and treatment VAS data. MAIN OUTCOME MEASURES: Before and after treatment VAS comparisons for intensity of pain, sensory disturbance, and weakness. RESULTS: 143 charts out of 204 met the inclusion VAS criteria. The 143 patients had a mean age of 55.8 +/- 14, duration of pain of 9.8 +/- 11 years, and an initial Oswestry Disability Index of 42.8 +/- 18, with 83% having back pain, 61% sciatica, and 33% neck pain. 30% had previous spinal surgery, and 69% had previously received epidural steroid injections (mean 3.0 +/- 3). The patients received a mean of 2.3 +/- 0.7 doses of perispinal etanercept separated by a mean interval of 13.6 +/- 16.3 days. The mean VAS intensity of pain, sensory disturbance, and weakness were significantly reduced after perispinal etanercept at 20 min, 1 day, 1 week, 2 weeks, and 1 month with a p < 0.0001 at each time interval for the first dose in this patient population. CONCLUSIONS: Perispinal etanercept is a new treatment modality which can lead to significant clinical improvement in selected patients with chronic, treatment-refractory disc-related pain. Generalizability of the present study results is limited by the open-label, uncontrolled methodology employed. Based on this and other accumulating recent studies, etanercept may be useful for both acute and chronic disc-related pain. Further study of this new treatment modality utilizing double-blind placebo controlled methodology is indicated. NOTE: This treatment method is protected by multiple patents awarded to Edward Tobinick MD, including U. S. patents 6 015 557; 6 177 077; 6 419 944; 6 537 549 and Australian patent 758 523.

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Fortschr Neurol Psychiatr. 2004 Jun;72(6):344-50.
[Therapy of back pain: what is evidence-based?]
[Article in German]
Weiland T, Wessel K.
Neurologische Klinik des Stadtischen Klinikums, Braunschweig. k.wessel@klinikum-braunschweig.de

Back pain has to be classified by localisation, duration, and existence or absence of neurological deficits. Therapy mainly depends on the severity of neurological symptoms. The time period between the onset of symptoms and efficient therapy should be short in order to prevent the development of chronic pain. Therefore a sufficient, consistent and evidence-based conservative treatment should be initiated early on, with the only exception of special emergency situations as described further down in this article. Patients should not be immobilized, a better outcome is proven in patients who immediately continued practising their daily activities. First line medication consists of non-steroidal-anti-inflammatory-drugs (NSAID). If necessary, opioids and muscle-relaxants may be applied additionally. Surgical procedures are only indicated in a small number of patients. A sufficient data base with regard to the benefit of acupuncture, orthesis, and chiropractic medicine is lacking. Local injections should only be done in very special cases. Concerning chronic back pain a multimodal, multi-disciplinary pain treatment concept with physical training and behavioural therapy should be applied in order to teach the patient to avoid a passive and maladjusted attitude. Antidepressant drugs may also be indicated in chronic back pain.

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Aust Fam Physician. 2004 Jun;33(6):427-30.
Back pain rehabilitation.
Thomas CH, MacAdams D.
Medical Services, Victorian Rehabilitation Centre, Affinity Health. clayton.thomas@affinityhealth.com.au

BACKGROUND: Back pain is a universal problem that becomes persistent in 5-10% of patients following an acute episode. This makes it one of the most costly areas of health care in Australia. OBJECTIVE: This article outlines the paradigm that general practitioners should adopt to assist the patient to live with their pain experience. DISCUSSION: The development of persistent back pain is not a static process but one that is heavily influenced by the context in which it occurs. Patient characteristics, health care providers and the health system environment contribute and interact to promote the development of persistent pain. Health care providers involved in managing persistent pain should remain confidant, positive and reassuring. They should encourage activity, discourage fear avoidance behaviour, and consider rehabilitation early before illness beliefs become entrenched. Multidisciplinary rehabilitation, when used early, aims to improve function and assist in the return to work process; when used late, it aims to prevent worsening disability and increased coping for patients.

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Aust Fam Physician. 2004 Jun;33(6):421-6.
Interventions in chronic low back pain.
Verrills P, Vivian D.
Metropolitan Spinal Clinic, Victoria. pverrills@metspinal.com

BACKGROUND: Chronic low back pain presents a major challenge for general practitioners and is a significant drain on community resources. Patients often feel frustrated by modern medicine's apparent failure to validate their symptoms with a specific diagnosis and management plan. OBJECTIVE: This article presents an evidence based guide to current interventions, including an algorithm for the interventional diagnostic workup of low back pain that has persisted beyond 3 months. DISCUSSION: Modern imaging techniques rarely determine the cause of pain. The GP must look for 'red flag' clues in the history. Management of low back pain includes NSAIDs, simple injections of plain local anaesthetic without adrenalin or cortisone, referral to a masseuse, cortisone, physiotherapist and/or a musculoskeletal pain physician. Specific management includes medial branch and sacroiliac joint blocks, and radiofrequency neurotomy. Patients with long term pain may be referred to a psychologist for cognitive behavioural therapy.

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Clin Rheumatol. 2004 Jun 22 [Epub ahead of print]
Effects of alendronate on metacarpal and lumbar bone mineral density, bone resorption, and chronic back pain in postmenopausal women with osteoporosis.
Iwamoto J, Takeda T, Sato Y, Uzawa M.
Department of Sports Medicine, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku-ku, 160-8582, Tokyo, Japan.

The purpose of this study was to investigate the effect of alendronate on metacarpal and lumbar bone mineral density (BMD), bone resorption, and chronic back pain in postmenopausal women with osteoporosis. Eighty postmenopausal women with osteoporosis, 59-88 years of age, were divided into two groups of 40 each according to the site of BMD measurement: the metacarpus (M) and the lumbar spine (L). All of them were treated with alendronate (5 mg/day) for 12 months. Metacarpal or lumbar BMD was measured by computed X-ray densitometry or dual-energy X-ray absorptiometry in the M or the L group, respectively, at baseline and every 6 months. Urinary cross-linked N-terminal telopeptides of type I collagen (NTX) were measured by enzyme-linked immunosorbent assay, and chronic back pain was evaluated by face scale score at baseline and every 6 months in both groups. There were no significant differences in baseline characteristics, including age, body mass index, years since menopause, urinary NTX level, face scale score, or number of prevalent vertebral fractures per patient between the two groups. Urinary NTX level was reduced and chronic back pain was improved similarly in both groups. Whereas metacarpal BMD did not significantly change in the M group (0.20% increase), lumbar BMD increased by 8.15% in the L group. These results suggest that although alendronate increases BMD of the lumbar spine, which is rich in cancellous bone, and improves chronic back pain, with suppression of bone resorption in postmenopausal women with osteoporosis, it may fail to increase cortical BMD of the metacarpus, a distal site of the upper extremity.

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Drugs Today (Barc). 2004 May;40(5):395-414.
Etoricoxib.
Matsumoto AK, Cavanaughr PF Jr.
Arthritis and Rheumatism Associates, Wheaton, Maryland 20902, USA. akmatsumoto@arapc.com

Etoricoxib (Arcoxia, Merck & Co., Inc.) is a selective inhibitor of cyclooxygenase-2 (COX-2), an enzyme involved in pain and inflammation. It is a member of the COX-2-selective (coxib) class of nonsteroidal antiinflammatory drugs (NSAIDs). Extensive clinical trials have confirmed its analgesic and antiinflammatory efficacy to be at least as good as and in some cases superior to nonselective NSAIDs in a number of disease and patient treatment settings. Etoricoxib displays improved gastrointestinal safety compared with nonselective NSAIDs and has a favorable overall safety and tolerability profile. It is rapidly and completely absorbed following oral administration providing a rapid onset of action. Its long plasma half-life allows for once-daily dosing. Etoricoxib is currently approved in a number of countries for various indications including the treatment of acute pain, acute gouty arthritis, chronic low back pain, primary dysmenorrhea, and chronic treatment for the signs and symptoms of osteoarthritis and rheumatoid arthritis. In countries where it is approved, the highest recommended daily dose for chronic use is 90 mg for rheumatoid arthritis and 60 mg for osteoarthritis and chronic low back pain. The recommended daily dose for acute pain relief treatment from primary dysmenorrhea and acute gouty arthritis is 120 mg. This review summarizes the published preclinical and clinical data relevant to the use of etoricoxib in clinical practice. (c) 2004 Prous Science. All rights reserved.

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Curr Pain Headache Rep. 2004 Jun;8(3):173-7.
Anti-inflammatory Agents for the Treatment of Musculoskeletal Pain and Arthritis.
Fakata KL.
University of Utah Health Sciences Center, Pharmacy Practice, 30 South 2000 East, Room 201, Salt Lake City, UT 84132, USA. Keri.fakata@hsc.utah.edu

Pain produced by musculoskeletal disorders commonly misconceived as having mechanical etiology often is caused by inflammatory mechanisms. Simple analgesics (ie, those that lack anti-inflammatory action) often are used to treat musculoskeletal pain when an anti-inflammatory analgesic may be more effective for the painful condition. This review addresses the anti-inflammatory agents available for the symptomatic management of common inflammatory musculoskeletal conditions including osteoarthritis, rheumatoid arthritis, and low back pain.

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Eur J Pain. 2004 Jun;8(3):211-9.
Catastrophizing and internal pain control as mediators of outcome in the multidisciplinary treatment of chronic low back pain.
Spinhoven P, Ter Kuile M, Kole-Snijders AM, Hutten Mansfeld M, Den Ouden DJ, Vlaeyen JW.
Leiden University Medical Center, Leiden, The Netherlands.

The aim of the present study was to examine (a) whether a cognitive-behavioral treatment (differentially) affects pain coping and cognition; and (b) whether changes in pain coping and cognition during treatment mediate treatment outcome. Participants in this randomized clinical trial were 148 patients with chronic low back pain attending a multidisciplinary treatment program consisting of operant-behavioral treatment plus cognitive coping skills training ( [Formula: see text] ) or group discussion ( [Formula: see text] ) or allocated to a waiting list control condition ( [Formula: see text] ). Patients improved with respect to level of depression, pain behavior and activity tolerance at posttreatment and 12-month follow-up. Treatment also resulted in a short- and long-term decrease in catastrophizing and an enhancement of internal pain control. Changes in catastrophizing and to a lesser degree in internal pain control mediated the reduction in level of depression and pain behavior following treatment. The use of behavioral and cognitive interventions aimed at decreasing catastrophizing thoughts about the consequences of pain and promoting internal expectations of pain control possibly constitute an important avenue of change irrespective of the type of treatment.

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Acta Neurochir (Wien). 2004 May;146(5):469-76. Epub 2004 Apr 08.
Treatment of pain from osteoporotic vertebral collapse by percutaneous PMMA vertebroplasty.
Winking M, Stahl JP, Oertel M, Schnettler R, Boker DK.
Neurosurgical Clinic, Justus-Liebig University Giessen, Giessen, Germany.

Background. Vertebral compression fractures are common complications in advanced osteoporosis. In general, this disease of the elderly patient is characterized by severe local back pain. Pathophysiologically, bony instability triggers local pain during body movement. Serious pain immobilizes the patients and forces them to bed rest. As a result, complications like thrombosis or pneumonia occur. Invasive treatment with surgical instrumentation for vertebral stabilization is not indicated in elderly patients especially with additional diseases.The purpose of this study was to test the hypothesis that percutaneous polymethylmethacrylate (PMMA) vertebroplasty significantly reduces pain due to vertebral collapse in osteoporotic patients and improves quality of life. Methods. A total of 38 patients with osteoporotic vertebral compression fractures of the thoracic and lumbar spine were treated by PMMA vertebroplasty. After admission, before discharge from the hospital, six weeks, half a year and one year later patients answered the Oswestry Low Back Pain Disability (OLBPD) Questionnaire for assessment of treatment related change in disability. In all patients percutaneous vertebroplasty was performed under local anesthesia. Findings. A total of 92% of patients reported a significant pain reduction immediately after treatment. Also one year after vertebroplasty pain remained significantly reduced. Vertebroplasty was highly beneficial for patients with pain related to local instability of the spine. Extravasation of PMMA beyond the vertebral margins was observed in 26% of the cases. No treatment related clinical or neurological complications were noticed. Interpretation. PMMA vertebroplasty is a useful and safe method of pain relief which rapidly regains quality of life for patients with osteoporotic vertebral compression.

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Cochrane Database Syst Rev. 2004;2:CD004059.
Prolotherapy injections for chronic low-back pain.
Yelland M, Mar C, Pirozzo S, Schoene M, Vercoe P.
School of Medicine, University of Queensland, Inala Health Centre General Practice, 64 Wirraway Pde, Inala, Queensland, AUSTRALIA, 4077.

BACKGROUND: Prolotherapy is an injection-based treatment for chronic low-back pain. Proponents of prolotherapy suggest that some back pain stems from weakened or damaged ligaments. Repeatedly injecting them with irritant solutions is believed to strengthen the ligaments and reduce pain and disability. Prolotherapy protocols usually include co-interventions to enhance the effectiveness of the injections. OBJECTIVES: To determine the efficacy of prolotherapy injections in adults with chronic low-back pain. SEARCH STRATEGY: We searched CENTRAL (2004, issue 1), MEDLINE, EMBASE, CINAHL and Science Citation Index from their respective beginnings to January 2004, with no restrictions on language. We consulted content experts to ensure we had not missed any references. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing prolotherapy injections to control injections, either alone or in combination with other treatments, were included. Studies had to include measures of pain and disability before and after the intervention. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected the trials and assessed them for methodological quality. Treatment and control group protocols varied from study to study, making meta-analysis impossible. MAIN RESULTS: We included four high quality studies with a total of 344 participants. All trials measured pain and disability levels at six months, three measured the proportion of participants reporting a greater than 50% reduction in pain or disability scores from baseline to six months.Two studies showed significant differences between the treatment and control groups for those reporting over 50% reduction in pain or disability. Their results could not be pooled. In one, co-interventions confounded interpretation of results; in the other, there was no significant difference in mean pain and disability scores between the groups. In the third study, there was little or no difference between groups in the number of individuals who reported over 50% improvement in pain and disability. The fourth study reporting only mean pain and disability scores showed no differences between groups. REVIEWERS' CONCLUSIONS: There is conflicting evidence regarding the efficacy of prolotherapy injections in reducing pain and disability in patients with chronic low-back pain. Conclusions are confounded by clinical heterogeneity amongst studies and by the presence of co-interventions. There was no evidence that prolotherapy injections alone were more effective than control injections alone. However, in the presence of co-interventions, prolotherapy injections were more effective than control injections, more so when both injections and co-interventions were controlled concurrently.

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Spine. 2004 Mar 11;29(6):E107-E112.
Hip Strategy for Balance Control in Quiet Standing Is Reduced in People With Low Back Pain.
Mok NW, Brauer SG, Hodges PW.
*Department of Physiotherapy, University of Queensland, and the; daggerDepartment of Physiotherapy, Princess Alexandra Hospital, Brisbane, Queensland, Australia.

STUDY DESIGN.: Quiet stance on supporting bases with different lengths and with different visual inputs were tested in 24 study participants with chronic low back pain (LBP) and 24 matched control subjects. OBJECTIVES.: To evaluate postural adjustment strategies and visual dependence associated with LBP. SUMMARY OF BACKGROUND DATA.: Various studies have identified balance impairments in patients with chronic LBP, with many possible causes suggested. Recent evidence indicates that study participants with LBP have impaired trunk muscle control, which may compromise the control of trunk and hip movement during postural adjustments (e.g., hip strategy). As balance on a short base emphasizes the utilization of the hip strategy for balance control, we hypothesized that patients with LBP might have difficulties standing on short bases. METHODS.: Subjects stood on either flat surface or short base with different visual inputs. A task was counted as successful if balance was maintained for 70 seconds during bilateral stance and 30 seconds during unilateral stance. The number of successful tasks, horizontal shear force, and center-of-pressure motion were evaluated. RESULTS.: The hip strategy was reduced with increased visual dependence in study participants with LBP. The failure rate was more than 4 times that of the controls in the bilateral standing task on short base with eyes closed. Analysis of center-of-pressure motion also showed that they have inability to initiate and control a hip strategy. CONCLUSIONS.: The inability to control a hip strategy indicates a deficit of postural control and is hypothesized to result from altered muscle control and proprioceptive impairment.

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Pain Med. 2004 Mar;5(1):6-13.
Intrathecal Drug Delivery for Treatment of Chronic Low Back Pain: Report from the National Outcomes Registry for Low Back Pain.
Deer T, Chapple I, Classen A, Javery K, Stoker V, Tonder L, Burchiel K.
Center for Pain Relief, Charleston, West Virginia; Carolina Pain Specialists, West Columbia, South Carolina; Trinity Pain Medicine Associates, Osteopathic Medical Center, Fort Worth, Texas; Michigan Pain Consultants, Metropolitan Hospital, Grand Rapids, Michigan; Medtronic Neurological, Minneapolis, Minnesota; Oregon Health Sciences University, Department of Neurological Surgery, Portland, Oregon.

OBJECTIVE: To obtain data on patient demographics, clinical practices, and long-term outcomes for patients with chronic low back pain treated with implantable drug-delivery systems. DESIGN: The National Outcomes Registry for Low Back Pain collected data at baseline, trialing, implant (or decision not to implant), and at 6- and 12-month follow-ups. Data were collected at all time points, regardless of implant status. OUTCOME MEASURES: Numeric pain ratings and Oswestry Low Back Pain Disability scores from implanted patients were compared among baseline and 6- and 12-month follow-ups. Patients were also asked to rate their quality of life and satisfaction with the therapy. RESULTS: Thirty-six physicians enrolled 166 patients to be trialed for drug-delivery systems. The trialing success rate was 93% (154 patients). In all, 136 patients (82%) were implanted. In the implant group, numeric pain ratings dropped by more than 47% for back pain and more than 31% for leg pain at the 12-month follow-up. More than 65% of implanted patients reduced their Oswestry scores by at least one level at their 12-month follow-ups compared with baseline. At 12-month follow-ups, 80% of implanted patients were satisfied with their therapy and 87% said they would undergo the procedure again. CONCLUSIONS: Current clinical practices related to trialing of drug-delivery systems resulted in the majority of patients successfully trialed. At 12-month follow-ups, implanted patients experienced reductions in numeric back and leg pain ratings, improved Oswestry scores, and high satisfaction with the therapy.

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Ann Readapt Med Phys. 2004 Feb;47(1):20-7.
[Use of isokinetic techniques vs standard physiotherapy in patients with chronic low back pain. Preliminary results]
[Article in French]
Calmels P, Jacob JF, Fayolle-Minon I, Charles C, Bouchet JP, Rimaud D, Thomas T.
Service de medecine physique et de readaptation, CHU de Saint-Etienne, hopital Bellevue, 42055 Saint-Etienne cedex 2, France. paul.calmels@chu-st-etienne.fr

OBJECTIVE: To determine if the use of an isokinetic device for trunk exercise is more effective than standard physiotherapy in promoting motor disinhibition for patients with chronic low back pain. POPULATION: chronic low back pain outpatients who are treated in a Rheumatology or PM & R unit within an academic hospital. METHODOLOGY: This is a prospective, controlled, randomized study, with two groups of treatment: one treated with isokinetic techniques and the other with standard physiotherapy, six sessions for each treatment during 2 weeks. Outcome measures include pain (VSA), trunk mobility (Schober index, distance from fingers to floor), muscle extensibility and muscle strength (Biering-Sorensen and Shirado-Ito test), and functional capacity (Quebec scale). RESULTS: Seventeen subjects were enrolled. The results suggest that both isokinetic exercise and physiotherapy result in improved range of motion, extensibility, muscle strength, and pain, without any significant superiority of one technique over the other. However, each technique has specific advantage. DISCUSSION: Despite methodologic limitations, this study shows that isokinetic exercise is not better than physiotherapy in reversing motor inhibition in chronic low back pain. Our results are consistent with those of other studies in the literature, with regard to the absence of established overall superiority of one exercise technique or program over the other in this population, and with regard to partial benefits of specific exercise techniques. CONCLUSION: The non-specific benefit of one technique indicates that further studies are needed to evaluate the benefit of combining exercise techniques in chronic low back pain, in order to address the multiple factors involved in this pathology.

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Cochrane Database Syst Rev. 2004;1:CD000447.
Spinal manipulative therapy for low back pain.
Assendelft W, Morton S, Yu EI, Suttorp M, Shekelle P.
Department of Guideline Development and Research Policy, Dutch College of General Practioners, P.O. Box 3231, Utrecht, NETHERLANDS, 3502 GE.

BACKGROUND: Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain. OBJECTIVES: To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened. SELECTION CRITERIA: Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). MAIN RESULTS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. REVIEWER'S CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

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Am J Phys Med Rehabil. 2004 Feb;83(2):104-11.
Electrical twitch-obtaining intramuscular stimulation in lower back pain: a pilot study.
Chu J, Yuen KF, Wang BH, Chan RC, Schwartz I, Neuhauser D.
Department of Rehabilitation Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA.

OBJECTIVES: To determine if electrical twitch-obtaining intramuscular stimulation (ETOIMS) provides greater myofascial lower back pain relief than muscle stimulation or skin stimulation. DESIGN: In this single-blinded, crossover, pilot trial performed at a university-affiliated outpatient rehabilitation medicine department in Taiwan, 12 acupuncture-naive patients with lower back pain of 3-60 mos duration received one crossover treatment every 2 wks by monopolar needle electrode insertion at bilateral T10-S1 levels to: (1) paraspinal muscles, (2) overlying skin, and (3) paraspinal muscles with ETOIMS applied via the needle electrode at individual treatment sites. A total of 30 manual insertions per side per treatment were performed, with withdrawal after 2 secs. Beginning 1 wk before each trial and continuing until 2 wks after, patients completed a visual analog scale twice daily. In addition, on the day of treatment, patients received a physical examination and completed a visual analog scale both before and after treatment. RESULTS: Significant and immediate reduction in the visual analog scale levels was noted only with ETOIMS. Immediate improvement occurred in one of nine physical tests with muscle stimulation and ETOIMS only. In the 2 wks after treatment, absolute visual analog scale levels for ETOIMS were significantly lower than muscle stimulation and skin stimulation. ETOIMS resulted in a greater percentage of pain relief in the first week after treatment, although it was not statistically significant from muscle stimulation and skin stimulation. CONCLUSIONS: ETOIMS provided significantly greater immediate and sustained myofascial lower back pain relief than muscle stimulation and skin stimulation. Although a greater percentage of pain reduction occurred with ETOIMS, it was not statistically significant.

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Am J Phys Med Rehabil. 2004 Feb;83(2):94-103.
Effectiveness of a multidisciplinary occupational training program for chronic low back pain: a prospective cohort study.
Koopman FS, Edelaar M, Slikker R, Reynders K, van der Woude LH, Hoozemans MJ.
Institute for Fundamental and Clinical Human Movement Sciences, Faculty of Human Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands.

OBJECTIVE: To evaluate the effectiveness of a 12-wk multidisciplinary occupational training program for patients with chronic low back pain and to identify prognostic factors for treatment success. DESIGN: A total of 51 participants were evaluated at baseline, at discharge, and at 1 yr after conclusion of the program. The evaluation included a physical examination and assessment of functional disability, psychological factors, and coping styles. The main target of the program is full work resumption. The central outcome measures therefore are three variables on return to work. RESULTS: Analysis of variance for repeated measures revealed significant beneficial changes during the program for all measures except for several coping-style variables. The acquired level of maximum oxygen uptake, trunk flexibility, functional disability, and catastrophizing were maintained at 1-yr follow-up. At 1-yr follow-up, >60% of the participants had fully returned to work, which is an increase of >40% compared with baseline. Regression analyses showed that sex, age, the baseline values of reinterpretation of pain sensations, and functional disability and changes in trunk flexibility scores during the program are important prognostic factors for complete return to work. CONCLUSIONS: Based on the current findings, the program seems to be efficacious in the short term. Future attention must be directed toward maintaining these results, although work resumption rates improved considerably 1 yr after conclusion of the program.

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Curr Opin Pediatr. 2004 Feb;16(1):37-46.
Symptomatic spondylolysis: diagnosis and treatment.
Lim MR, Yoon SC, Green DW.
Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY 10021, USA. moelim@yahoo.com

PURPOSE OF REVIEW: Approximately 35% of adolescents experience back pain. In athletic adolescents, spondylolysis is the most common offending cause. With growing numbers of adolescents participating in sports with higher levels of intensity, spondylolysis is becoming an increasingly common clinical problem. RECENT FINDINGS: A recent report demonstrated the benign natural history of asymptomatic spondylolysis. However, long-term follow-up studies of patients who experience painful spondylolysis as adolescents remain unavailable. Modern imaging modalities have led to earlier diagnosis with greater accuracy. Conservative management with bracing continues to be a mainstay of treatment. In patients who are not helped by conservative therapy, recent studies have demonstrated the satisfactory long-term results of surgical repair. SUMMARY: The long-term sequelae of symptomatic spondylolysis and unhealed pars defects require investigation. MRI promises to be a valuable tool for diagnosis and clinical stratification, but further studies are necessary to demonstrate its clinical utility.

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Spine J. 2004 Jan-Feb;4(1):106-15.
Exercise as a treatment for chronic low back pain.
Rainville J, Hartigan C, Martinez E, Limke J, Jouve C, Finno M.
The Spine Center at New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120, USA. jrainvil@caregroup.harvard.edu

BACKGROUND CONTEXT: Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work. PURPOSE: The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain. STUDY DESIGN/SETTING: A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article. RESULTS: For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research. CONCLUSIONS: Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.

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Spine J. 2004 Jan-Feb;4(1):56-63.
National trends in nonoperative care for nonspecific back pain.
Feuerstein M, Marcus SC, Huang GD.
Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA. mfeuerstein@usuhs.mil

BACKGROUND CONTEXT: Few empirical data are available that document changes in population-based rates for the evaluation and treatment of nonspecific back pain. PURPOSE: To determine the extent of change in the pattern of outpatient evaluation and treatment of nonspecific low back pain in the United States between 1987 and 1997. STUDY DESIGN AND SETTING: The 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey, two nationally representative surveys with similar sampling methods and questions, were used. PATIENT SAMPLE: Noninstitutionalized adults in the United States. OUTCOME MEASURES: Changes in rates of any health service for nonspecific back pain and occurrence of provider-specific care and types of services provided. Changes in the prescription of specific medication classes (ie, nonsteroidal anti-inflammatory drugs [NSAIDs], muscle relaxants, nonnarcotic and narcotic analgesics) were also investigated. RESULTS:Overall rate for outpatient treatment for nonspecific back pain in the US population was relatively stable over the decade (4.48% in 1987, 4.53% in 1997, p=.85). Among those receiving care, the proportion receiving physician care increased from 64% in 1987 to 74% in 1997 (p<.001), whereas those obtaining care from physical therapists increased from 5% to 9% during the same time period (p<.01). The proportion of respondents receiving NSAIDs, muscle relaxants, nonnarcotic analgesics and narcotic analgesics remained stable. However, the mean number of patient visits in which these medications were prescribed increased from 2.0 to 3.9 over the decade (p<.001). The proportion of individuals receiving chiropractic care (p<.01) and X- rays (p<.001) were lower in 1997 than 1987. CONCLUSIONS:The national pattern of health care for nonspecific low back pain observed in the present study serves as a basis for future investigations into the management of this major public health problem. Findings suggest that perhaps a duplication of care is partly responsible for the high degree of health care utilization in this population.

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Spine J. 2004 Jan-Feb;4(1):27-35.
A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain.
Pauza KJ, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N.
Texas Spine and Joint Hospital, 1814 Roseland Boulevard, Tyler, TX 75701, USA. kevinpauza@tyler.net

BACKGROUND: Intradiscal electrothermal therapy (IDET) is a treatment for discogenic low back pain the efficacy of which has not been rigorously tested. PURPOSE: To compare the efficacy of IDET with that of a placebo treatment. STUDY DESIGN/SETTING: Randomized, placebo-controlled, prospective trial. PATIENT SAMPLE: Patients were recruited by referral and the media. No inducements were provided to any patient in order to have them participate. Of 1,360 individuals who were prepared to submit to randomization, 260 were found potentially eligible after clinical examination and 64 became eligible after discography. All had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-seven were allocated to IDET and 27 to sham treatment. Both groups were satisfactorily matched for demographic and clinical features. METHODS: IDET was performed using a standard protocol, in which the posterior annulus of the painful disc was heated to 90 C. Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure. Thirty-two (85%) of the patients randomized to the IDET group and 24 (89%) of those assigned to the sham group complied fully with the protocol of the study, and complete follow-up data are available for all of these patients. OUTCOME MEASURES: The principal outcome measures were pain and disability, assessed using a visual analog scale for pain, the Short Form (SF)-36, and the Oswestry disability scale. RESULTS: Patients in both groups exhibited improvements, but mean improvements in pain, disability and depression were significantly greater in the group treated with IDET. More patients deteriorated when subjected to sham treatment, whereas a greater proportion showed improvements in pain when treated with IDET. The number needed to treat, to achieve 75% relief of pain, was five. Whereas approximately 40% of the patients achieved greater than 50% relief of their pain, approximately 50% of the patients experienced no appreciable benefit. CONCLUSIONS: Nonspecific factors associated with the procedure account for a proportion of the apparent efficacy of IDET, but its efficacy cannot be attributed wholly to a placebo effect. The results of this trial cannot be generalized to patients who do not fit the strict inclusion criteria of this study, but IDET appears to provide worthwhile relief in a small proportion of strictly defined patients undergoing this treatment for intractable low back pain.

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Work. 2004;22(1):9-15.
Outcome of an interdisciplinary pain management program in a rehabilitation clinic.
Olason M.
Chronic Pain Section, Reykjalundur Rehabilitation Center, 270 Mosfellsbaer, Iceland. magnuso@reykjalundur.is

The Chronic Pain Section at Reykjalundur has 33 beds for patients with various chronic pain problems. About 200 patients are treated annually. For 3 years, 158 patients were enrolled in a random study focusing on increasing the patients' functioning and eliminating analgesic drugs through an interdisciplinary rehabilitation program. Patients answered a questionnaire at admission, before discharge from the clinic and about one year after discharge. The follow-up was done with a mailed questionnaire. The focus was on the patients' functioning rather than absence of pain. The program's duration was 7 weeks. The first 2 weeks were utilized for evaluation, information and education (pain school). Pain relieving drugs were gradually withdrawn but anti-inflammatory drugs were used when indicated. Cognitive behavioral therapy was applied in an increasing number of cases over the 3 year period by specially trained nurses and a psychiatrist. Pain, anxiety and depression were self-evaluated on a numeric rating scale (NRS). About 50% of the patients had a history of pain for more than 5 years. Low back pain was the most common diagnosis (48.1%) and 28.5% had post-traumatic pain. A significant reduction in pain, anxiety and depression was found both at discharge (p < 0.0001) and at follow-up (p < 0.001). Before entering the program, only 18.4% of the patients were able to work whereas 48.1% returned to work after discharge and 59.2% were working at follow-up.

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Eur J Anaesthesiol. 2004 Jan;21(1):32-7.
Comparison between bupivacaine 0.125% and ropivacaine 0.2% for epidural administration to outpatients with chronic low back pain.
Lierz P, Gustorff B, Markow G, Felleiter P.
Marienkrankenhaus Soest, Department of Anaesthesiology and Intensive Care Medicine, Soest, Germany. dr.lierz@marienkrankenhaus-soest.de

BACKGROUND AND OBJECTIVE: Epidural blocks should provide good analgesia for the treatment of chronic low back pain without any motor block to allow active physiotherapy. Epidural ropivacaine is known to produce less motor block compared to bupivacaine at anaesthetic concentrations. This prospective, randomized double blind study compares the analgesic, motor block, and haemodynamic effects of single shot epidural injections of ropivacaine 0.2% 10 mL with bupivacaine 0.125% in outpatients suffering from chronic low back pain. METHODS: Forty patients were assigned to receive either ropivacaine 0.2% (n = 20) or bupivacaine 0.125% (n = 20) within a series of eight single shot epidural blocks. RESULTS: Thirty-six patients received either ropivacaine 0.2% (n = 18) or bupivacaine 0.125% (n = 18) within a series of eight single shot epidural blocks. Both groups showed no significant differences either in analgesia, or in motor blockade or haemodynamic changes. Thus ropivacaine 0.2% did not reduce the incidence of motor block (9.0% of patients with motor block Bromage scores 1, 2 or 3 in ropivacaine or bupivacaine). The combination of repeated epidural analgesia and physiotherapy reduced the median pain-scores (visual analogu scale, 0-10) from 7 (SD +/- 1.6) at the beginning of the study to 4.1 (SD +/- 1.7) at the end of the series. CONCLUSIONS: Both bupivacaine 0.125% and ropivacaine 0.29% appear suitable for epidural administration to outpatients with chronic low back pain attending for epidural analgesia associated with physiotherapy (physical therapy).

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Med J Aust. 2004 Jan 19;180(2):79-83.
Management of chronic low back pain.
Bogduk N.
Newcastle Bone and Joint Institute, Royal Newcastle Hospital, Newcastle, NSW, Australia. mgillam@mail.newcastle.edu.au

Treatment for chronic low back pain (pain persisting for over 3 months) falls into three broad categories: monotherapies, mulitidisciplinary therapy, and reductionism. Most monotherapies either do not work or have limited efficacy (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery). Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on pain. The reductionist approach (pursuit of a pathoanatomical diagnosis with the view to target-specific treatment) should be implemented when a specific diagnosis is needed. While conventional investigations do not reveal the cause of pain, joint blocks and discography can identify zygapophysial joint pain (in 15%-40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.

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J Surg Orthop Adv. 2003 Winter;12(4):200-2.
Low back pain intervention: conservative or surgical?
Lee D.
Nevada Orthopedics and Spine Center, PO Box 36550, Las Vegas, NV 89133-6550, USA.

Low back pain (LBP) is a very common disorder with a U.S. population incidence of 80%. The risk for developing chronic LBP is relatively low but the majority of the costs associated with LBP are generated specifically by this group. Unfortunately, there is no gold standard intervention and few comparative, randomized, prospective treatment studies have been done. Therefore, the optimal treatment approach continues to be controversial. Surgery is usually reserved for those patients with severe and debilitating symptoms and, with careful selection, can result in good outcomes with rapid return to function. For patients who are not surgical candidates, conservative treatment must emphasize restoration and maintenance of functional movement.

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Prescrire Int. 2003 Dec;12(68):211-3.
Paracetamol + tramadol: new preparation. No advance.
[No authors listed]

(1) First-line treatment for both acute and chronic pain is paracetamol or, if necessary, ibuprofen, a nonsteroidal antiinflammatory drug. If relief is inadequate, the best option is a combination of paracetamol with codeine (a weak opiate). (2) A fixed-dose combination of paracetamol (325 mg) and tramadol (37.5 mg), a weak opiate, arrived on the French market in May 2003. (3) In the acute setting, three trials in a total of 1197 patients showed that a single dose of the paracetamol 650 mg + tramadol 75 mg combination after dental surgery was no more effective than ibuprofen 400 mg. Compared with each drug used alone, the paracetamol + tramadol combination prolongs the analgesic effect but does not increase its intensity. (4) A trial after gynaecological surgery and another trial after orthopaedic surgery showed that a single dose of paracetamol 975 mg + tramadol 112.5 mg had similar efficacy to tramadol alone at 112.5 mg. (5) In the chronic setting, we found no trials comparing the paracetamol + tramadol combination with each drug used alone. A comparative double-blind trial in 462 patients with low back pain or osteoarthritic pain showed no difference in efficacy between paracetamol 325 mg + tramadol 37.5 mg and paracetamol 300 mg + codeine 30 mg. (6) The main adverse effects of the paracetamol + tramadol combination are the same as other weak opiates: nausea, vomiting, dizziness, headache, drowsiness and constipation. Tramadol carries a higher risk of drug interactions than codeine. (7) In practice, the paracetamol + tramadol combination offers patients no advantages relative to standard analgesics.

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Pain Med. 2003 Dec;4(4):321-30.
Lidocaine patch 5% with systemic analgesics such as gabapentin: a rational polypharmacy approach for the treatment of chronic pain.
White WT, Patel N, Drass M, Nalamachu S.
Southern Drug Research, Birmingham, Alabama 35205, USA. bwhite@sdr.us

OBJECTIVE: To assess the effectiveness and safety of the lidocaine patch 5%, a targeted peripheral analgesic, in the treatment of postherpetic neuralgia, painful diabetic neuropathy, and low back pain patients with incomplete responses to their current analgesic treatment regimen containing gabapentin. DESIGN: This was a 2-week, open-label, nonrandomized, multicenter pilot trial in the clinical setting. Patients with postherpetic neuralgia, painful diabetic neuropathy, or low back pain with partial responses (average daily pain intensity >4/10) to their current analgesic treatment regimen were included. Treatment consisted of daily application of up to four lidocaine patches to areas of maximal peripheral pain. Effectiveness was evaluated using the Brief Pain Inventory (BPI). Safety was assessed by adverse events, physical and neurologic examinations, vital signs, and clinical laboratory tests. RESULTS: Significant improvements in BPI measures of pain intensity and pain relief were reported for all groups of patients after 2 weeks of lidocaine patch 5% treatment. Significant improvements in BPI measures of pain interference with general activity, mood, walking ability, normal work, relationships with others, sleep, and enjoyment of life were noted. The lidocaine patch 5% was found to be safe and well tolerated. CONCLUSIONS: Results of this study highlight the potential advantages achieved with rational polypharmacy using a targeted peripheral analgesic, the lidocaine patch 5%, with centrally acting agents such as the anticonvulsant gabapentin. Controlled trials are warranted to further define the impact of such combination therapy.

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J Manipulative Physiol Ther. 2003 Nov-Dec;26(9):593-601.
Efficacy of spinal manipulative therapy for low back pain of less than three months' duration.
Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG.
School of Physiotherapy, University of Sydney, Australia.

OBJECTIVES: To review the efficacy of spinal manipulation for low back pain of less than 3 months duration.Data sources Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro).Study selection Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy.Data extraction Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model.Data synthesis Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment. CONCLUSIONS: Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.

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AJR Am J Roentgenol. 2003 Nov;181(5):1255-8.
Efficacy of epidural injections of Kenalog and Celestone in the treatment of lower back pain.
Stanczak J, Blankenbaker DG, De Smet AA, Fine J.
Department of Radiology, Division of Musculoskeletal Imaging, University of Wisconsin Hospitals and Clinics, Clinical Science Center E3/311, 600 Highland Ave., Madison, WI 53792-3252, USA. jefferystanczak@hotmail.com

OBJECTIVE: Epidural corticosteroid injections have been used extensively to treat lower back pain, but the relative effectiveness of one corticosteroid versus another has never been reported in a large patient series. We retrospectively reviewed 597 patients who had epidural corticosteroid injections to determine any difference in Kenalog or Celestone efficacy. MATERIALS AND METHODS: We reviewed charts and self-reported pain score evaluations of 597 patients who received either Kenalog or Celestone Soluspan as an epidural injection for the treatment of lower back pain from 1997 to 2002 at our university hospital and affiliated Veterans Affairs hospital. Kenalog was used for the initial 2 years and Celestone was used for the next 3 years. Fluoroscopic guidance was used to confirm epidural location, and each patient was injected with a mixture of 5 mL of 0.5% preservative-free lidocaine and 2 mL of either Kenalog 40 mg/mL (triamcinolone acetonide injectable suspension) or Celestone Soluspan 6 mg/mL (betamethasone sodium phosphate and betamethasone acetate injectable suspension). Each patient was given a standardized pain evaluation sheet that used an 11-point scale for initial pain severity. Scoring of pain compared with baseline during the following 14 days was based on a 5-point scale of pain improvement or worsening. RESULTS: On days 0-3 after the procedure, no statistical significance in improvement of lower back and buttock pain was seen between groups. On day 7, 59% of Celestone recipients and 73% of Kenalog recipients showed improvement in lower back pain (p = 0.002, Pearson's chi-square test), and 58% of Celestone recipients and 75% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). On day 14, 54% of Celestone recipients and 71% of Kenalog recipients showed improvement in lower back pain (p < 0.001), and 54% of Celestone recipients and 71% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). CONCLUSION: The epidural injection of Celestone Soluspan and Kenalog reduced lower back and radicular pain in more than half the patients, although Kenalog reduced pain in a significantly larger number of patients than Celestone Soluspan at 1 and 2 weeks after injection.

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Mayo Clin Proc. 2003 Oct;78(10):1249-56.
Minimally invasive procedures for disorders of the lumbar spine.
Deen HG, Fenton DS, Lamer TJ.
Department of Neurosurgery , Mayo Clinic, Jacksonville, Fla 32224, USA.

In the past decade, there has been a substantial increase in interest in minimally invasive procedures in all areas of medicine, particularly for spinal disorders. Some of these techniques represent notable advances in spinal care and have major roles in the care of patients with back-related symptoms. Other techniques appear to offer no benefit and in some cases may be less effective than conventional treatments. Percutaneous lumbar diskectomy techniques hold considerable promise; however, lumbar microdiskectomy is the gold standard for surgical treatment of lumbar disk protrusion with radiculopathy. Intradiskal electrothermal therapy is emerging as a useful option for selected patients with intractable mechanical back pain whose only other option historically has been a spinal fusion. Percutaneous fusion techniques are in their infancy and may prove to be beneficial for these patients as well. Percutaneous vertebral augmentation, including vertebroplasty and kyphoplasty, has become the treatment of choice for many patients with intractable back pain secondary to vertebral insufficiency fractures. Spinal injections are important for evaluating and managing spinal pain and can be extremely useful diagnostically and therapeutically. This multidisciplinary review outlines the status of these procedures and offers suggestions for their use in patient care

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Phys Ther. 2003 Oct;83(10):907-17.
Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living.
Scannell JP, McGill SM.
University of Waterloo, Waterloo, Ontario, Canada.

BACKGROUND AND PURPOSE: Physical therapists commonly attempt to reduce and prevent low back pain by "improving" individuals' lumbar posture. To investigate the physical therapy clinical practice of attempting to "improve" lumbar posture, measures of passive tissue stiffness and angular deformation during activities of daily living were used. PARTICIPANTS: The lumbar spine posture of 150 university students was measured as the inclinometer angle difference between L1 and S1. Eighteen female participants (6 with hypolordosis, 6 with hyperlordosis, and 6 controls without lumbar spine impairment) were recruited from this lumbar posture database. Hypolordosis and hyperlordosis were clinically classified by physical therapists. METHODS: Lumbar passive tissue stiffness was measured during sitting, standing, and walking before and after a 12-week exercise program, and estimates of lumbar passive tissue strain were calculated from those measurements. RESULTS: The neutral zone (NZ), a range of lumbar positions of low passive tissue stiffness, was identified. Prior to training, the subjects with hypolordosis had more passive tissue strain during sitting than the subjects with hyperlordosis, and the subjects with hyperlordosis stood in extension relative to their NZs while the control subjects and subjects with hypolordosis stood within their NZs. Before and after training, subjects in all 3 groups walked with lumbar spine positions within their NZs. After training, the lumbar posture of the subjects with hypolordosis and the subjects with hyperlordosis changed toward a "mean" (mid-range) lumbar posture. After the exercise program, subjects in all 3 groups stood and walked with their lumbar spines in positions within their NZs, and they sat with their lumbar spines flexed relative to their NZs. DISCUSSION AND CONCLUSION: Knowing that tissue failure can be related to passive tissue strain, the results of this study support the clinical practice of attempting to change individuals' posture-related lumbar spine positions during activities of daily living. Lumbar passive tissue strain, as estimated from the NZ and angular deformation during activities of daily living, can be decreased, but can also be increased, by an exercise program.

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Arch Phys Med Rehabil. 2003 Oct;84(10):1542-53.
The efficacy of traction for back pain: a systematic review of randomized controlled trials.
Harte AA, Baxter GD, Gracey JH.
School of Rehabilitation Sciences, University of Ulster, Jordanstown, Northern Ireland. Aa.harte@ulster.ac.uk

OBJECTIVE: To assess the efficacy of traction for patients with low back pain (LBP) with or without radiating pain, taking into account the clinical technique or parameters used. DATA SOURCES: A computer-aided search of MEDLINE, CINAHL, AMED, and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) in the English language, from 1966 to December 2001. STUDY SELECTION: RCTs were included if: participants were over the age of 18 years, with LBP with or without radiating pain; the intervention group received traction as the main or sole treatment; the comparison group received sham traction or another conservative treatment; and the study used 1 of 4 primary outcome measures. DATA EXTRACTION: The study was conducted in 2 strands. Strand 1 assessed methodologic quality using a specific criteria list recommended by the Cochrane Back Review Group. The strength of the evidence was then rated using the Agency for Health Care Policy and Research system. Strand 2 applied further inclusion criteria based on recommended clinical parameters. One reviewer conducted the selection and data extraction. DATA SYNTHESIS: Strand 1: 1 study scored 9 points (maximum score, 10 points); the other 12 scored between 0 and 3 points, indicating that most were of poor quality. Nine studies reported negative findings, but only 1 study was of a high quality. Three studies reported positive findings and 1 study was inconclusive. Strand 2: only 4 trials having low methodologic quality were included, 2 of which reported negative findings, and 2 positive findings. CONCLUSION: The evidence for the use of traction in LBP remains inconclusive because of the continued lack of methodologic rigor and the limited application of clinical parameters as used in clinical practice. Further trials, which give attention to these areas, are needed before any firm conclusions and recommendations may be made.

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Spine J. 2003 Sep-Oct;3(5):360-2.
Pulsed radiofrequency application in treatment of chronic zygapophyseal joint pain.
Mikeladze G, Espinal R, Finnegan R, Routon J, Martin D.
Pain Medicine Program, Department of Anesthesiology, Medical College of Georgia, 1120 15th Street BIW 2144, Augusta, GA 30912, USA.

BACKGROUND CONTEXT: Chronic zygapophyseal joint arthropathy is a cause of back and neck pain. One proposed method of treating facet joint pathology is ablation of medial branches and dorsal rami with pulsed radiofrequency (RF) waves. PURPOSE: Assessment of efficacy of pulsed RF application for treatment of chronic zygapophyseal joint pain. STUDY DESIGN/SETTING: Retrospective study of 114 patients at a pain management clinic. PATIENT SAMPLE: A total of 114 patients with clinical signs of facet joint involvement and a favorable response to a diagnostic medial branch block using local anesthetic, including 82 females and 32 males with a mean age of 52.8+/-12.6 years. Mean duration of pain was 7.52+/-5.26 years. Twenty-seven had previous back surgery, 83 patients had low back pain and 31 had cervical pain. Pain was on the left side in 47 patients, on the right side in 45 patients, bilateral in 22. OUTCOME MEASURES: Result was regarded as successful if pain reduction was more than 50% on visual analog scale and the duration of effect was more than 1.5 months. METHODS: After obtaining positive stimulation, pulsed RF was applied to medial branches of dorsal rami for 120 seconds with temperature at the tip of the electrode 42 C. RESULTS: Of 114 patients, who had positive response to diagnostic block, 46 patients did not respond favorably to pulsed RF application (pain reduction less than 50%). In 68 patients, the procedure was successful and lasted on average 3.93+/-1.86 months. Eighteen patients had the procedure repeated with the same duration of pain relief that was achieved initially. Previous surgery, duration of pain, sex, levels (cervical vs. lumbar) and stimulation levels did not influence outcomes. CONCLUSION: The results of our study showed that the application of pulsed RF to medial branches of the dorsal rami in patients with chronic facet joint arthropathy provided temporary pain relief in 68 of 118 patients.

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Arch Phys Med Rehabil. 2003 Sep;84(9):1324-31.
Enhancing function in older adults with chronic low back pain: a pilot study of endurance training.
Iversen MD, Fossel AH, Katz JN.
Department of Physical Therapy, School of Health Studies, Simmons College, Boston, MA 02115, USA.

OBJECTIVES: To assess the effectiveness of a bicycle endurance program in older adults with chronic low back pain (CLBP) and to identify correlates of exercise adherence. DESIGN: Prospective cohort. SETTING: Residential facilities and a tertiary care hospital. PARTICIPANTS: Adults with CLBP aged 55 years and older. Of 29 subjects who agreed to participate, 3 (10%) were deemed ineligible at baseline. Nineteen subjects (73%) were women, and the median age was 72 years. INTERVENTIONS: Subjects were assessed at baseline and at 6 and 12 weeks by using standardized questionnaires, physical examination, and endurance testing by a physical therapist. Subjects received a bicycle and instructions to exercise 3 times a week for 12 weeks at a set wattage. A trained rescarcher collected exercise data weekly.Main outcome measures The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the lumbar spinal stenosis symptom severity and function scales, and kilocalories were used to assess change. RESULTS: At baseline, subjects were moderately impaired (mean SF-36 physical function score, 52.6). Eighteen (65%) completed the trial. At 12 weeks, physical functioning (SF-36) improved by 11%, mental health (Mental Health Inventory 5-Item Questionnaire) improved by 14%, and CLBP symptoms decreased by 8%. Reasons for withdrawing included illness, family issues, and bicycle-related discomfort. CONCLUSIONS: The bicycle program was safe and effective for improving functional status and well-being.

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Pain Med. 2003 Sep;4(3):223-30.
Cognitive-behavioral therapy for chronic low back pain in older persons: a preliminary study.
Reid MC, Otis J, Barry LC, Kerns RD.
Division of Geriatrics and Gerontology, Weill Medical College, Cornell University, New York, New York 10021, USA. mcr2004@med.cornell.edu

OBJECTIVE: To determine the feasibility and potential efficacy of providing cognitive-behavioral therapy (CBT) to older persons with chronic low back pain (CLBP). METHODS: This was an uncontrolled pilot study conducted at a senior housing center (SHC) in New Haven, Connecticut. Fourteen SHC residents aged 65 years and older who were cognitively intact (Mini Mental State Examination score > or =24) and had CLBP were recruited for the study. CBT was administered in 10 weekly individual sessions. Participants were phoned 5 days on average after each session (range: 3-7 days) to determine their comprehension and perceived usefulness of the CBT materials and adherence with the assigned homework exercises. Using standardized measures, we determined participants' levels of pain intensity, pain-related disability, and physical and social activity at baseline, and at 2 and 24 weeks posttreatment. RESULTS: Participants had a mean age of 77.4 (+/-7.9 SD) years and were mostly female (86%). Thirteen (93%) participants completed all 10 sessions. Comprehension of CBT, defined as self-reported understanding of the materials presented each week, exceeded 97%. The perceived usefulness of each treatment session was assessed on a 0-10 scale, and the mean ratings for the sessions ranged from 7.5-9.4. The mean number of days that participants practiced the homework exercises each week varied from 1.8 to 4.0. Significant reductions (P < 0.01) in participants' pain intensity and pain-related disability scores were found at the 2-week posttreatment (vs pretreatment) assessment. These treatment effects waned over time, but did not return to pretreatment levels at 24 weeks. Participants' physical and social activity levels did not change. CONCLUSIONS: CBT is a feasible treatment for cognitively intact, older persons with CLBP, and may be efficacious as well.

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J Spinal Disord Tech. 2003 Aug;16(4):424-33.
SB Charite disc replacement: report of 60 prospective randomized cases in a US center.
McAfee PC, Fedder IL, Saiedy S, Shucosky EM, Cunningham BW.
Spine and Scoliosis Center, St Joseph's Hospital, Baltimore, Maryland 21204, USA. mack8132@aol.com

Sixty patients with one-level discogenic pain confirmed by plain radiography, magnetic resonance imaging, and provocative discography for degenerative disc disease were randomized: one-third BAK anterior interbody fusion and two-thirds anterior SB Charite artificial disc replacement. The mean age was 40.3 years (range 21-56 years). Nineteen cases were at L4-L5 and 41 cases were at L5-S1. Nineteen cases had BAK anterior interbody fusion and 41 cases were randomized as SB Charite disc replacement. The length of surgery was mean 88.4 minutes (range 54-137 minutes) for both groups. The estimated blood loss was mean 289.5 mL (range 50-1800 mL). The length of hospital stay was a mean of 3.03 days (range 2-6 days). Oswestry Disability Index scores for the SB Charite disc (aggregate study group) were 50.0 +/- 14.3 preoperatively and 25.0 +/- 20.1 at 1-3 years' follow-up (P < 0.001). This is the first study that shows improvement of functional outcome measures in a prospective randomized design with disc arthroplasty treating primarily mechanical back pain and achieving comparable successful results to lumbar fusion-interbody fusion cage and BMP or interbody autograft and pedicle screw instrumentation.

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J Spinal Disord Tech. 2003 Aug;16(4):324-30.
Partial disc replacement with the PDN prosthetic disc nucleus device: early clinical results.
Shim CS, Lee SH, Park CW, Choi WC, Choi G, Choi WG, Lim SR, Lee HY.
Departments of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea. shimcs@wooridul.co.kr

The aim of this study was to evaluate the efficacy of the PDN prosthetic disc nucleus device for the treatment of chronic discogenic back pain caused by degenerative disc disease. Among the 48 patients who underwent nucleus replacement surgery from January 2001 through May 2002, 46 patients were followed >6 months. The mean Oswestry Disability Index score was 58.9% preoperatively, and it improved to 18% at the 1-year follow-up. Visual Analogue Pain Scale scores improved from a preoperative mean of 8.5 to 3.1 after 1 year. The mean Prolo Scale score also improved from 5.2 preoperatively to 7.2 at 1 year. Major complications included four cases of device migration, requiring revision surgery, and infection in one patient. According to MacNab's criteria, results were excellent in 5 patients (10.9%), good in 31 (67.4%), fair in 3 (6.5%), and poor in 7 (15.1%). The overall clinical success rate was 78.3%. Nucleus replacement with the PDN device seemed to be effective in treating patients with chronic discogenic back pain caused by degenerative disc disease.

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J Am Acad Orthop Surg. 2003 Jul-Aug;11(4):228-37.
Spinal manipulative therapy for low back pain.
Swenson R, Haldeman S.
Section of Neurology, Darmouth Medical School, Lebanon,

Growing interest in complementary and alternative medicine in the United States has been paralleled by increased use of spinal manipulative therapy in an attempt to manage symptoms of low back pain, spinal stenosis, and spondylolisthesis. Chiropractors have been the main practitioners of spinal manipulative therapy, with osteopaths and physical therapists providing a smaller fraction of these services. Theories explaining the mode of action of spinal manipulative therapy are largely preliminary and have focused on the mechanical effects of manipulative forces on the spine and neurologic responses to manipulation. The effects of spinal manipulation on patients with both acute and chronic low back pain have been investigated in randomized clinical trials. Most reviews of these trials indicate that spinal manipulative therapy provides some short-term benefit to patients, especially with acute low back pain.

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Reg Anesth Pain Med. 2003 Jul-Aug;28(4):289-93
Topical amitriptyline in healthy volunteers.
Gerner P, Kao G, Srinivasa V, Narang S, Wang GK.
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA. pgerner@partners.org

BACKGROUND AND OBJECTIVES: The antidepressant amitriptyline is used as an adjuvant in the treatment of a variety of chronic pain conditions. This drug interacts with many receptors and ion channels, such as Na+ channels. In a randomized, double-blinded, and placebo-controlled trial, we investigated whether amitriptyline also is capable of providing cutaneous analgesia when applied topically in 14 healthy volunteers. METHODS: Amitriptyline hydrochloride was prepared as a 45% water/45% isopropanol/10% glycerin solution and titrated to pH 8.5 with sodium hydroxide. Four areas, 2 on each arm, of approximately 1 cm(2) each were marked on the ventral aspect of the upper arm. A piece of gauze, placed on each of the marked areas and affixed to the arm with an occlusive plastic dressing, was saturated via syringe with placebo and amitriptyline solutions (10 mmol/L, 50 mmol/L, and 100 mmol/L). After 1 hour, the dressings and gauze were removed. A 16-G blunt needle was used to grade the pain at the marked area once per hour (1 = complete analgesia, 10 = normal pain sensation). RESULTS: The analgesic effects of 50 mmol/L and 100 mmol/L solutions of amitriptyline were significantly higher than those of the placebo or the 10 mmol/L solution. However, no significant difference was found between the analgesia provided by the placebo solution versus the 10 mmol/L solution or between the 50 mmol/L versus the 100 mmol/L solution. The only side effect observed was a concentration-dependent redness of the skin. CONCLUSIONS: Topically applied amitriptyline is effective as an analgesic in humans. Different vehicles may improve its efficacy and decrease the skin redness observed.

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J Obstet Gynecol Neonatal Nurs. 2003 Jul-Aug;32(4):495-502.
Use of a maternity support binder for relief of pregnancy-related back pain.
Carr CA.
Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle 98195-7262, USA. ccarr@u.washington.edu

OBJECTIVE: To examine the feasibility, acceptability, and effectiveness of a support binder for low back pain in pregnancy. DESIGN: Pilot study, using a prospective, two-group design with repeated measures. SETTING: Ambulatory maternity clinic in a tertiary care teaching hospital. PARTICIPANTS: Women of at least 20 weeks gestation with low back pain, but no preexisting back or disc disease. Thirty women assigned to the intervention group and 10 to a comparison group. INTERVENTIONS: Participants completed a pain assessment at pretest. Intervention participants received a maternity support binder to wear while awake for 2 weeks. At an appointment 2 weeks later, a posttest questionnaire and a taped interview were administered. The comparison group participants received the support binder after the second appointment. MAIN OUTCOME MEASURES: Back pain intensity, duration, and effect on daily activities were assessed using a pain in pregnancy questionnaire. RESULTS: The intervention group had significant reduction in mean pain scores and effect of pain on daily activities, including family, house and yard, recreational, exercise, and sleep. Interaction of group by time was significant for change in pain and effect on family, house and yard, and exercise activities. CONCLUSION: The use of a support binder for pregnancy-related low back pain is a promising intervention and was well-accepted by the participants.

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Spine J. 2003 Jul-Aug;3(4):270-6.
Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community:
effects on quality of life.
Lang E, Liebig K, Kastner S, Neundorfer B, Heuschmann P.
Department of Neurology, University of Erlangen-Nuremberg, D-91054 Erlangen, Germany. eberhard.lang@rzmail.uni-erlangen.de

BACKGROUND CONTEXT: Multidisciplinary biopsychosocial rehabilitation has been shown in controlled studies to improve pain and function in patients with chronic back pain. However, specialized back pain rehabilitation centers are rare and only a few patients can participate on this therapy. Implementation of multidisciplinary rehabilitation services in community medicine may enhance both early availability and treatment capacity for comprehensive back pain rehabilitation. PURPOSE: To compare the outcome of a multidisciplinary rehabilitation program (MRP) that was organized by cooperation of local health-care providers in the community with that of the usual care by independent physicians for patients with chronic low back pain. STUDY DESIGN: A comparison between the outcomes (follow-up time of 6 months) of treatment for chronic back pain in the community in a prospective intervention group versus a prospective observational usual care group. PATIENT SAMPLE: All patients were recruited from independent physicians in the community of a selected region who participated voluntarily in the study. Patients were included in the study if they were seeking treatment of pain in the back with possible irradiation into the legs, the pain persisted for at least 3 months without decreasing intensity and there was no indication for surgical intervention. OUTCOME MEASURES: Outcome was assessed from patients' responses in self-report questionnaires at baseline and after an interval of 6 months. For outcome, we evaluated the health-related quality of life (German version of Short Form [SF] 36), the average pain severity (Numeric Rating Scale), the pain-related interference of function (German version of Brief Pain Inventory), depression (Allgemeine Depressionsskele), time off from work within 3 months before entering and leaving the study and the self-appraisal of improvement. METHODS: In a baseline group, the independent physicians treated the patients with usual care. In the intervention group, the patients were referred by the independent physicians to the study coordinator in the outpatient facilities of the Departments of Neurology or Orthopedics for inclusion in the MRP. The MRP was organized by cooperation of local health-care providers in the community with different specialties (sport teachers, clinical psychologist, physiotherapist and physician) who were experienced in the management of back pain. The MRP (4 hours per day, 3 days per week, 20 days) included 1.5 hours restorative exercise therapy, 0.5 hours physiotherapy, 1 hour cognitive-behavioral therapy, 0.5 hours progressive muscle relaxation and 0.5 hours education. RESULTS: Complete data sets were obtained from 157 patients in the usual care group (documented by 35 independent physicians) and 51 patients in the MRP group. Patients of the MRP group improved in the physical and mental health domains of the SF-36 more than patients treated by usual care (p<.05). Furthermore, days off work were more (p<.05) reduced by the MRP (16+/-35 days) than by usual care (-2+/-39 days). Finally, overall appraisal of successful outcome was better (p<.01) after MRP (54% of patients) as compared with usual care (24% of patients). However, the pain intensity (NRS), the pain-related interference with function (Brief Pain Inventory; BPI) and the depression scores (ADS) did not differ significantly between both groups. CONCLUSIONS: MRP is promising to improve health-related quality of life for patients with chronic back pain in the community. Before implementation of MRP in the repertoire of community medicine, superiority of MRP over usual care should be confirmed by a randomized controlled trial.

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J Pain Symptom Manage. 2003 Jul;26(1):678-83.
Treatment of chronic mechanical spinal pain with intravenous pamidronate: a review of medical records.
Pappagallo M, Breuer B, Schneider A, Sperber K.
Comprehensive Pain Treatment Center, Hospital for Joint Diseases, Orthopaedic Institute, and Department of Neurology, New York University School of Medicine, New York, New York 10003, USA.

We explored the effect of intravenous infusions of a bisphosphonate, pamidronate, in the management of chronic mechanical spinal pain, a worldwide public health problem in terms of lost workdays, medical treatment costs, and suffering. Bisphosphonates have an anti-nociceptive effect in animals. In humans, intravenous pamidronate relieves numerous painful conditions, including metastatic bone pain, ankylosing spondylitis, rheumatoid arthritis, and complex regional pain syndrome. We reviewed the charts of 25 patients who had experienced disabling spinal pain for several years, and whom we treated with intravenous pamidronate. None had a history of osteoporotic vertebral fractures or metastatic disease. Pain rating scores decreased in 91% of patients: on a 0-10 numeric rating scale, the mean pain change was -3.6 points and mean percentage change was -41% (P<0.0001). There was no increase in opioid or nonopioid analgesic medications associated with pain relief. The apparent analgesic effect of pamidronate for chronic mechanical spinal pain needs to be confirmed with placebo-controlled trials.

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Arch Phys Med Rehabil. 2003 Jul;84(7):1057-60.
The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain.
Flynn TW, Fritz JM, Wainner RS, Whitman JM.
US Army-Baylor University Graduate Program in Physical Therapy, San Houston, Texas, 78234-6138, USA. timothy.flynn@cen.amedd.army.mil

OBJECTIVE: To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN: A prospective cohort study. SETTING: Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS: A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS: Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted.Main Outcome Measures: Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS: An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION: There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.

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Spine J. 2003 May-Jun;3(3):220-6.
Biochemical injection treatment for discogenic low back pain: a pilot study.
Klein RG, Eek BC, O'Neill CW, Elin C, Mooney V, Derby RR.
Orthopedic Medicine, 2927 De La Vina, Suite D, Santa Barbara, CA 93105, USA. RKlein42@aol.com

BACKGROUND CONTEXT: Biochemical treatment options including attempts at intervertebral disc restoration are desirable for the physiologic treatment of degenerative disc disease. PURPOSE: This was a pilot study to test the potential effectiveness of intradiscal injection therapy using agents known to induce proteoglycan synthesis in the treatment of intervertebral disc disease. STUDY DESIGN: Prospective, within subject, experimental design was applied in the study. PATIENT SAMPLE: Thirty patients, average age 46.5 years, with chronic intractable low back pain of 8.5 years average duration, took part in the study. All patients had lumbar discography with reproduction of pain. OUTCOME MEASURES: Pretreatment Roland-Morris disability scores and visual analogue scores were compared with 1-year follow-up posttest values of these scores. METHODS: Lumbar intervertebral discs were injected with a solution of glucosamine and chondroitin sulfate combined with hypertonic dextrose and dimethlysulfoxide (DMSO). Assessment of pain and disability was completed before treatment and an average of 12 months after the last treatment. RESULTS: Posttreatment Roland-Morris scores for the entire group of 30 patients of 6.4+/-.994 were significantly (p<.001) lower than pretreatment scores of 12.0+/-.92 (mean+/-SE). The posttreatment visual analogue scores of 3.00+/-.44 were also significantly less than the pretreatment of 6.11+/-.33 (mean+/-SE). Although the results were statistically significant for the 30 patients as a whole, 17 of the 30 patients (57%) improved markedly with an average of 72% improvement in disability scores and 76% in visual analogue scores. The other 13 patients (43%) had little or no improvement. Patients who did poorly included those with failed spinal surgery, spinal stenosis and long-term disability. There were no complications or serious side effects, although postinjection pain was moderate to severe for 48 to 72 hours and required epidural steroids in five cases. CONCLUSIONS: The results of this pilot study suggest that intradiscal injection therapy with glucosamine, chondroitin sulfate, hypertonic dextrose and DMSO warrants further evaluation with randomized controlled trials.

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Clin Ther. 2003 Apr;25(4):1123-41.
Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study.
Ruoff GE, Rosenthal N, Jordan D, Karim R, Kamin M; Protocol CAPSS-112 Study Group.
Michigan State University College of Medicine, and Westside Family Medical Center, Kalamazoo, Michigan 49009, USA.

BACKGROUND: Tramadol and acetaminophen (APAP) have both shown efficacy in the treatment of lower back pain. The combination of these 2 agents has demonstrated synergistic analgesic action in animal models at specific ratios. OBJECTIVE: This study assessed the long-term (3-month) efficacy and safety of tramadol 37.5 mg/APAP 325 mg combination tablets in the treatment of chronic lower back pain. METHODS: Patients with at least moderate lower back pain (pain visual analog [PVA] score >/=40 mm on a 100-mm scale) were randomized to receive up to 8 tablets of tramadol/APAP per day or placebo for 91 days. Medication was titrated from 1 to 4 tablets/d by day 10. The primary efficacy measure was PVA score at the final visit. Secondary measures included scores on the Pain Relief Rating Scale (PRRS), Short-Form McGill Pain Questionnaire (SF-MPQ), Roland Disability Questionnaire (RDQ), and 36-Item Short-Form Health Survey (SF-36); the incidence of discontinuation due to insufficient pain relief (Kaplan-Meier analysis); and overall assessments of medication by the patients and investigators. RESULTS: Three hundred eighteen patients (161 tramadol/APAP, 157 placebo) were included in the intent-to-treat population, defined as all patients who took >/=1 dose of study medication and had >/=1 postrandomization efficacy measurement. The mean age of the study population was 53.9 years, 63.2% were female, 90.3% were white, and the mean baseline PVA score was 70.0 mm. There were no significant differences between groups at baseline. Tramadol/APAP significantly improved final PVA scores (P = 0.015) and final PRRS scores (P < 0.001) compared with placebo. Tramadol/APAP also significantly improved RDQ scores (P </= 0.027) and scores on many subcategories of the SF-MPQ, including total score (P = 0.021). The tramadol/APAP group had significant improvements on the role-physical (P = 0.005), bodily pain (P = 0.046), role-emotional (P = 0.001), mental health (P = 0.026), reported health transition (P = 0.038), and mental component summary (P = 0.008) subscales of the SF-36. The cumulative incidence of discontinuation due to insufficient pain relief was 22.1% for tramadol/APAP and 41.0% for placebo (P < 0.001). Treatment-emergent adverse events in the tramadol/APAP group included nausea (13.0%), somnolence (12.4%), and constipation (11.2%). CONCLUSIONS: In this study, tramadol 37.5 mg/APAP 325 mg combination tablets were effective and had a favorable safety profile in the treatment of chronic lower back pain.

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Clin Ther. 2003 Apr;25(4):1056-73.
Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials.
Borenstein DG, Korn S.
The George Washington University Medical Center, Washington, DC 20006, USA. dborenstein715@aol.com

BACKGROUND: Cyclobenzaprine hydrochloride is a muscle relaxant that is effective in improving muscle spasm, reducing local pain and tenderness, and increasing range of motion in acute, painful musculoskeletal conditions. Sedation is the most common adverse event associated with its use at the usual dosage of 10 mg TID. Studies in healthy adults suggest that a lower dose may produce less sedation. Because cyclobenzaprine's duration of action is 4 to 6 hours, reducing the dosing frequency to 10 mg BID would create a potentially painful untreated interval between doses. The alternative is administration of a lower dose (eg, 5 or 2.5 mg) TID. OBJECTIVE: These studies were designed to assess the efficacy and tolerability of cyclobenzaprine 2.5, 5, and 10 mg TID compared with placebo in patients with acute musculoskeletal spasm. METHODS: In 2 randomized, double-blind, placebo-controlled, parallel-group trials conducted at primary care centers in the United States, adult patients with acute painful muscle spasm of the lumbar or cervical region were randomly assigned to receive treatment with 2.5, 5, or 10 mg cyclobenzaprine TID or placebo for 7 days (study 1: cyclobenzaprine 5 or 10 mg TID or placebo; study 2: cyclobenzaprine 2.5 or 5 mg TID or placebo). The primary efficacy measures were patient-rated clinical global impression of change, medication helpfulness, and relief from starting backache. Neither study included a nonsteroidal anti-inflammatory drug (NSAID) as an active control. Although physicians frequently prescribe an analgesic or NSAID in addition to cyclobenzaprine, these studies were not designed to assess whether adding cyclobenzaprine provides a benefit over that of an analgesic. RESULTS: One thousand four hundred five patients (737 study 1; 668 study 2), two thirds with low back pain and one third with neck pain, were randomized to treatment. Their mean age was 42 years, and approximately 89% were white. In both studies, patients receiving cyclobenzaprine 5 or 10 mg had significantly higher mean scores on the primary efficacy measures compared with those receiving placebo (study 1-P</=0.001 cyclobenzaprine 5 and 10 mg vs placebo, all measures at visits 2 and 3; study 2-P</=0.03 cyclobenzaprine 2.5 mg vs placebo, relief from starting backache on day 3 only; cyclobenzaprine 5 mg vs placebo, patient-rated clinical global impression of change, medication helpfulness, and relief from starting backache at visit 3 or day 7 only). On day 7, significantly more patients receiving cyclobenzaprine 5 or 10 mg reported relief compared with placebo recipients (P < 0.05 all cyclobenzaprine groups vs placebo). Onset of relief was apparent within 3 or 4 doses of the 5-mg regimen. In the subanalysis of the proportion of responders in the pooled 5-mg groups who did and did not report somnolence, a meaningful treatment effect was observed on all primary efficacy variables in patients who did not report somnolence, suggesting that efficacy was independent of sedation. Cyclobenzaprine was well tolerated. Somnolence and dry mouth, the most common adverse effects, were mild and dose related. Overall, >/= 1 adverse event was reported in 54.1%, 61.8%, and 35.4% of patients receiving cyclobenzaprine 5 or 10 mg or placebo, respectively, in study 1 and by 43.9%, 55.9%, and 35.4% of patients receiving cyclobenzaprine 2.5 or 5 mg or placebo, respectively, in study 2. Adverse events were the primary reason for discontinuation of treatment in the cyclobenzaprine 5- and 10-mg groups in both studies. In study 2, ineffectiveness of therapy was the main reason for discontinuation of therapy in the group receiving cyclobenzaprine 2.5 mg. CONCLUSIONS: Cyclobenzaprine 2.5 mg TID was not significantly more effective than placebo. The cyclobenzaprine 5- and 10-mg TID regimens were associated with significantly higher mean efficacy scores compared with placebo. Cyclobenzaprine 5 mg TID was as effective as 10 mg TID, and was associated with a lower incidence of sedation.

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Cochrane Database Syst Rev. 2003;(2):CD004252.
Muscle relaxants for non-specific low back pain.
van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM.
Institute for Research in Extramural Medicine, Vrije Universiteit, van der Boechorststraat 7, Amsterdam, Netherlands. mw.van_tulder.emgo@med.vu.nl

BACKGROUND: The use of muscle relaxants in the management of non-specific low back pain is controversial. It is not clear if they are effective, and concerns have been raised about the potential adverse effects involved. OBJECTIVES: The aim of this review was to determine if muscle relaxants are effective in the treatment of non-specific low back pain. SEARCH STRATEGY: A computer-assisted search of the Cochrane Library (Issue 2, 2002), MEDLINE (1966 up to October 2001) and EMBASE (1988 up to October 2001) was carried out. These databases were searched using the algorithm recommended by the Cochrane Back Review Group. References cited in the identified articles and other relevant literature were screened. SELECTION CRITERIA: Randomised and/or double-blinded controlled trials, involving patients diagnosed with non-specific low back pain, treated with muscle relaxants as monotherapy or in combination with other therapeutic modalities, were included for review. DATA COLLECTION AND ANALYSIS: Two reviewers independently carried out the methodological quality assessment and data extraction of the trials. The analysis comprised not only a quantitative analysis (statistical pooling) but also a qualitative analysis ("best evidence synthesis"). This involved the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Evidence was classified as "strong", "moderate", "limited", "conflicting" or "no" evidence. MAIN RESULTS: Thirty trials met the inclusion criteria. Twenty-three trials (77%) were of high quality, 24 trials (80%) were on acute low back pain. Four trials studied benzodiazepines, 11 non-benzodiazepines and two antispasticity muscle relaxants in comparison with placebo. Results showed that there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute LBP on short-term pain relief. The pooled RR for non-benzodiazepines versus placebo after two to four days was 0.80 [95% CI; 0.71 to 0.89] for pain relief and 0.49 [95% CI; 0.25 to 0.95] for global efficacy. Adverse events, however, with a relative risk of 1.50 [95% CI; 1.14 to 1.98] were significantly more prevalent in patients receiving muscle relaxants and especially the central nervous system adverse effects (RR 2.04; 95% CI; 1.23 to 3.37). The various muscle relaxants were found to be similar in performance. REVIEWER'S CONCLUSIONS: Muscle relaxants are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or non-steroidal anti-inflammatory drugs.

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Orthop Clin North Am. 2003 Apr;34(2):255-62, vi.
Lumbar intervertebral thermal therapies.
Davis TT, Sra P, Fuller N, Bae H.
Spine Institute, St. John's Health Center, 1301 20th Street, Suite 400, Santa Monica, CA 90404, USA. tdavis@espineinstitute.com

In hopes of improving outcomes for patients with discogenic pain, less invasive techniques that reduce trauma and shorten the recovery period have been developed. This article attempts to present a comprehensive description of minimally invasive techniques, specifically heat treatments, for lumbar disc disease. The goal is to inform and educate the reader on the various thermal therapies available for lumbar disc disease by evaluating the scientific data in an objective manner.

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Orthop Clin North Am. 2003 Apr;34(2):245-54.
Core stability exercise in chronic low back pain.
Hodges PW.
Department of Physiotherapy, University of Queensland, Brisbane, Qld 4072, Australia. p.hodges@shrs.uq.edu.au

In conclusion, core stability exercise is an evolving process, and refinement of the clinical rehabilitation strategies is ongoing. Two major foci are addressed in contemporary core stability programs: motor control and muscle capacity. Both of these factors have considerable foundation in the literature and can be seen as a progression of exercise rather than conflicting approaches. Importantly, the clinical efficacy of these approaches is being realized in clinical trials. Further work is required, however, to refine and validate the approach, particularly with reference to contemporary understanding of the neurobiology of chronic pain.

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Pain Med. 2003 Mar;4(1):21-30.
Effectiveness and safety of new oxycodone/acetaminophen formulations with reduced acetaminophen for the treatment of low back pain.
Gammaitoni AR, Galer BS, Lacouture P, Domingos J, Schlagheck T.
Endo Pharmaceuticals Inc., Chadds Ford, Pennsylvania 19317, USA. Gammaitoni.Arnold@Endo.com

OBJECTIVE: To evaluate the analgesic effectiveness/safety of the new oxycodone 7.5- and 10-mg/acetaminophen 325-mg (Percocet) formulations in patients with low back pain (LBP) suboptimally responsive to nonsteroidal anti-inflammatory drugs, muscle relaxants, tramadol, cyclo-oxygenase-2 inhibitors, and/or prn opioids. DESIGN: Prospective, open-label, nonrandomized, 4-week trial. SETTING: Multicenter. PATIENTS: Thirty-three men and women (mean age: 52.2 years) with LBP (mean duration: 10.9 years). INTERVENTIONS: All prior analgesics were discontinued, and oxycodone/acetaminophen was dosed three times a day (TID), titrated to clinically meaningful pain relief. Initial oxycodone/acetaminophen dose: 2.5/325 mg TID; maximum: 20/650 mg TID. Outcome Measures: Effectiveness: Brief Pain Inventory (BPI) and Neuropathic Pain Scale 4 score (sharp, hot, dull, and deep pain). Quality of life: BPI and North American Spine Society Lumbar Spine questionnaire. Safety: Adverse events, physical/neurologic examinations, vital signs, and clinical laboratory tests. RESULTS: In all, 28 of 33 patients (85%) completed the study; discontinuations were for adverse events (N=3), patient choice (N=1), and lack of effectiveness (N =1). The mean oxycodone/acetaminophen dose at the end of treatment was 8.2/325 mg TID. After 4 weeks, treatment significantly reduced BPI pain intensity and improved pain relief (P < 0.0005), improved Neuropathic Pain Scale 4 score (P =0.007), reduced pain interference with quality of life (P < 0.0004), and reduced disability (P < 0.0001). Treatment was found to be safe and well tolerated. Adverse events were those most commonly expected from an opioid, and most were of mild-to-moderate intensity. CONCLUSIONS: The primary purpose of this study was to preliminarily test the effectiveness of the new formulations of oxycodone/acetaminophen with reduced acetaminophen in the clinical practice setting. The results from this trial suggest that these formulations are effective in the treatment of moderate-to-severe chronic LBP. Most patients (67%) reported significant pain relief/tolerable side effects with a TID dosing frequency or less (mean: 3.04 doses/day), suggesting chronic pain patients can experience meaningful pain relief with around-the-clock dosing of oxycodone/acetaminophen and minimal risk of hepatotoxicity. Further long-term, controlled studies of the efficacy/safety of the new formulations of oxycodone/acetaminophen in LBP are warranted to fully characterize efficacy in this patient population and corroborate the findings from our study.

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Ann Intern Med. 2003 Jun 3;138(11):898-906.
A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain.
Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG.
Group Health Cooperative and University of Washington, Seattle, Washington 98101, USA.

BACKGROUND: Few treatments for back pain are supported by strong scientific evidence. Conventional treatments, although widely used, have had limited success. Dissatisfied patients have, therefore, turned to complementary and alternative medical therapies and providers for care for back pain. PURPOSE: To provide a rigorous and balanced summary of the best available evidence about the effectiveness, safety, and costs of the most popular complementary and alternative medical therapies used to treat back pain. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. STUDY SELECTION: Systematic reviews of randomized, controlled trials (RCTs) that were published since 1995 and that evaluated acupuncture, massage therapy, or spinal manipulation for nonspecific back pain and RCTs published since the reviews were conducted. DATA EXTRACTION: Two authors independently extracted data from the reviews (including number of RCTs, type of back pain, quality assessment, and conclusions) and original articles (including type of pain, comparison treatments, sample size, outcomes, follow-up intervals, loss to follow-up, and authors' conclusions). DATA SYNTHESIS: Because the quality of the 20 RCTs that evaluated acupuncture was generally poor, the effectiveness of acupuncture for treating acute or chronic back pain is unclear. The three RCTs that evaluated massage reported that this therapy is effective for subacute and chronic back pain. A meta-regression analysis of the results of 26 RCTs evaluating spinal manipulation for acute and chronic back pain reported that spinal manipulation was superior to sham therapies and therapies judged to have no evidence of a benefit but was not superior to effective conventional treatments. CONCLUSIONS: Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.

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Clin Orthop. 2003 Jun;(411):159-65.
Efficacy of serotonin receptor blocker for symptomatic lumbar disc herniation.
Kanayama M, Hashimoto T, Shigenobu K, Yamane S.
Department of Orthopaedic Surgery, Hakodate Central General Hospital, Hokkaido, Japan. mkanayama@aol.com

Serotonin is one of the chemical mediators associated with nerve root inflammation and sciatic symptoms in lumbar disc herniation. The efficacy of serotonin 5-HT(2A) receptor blocker was examined in 44 patients with symptomatic lumbar disc herniation. A selective 5-HT(2A) receptor blocker (sarpogrelate hydroxychloride) was administered orally at a dose of 300 mg per day for 2 weeks. Visual analog scales of low back pain, sciatic pain, and numbness were significantly improved after the administration of the serotonin 5-HT(2A) receptor blocker. Clinical results were good (> 50% pain relief) in 23 patients, fair (25%-50% pain relief) in five patients, and poor (< 25% of pain relief) in 16 patients. Nineteen patients eventually required surgery because of muscle weakness or cauda equina symptoms. The effect of 5-HT(2A) blocker was good in 64% of patients who had uncontained disc herniation, whereas all patients with contained disc herniation had fair or poor results. Patients with uncontained disc herniation responded more favorably to the 5-HT(2A) blocker treatment than patients with contained disc herniation. A 5-HT(2A) blocker has the potential to block the cascade of acute nerve root inflammation and to alleviate symptoms in lumbar disc herniation.

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Ann Intern Med. 2003 Jun 3;138(11):871-81.
Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies.
Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.
The Cochrane Back Review Group, Toronto, Ontario, Canada.

BACKGROUND: Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. PURPOSE: To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. STUDY SELECTION: Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. DATA EXTRACTION: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). DATA SYNTHESIS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.

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J Am Geriatr Soc. 2003 May;51(5):599-608.
Efficacy of percutaneous electrical nerve stimulation for the treatment of chronic low back pain
in older adults.
Weiner DK, Rudy TE, Glick RM, Boston JR, Lieber SJ, Morrow LA, Taylor S.
Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh, Pennsylvania, USA. dweiner@pitt.edu

OBJECTIVES: To determine the efficacy of a complementary analgesic modality, percutaneous electrical nerve stimulation (PENS), for the treatment of chronic low back pain (CLBP) in community-dwelling older adults. DESIGN: Randomized, controlled clinical trial. SETTING: University of Pittsburgh Pain Evaluation and Treatment Institute. PARTICIPANTS: Thirty-four English speaking, community-dwelling adults aged 65 and older with CLBP of at least moderate intensity experienced every day or almost every day. INTERVENTION: Subjects were randomized to receive twice-weekly PENS and physical therapy (PT) or sham PENS and physical therapy for 6 weeks. MEASUREMENTS: At baseline, immediately after the 6-week intervention period, and 3 months later, the primary outcome measures pain intensity and pain-related disability were assessed. The secondary outcome measures physical performance (timed chair rise, functional reach, gait speed, static and isoinertial lifting), psychosocial factors (mood, sleep, and life control), and cognitive function (measures of attention, concentration, and mental flexibility) were also collected. RESULTS: Subjects randomized to PENS plus PT displayed significant reductions in pain intensity measures from pre- to posttreatment (P <.001), but the sham PENS plus PT group did not (P =.94). These pain reduction effects were maintained at 3-month follow-up. Similarly, significant reductions in pain-related disability were observed at posttreatment (P =.002) for the PENS plus PT group and were maintained at follow-up, but the sham PENS plus PT group did not show reductions in pain-related disability (P =.81). Of the secondary outcome measures, psychosocial function, timed chair rise, and isoinertial lifting endurance also improved significantly at posttreatment for the PENS plus PT group, and their improvement was sustained at 3-month follow-up, but the sham PENS plus PT did not display significant changes on these measures after treatment. CONCLUSION: This preliminary study suggests that PENS may be a promising treatment modality for community-dwelling older adults with CLBP, as demonstrated by reduction in pain intensity and self-reported disability, and improvement in mood, life control, and physical performance. Larger studies with longer duration of follow-up are needed to validate these findings and support the use of PENS in clinical practice.

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Med Pregl. 2002 Nov-Dec;55(11-12):495-9.
[Balneotherapy in the treatment of subjective symptoms of lumbar syndrome]
[Article in Serbo-Croatian (Roman)]
Batsialou I.
Fizikalna medicina i rehabilitacija Medicinski fakultet, Novi Sad.

INTRODUCTION: Chronic low back pain is a degenerative rheumatic disease and is characterized by various symptoms and clinical signs. BALNEOTHERAPY: Balneotherapy represents a therapy by various hot or warm baths in natural mineral waters of specific physical and chemical characteristics. When used externally, they have mechanical, chemical and thermic effects. Balneotherapy of lumbar syndrome includes: individual baths, swimming in the pool, hydrokinesitherapy, underwater massage, underwater extension, mud therapy, mud baths. The therapy should be closely monitored for optimal efficacy and it is necessary to examine: functional status of the lumbosacral region, general functional status (level of activity), lower extremities, pain measurement, use of non-steroid antirheumatic and analgesic agents. In order to follow-up the effects of therapy and establish the prognosis it is important to perform: detailed anamnesis, anthropometric measurements, socio-epidemiological research, clinical examinations. CONCLUSION: Lumbar syndrome is usually caused by a degenerative disease of the spinal column. More than 25% of people under 45 years of age are unable to work due to chronic low back pain. That is why preventive measures, prompt diagnosis and adequate therapy are of utmost importance.

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Eur Spine J. 2003 Apr;12(2):166-72. Epub 2002 Nov 28.
The effect of walking faster on people with acute low back pain.
Taylor NF, Evans OM, Goldie PA.
Faculty of Health Sciences, La Trobe University, Bundoora, Australia. N.Taylor@latrobe.edu.au

Little is known about self-selected speed and fast walking in people with acute low back pain. This study aimed to investigate (1) the strategies that people with acute low back pain use to change from self-selected speed to fast walking and (2) the effect of a period of treadmill walking on level of back pain. Eight participants with acute low back pain and eight matched control participants were evaluated during self-selected speed and fast walking on a treadmill. The eight participants with back pain were retested 6 weeks later when pain had resolved. Measurements were taken of (1) three-dimensional angular movements of the pelvis and lumbar spine using a videoanalysis system, (2) the timing and distance parameters of walking, and (3) pain levels as measured by a visual analogue scale. We found that to walk faster, those with acute low back pain increased stride length and the frontal plane movements of pelvic list and lumbar lateral flexion (pelvis) to a greater extent than when symptoms had resolved. We also found that 10 min of treadmill walking at self-selected speed led to a reduction in the level of back pain and that there was a high degree of negative correlation between level of back pain and stride length. An additional 5 min of fast walking did not lead to any further changes in level of back pain. These findings support clinical recommendations that the moderate physical activity of walking may be beneficial in the management of people with acute low back pain. To walk faster, people with acute low back pain may utilise strategies that had been limited at self-selected speed, without any increase in pain.

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Eur Spine J. 2003 Apr;12(2):108-16. Epub 2002 Dec 07.
Total disc replacement for chronic low back pain: background and a systematic review of the literature.
de Kleuver M, Oner FC, Jacobs WC.
Department of Orthopedic Surgery, Sint Maartenskliniek, Hengstdal 3, 6522 JV Nijmegen, The Netherlands. m.dekleuver@maartenskliniek.nl

In this paper the rationale for total disc replacement is discussed, and the authors suggest seven requirements that should be met before the implantation of these devices can be accepted as regular procedures. In an attempt to answer the questions raised, a systematic literature search was performed. The search yielded no controlled trials and nine case series with a total of 564 arthroplasties in 411 patients. The devices used were SB Charite in eight and Acroflex in one study. The percentage results classified as "good" or "excellent" in the studies varied from 50 to 81%. Complications were observed in 3-50% of the patients. Twenty-two of the operated levels were fused either spontaneously or after additional surgery. A meta-analysis to compare the results with other treatments could not be performed due to the lack of comparative studies. Despite the fact that these devices have been implanted for almost 15 years, on the basis of this literature survey there are currently insufficient data to assess the performance of total disc replacement adequately. There is no evidence that disc replacement reliably, reproducibly, and over longer periods of time fulfils the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement seems to be associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been addressed. Therefore, total disc replacements should be considered experimental procedures and should only be used in strict clinical trials.

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Arch Phys Med Rehabil. 2003 Mar;84(3 Suppl 1):S69-73; quiz S74-5.
Botulinum toxin type A therapy in chronic pain disorders.
Lang AM.
Department of Rehabilitation Medicine, Emory University School of Medicine and Hospitals, Atlanta, GA, USA. orthorehab@earthlink.net

This self-directed learning module highlights that the underlying problem in many types of muscle pain disorders is a distortion of critical structures that causes functional deficits and pain. An objective of treatment is to reverse this distortion, enabling repair of damaged tissues and strengthening of weakened muscles. Administering botulinum toxin type A (BTX-A; Botox) to reduce muscle tone and overactivity warrants consideration as part of an overall treatment approach that includes physical therapy to help restore normal muscle length and biomechanical balance to improve the prospect of ensuring long-term relief from associated pain. This article specifically focuses on pertinent review articles, results of controlled and open-trial data, and case reports to assess the role of BTX-A treatment in chronic pain disorders. OVERALL LEARNING OBJECTIVE: To review the clinical trial data of the safety and efficacy of BTX-A for the treatment of chronic pain syndromes associated with muscle disorders.

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J Am Acad Orthop Surg. 2003 Jan-Feb;11(1):6-11.
Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy.
Wetzel FT, McNally TA.
Section of Orthopaedic Surgery and Rehabilitation Medicine and Anesthesia and Critical Care, University of Chicago Spine Center Chicago, IL, USA.

The treatment of chronic, nonradicular, discogenic low back pain remains controversial. The posterior anulus fibrosus appears to be a potential site of origin of the pain, which is mediated by nociceptors in the inner layers of the anulus. Diagnosis requires a thorough history, physical examination, and imaging protocol; provocative diskography is key. Nonsurgical treatment options have been limited to physical therapy and pharmacotherapy. Success rates of spinal fusion range from 39% to 96%. Reported therapeutic success rates of intradiskal electrothermal therapy, a possible intermediate treatment, range from 60% to 80%. Despite this apparent therapeutic effect, however, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials.

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J Bone Joint Surg Br. 2003 Mar;85(2):250-3.
Nerve-root injections for the relief of pain in patients with osteoporotic vertebral fractures.
Kim DJ, Yun YH, Wang JM.
Department of Orthopaedic Surgery, Ewha Womans University Hospital and the Ewha Medical Research Centre, Seoul, Korea.

We have studied 58 patients with pain from osteoporotic vertebral fractures which did not respond to conservative treatment. These were 53 women and five men with a mean age of 72.5 years. They received a nerve-root injection with lidocaine, bupivicaine and DepoMedrol. The mean follow-up period was 13.5 months. The mean pain scores before treatment, at one and six months after treatment and at the final follow-up were 85, 24.9, 14.1, and 17.4, respectively. According to our modified criteria for grading results, six patients were considered to have an excellent result, 42 good and ten fair. A newly developed compression fracture was noted in three patients. There were no complications related to the injection. Our study suggests that nerve-root injections are effective in reducing pain in patients with osteoporotic vertebral fractures and that these patients should be considered for this treatment before percutaneous vertebroplasty or operative intervention is attempted.

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Spine. 2003 Mar 15;28(6):525-31; discussion 531-2.
Manual therapy and exercise therapy in patients with chronic low back pain: a randomized, controlled trial with 1-year follow-up.
Aure OF, Nilsen JH, Vasseljen O.
Larvik Fysioterapi, Norway. auro@sensewave.com

STUDY DESIGN: A multicenter, randomized, controlled trial with 1-year follow-up. OBJECTIVES: To compare the effect of manual therapy to exercise therapy in sick-listed patients with chronic low back pain (>8 wks). SUMMARY AND BACKGROUND DATA: The effect of exercise therapy and manual therapy on chronic low back pain with respect to pain, function, and sick leave have been investigated in a number of studies. The results are, however, conflicting. METHODS: Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 6 months were included. A total of 49 patients were randomized to either manual therapy (n = 27) or to exercise therapy (n = 22). Sixteen treatments were given over the course of 2 months. Pain intensity, functional disability (Oswestry disability index), general health (Dartmouth COOP function charts), and return to work were recorded before, immediately after, at 4 weeks, 6 months, and 12 months after the treatment period. Spinal range of motion (Schober test) was measured before and immediately after the treatment period only. RESULTS: Although significant improvements were observed in both groups, the manual therapy group showed significantly larger improvements than the exercise therapy group on all outcome variables throughout the entire experimental period. Immediately after the 2-month treatment period, 67% in the manual therapy and 27% in the exercise therapy group had returned to work (P < 0.01), a relative difference that was maintained throughout the follow-up period. CONCLUSIONS: Improvements were found in both intervention groups, but manual therapy showed significantly greater improvement than exercise therapy in patients with chronic low back pain. The effects were reflected on all outcome measures, both on short and long-term follow-up.

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Minim Invasive Neurosurg. 2003 Feb;46(1):1-4.
Endoscopic surgery of the lumbar epidural space (epiduroscopy): results of therapeutic
intervention in 93 patients.
Ruetten S, Meyer O, Godolias G.
Ressort Spine Surgery and Pain Therapy, Orthopaedic Clinic at the Faculty of Radiology and Microtherapy, University of Witten/Herdecke, St. Anna-Hospital, Herne, Germany. s-ruetten@t-online.de

Determination and therapy of the underlying pathology in chronic pain syndrome in the lumbar spine is frequently difficult. Minimally invasive and microsurgical techniques may offer advantages. Epiduroscopy is available for visualization of the lumbar epidural space. 93 patients with chronic back-leg pain syndrome were epiduroscopically operated. When findings were appropriate, mechanical instruments and the holmium:YAG laser were applied therapeutically. 45.9 % of these patients presented with positive results in postoperative examination. Pathomorphological processes corresponding to the multifactorial pain processes, which escape detection in modern imaging procedures, can be diagnosed in the epidural space using epiduroscopy Therapeutic intervention is basically possible. However, use is limited due to technical difficulties. Navigation of the endoscope is especially limited in access via the hiatus sacralis.

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Arch Phys Med Rehabil. 2003 Mar;84(3):335-42.
Overnight use of continuous low-level heatwrap therapy for relief of low back pain.
Nadler SF, Steiner DJ, Petty SR, Erasala GN, Hengehold DA, Weingand KW.
Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey--New Jersey Medical School, Newark, NJ 07103, USA. sfnadler@cs.com

OBJECTIVE: To evaluate of the efficacy and safety of 8 hours of continuous, low-level heatwrap therapy administered during sleep. DESIGN: Prospective, randomized, parallel, single-blind (investigator), placebo-controlled, multicenter clinical trial. SETTING: Two community-based research facilities. PARTICIPANTS: Seventy-six patients, aged 18 to 55 years, with acute, nonspecific low back pain. INTERVENTIONS: Subjects were stratified by baseline pain intensity and gender and randomized to one of the following treatments: evaluation of efficacy (heatwrap, n=33; oral placebo, n=34) or blinding (unheated wrap, n=5; oral ibuprofen, n=4). All treatments were administered for 3 consecutive nights with 2 days of follow-up. MAIN OUTCOME MEASURES: Primary: morning pain relief (hour 0) on days 2 through 4 (0-5-point verbal response scale). Secondary: mean daytime pain relief score (days 2-4, hours 0-8), mean extended pain relief score (day 4, hour 0; day 5, hour 0), muscle stiffness, lateral trunk flexibility, and disability (Roland-Morris Disability Questionnaire). RESULTS: Heatwrap therapy was significantly better than placebo at hour 0 on days 2 through 4 for mean pain relief (P=.00005); at hours 0 through 8 on days 2 through 4 for pain relief (P<.001); at hour 0 on day 4 and at hour 0 on day 5 for mean pain relief (P<.001); on day 4 in reduction of morning muscle stiffness (P<.001); for increased lateral trunk flexibility on day 4 (P<.002); and for decreased low back disability on day 4 (P=.005). Adverse events were mild and infrequent. CONCLUSIONS: Overnight use of heatwrap therapy provided effective pain relief throughout the next day, reduced muscle stiffness and disability, and improved trunk flexibility. Positive effects were sustained more than 48 hours after treatments were completed. Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Arch Phys Med Rehabil. 2003 Mar;84(3):329-34.
Continuous low-level heatwrap therapy for treating acute nonspecific low back pain.
Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Abeln SB, Weingand KW.
Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey--New Jersey Medical School, Newark, NJ 07103, USA. sfnadler@cs.com

OBJECTIVE: To evaluate the efficacy of 8 hours of continuous low-level heatwrap therapy for the treatment of acute nonspecific low back pain (LBP). DESIGN: Prospective, randomized, parallel, single-blind (investigator), placebo-controlled, multicenter clinical trial. SETTING: Five community-based research facilities. PARTICIPANTS: Two-hundred nineteen subjects, aged 18 to 55 years, with acute nonspecific LBP. INTERVENTION: Subjects were stratified by baseline pain intensity and gender and randomized to one of the following groups: evaluation of efficacy (heatwrap, n=95; oral placebo, n=96) and blinding (oral ibuprofen, n=12; unheated back, wrap n=16). All treatments were administered for 3 consecutive days with 2 days of follow-up. MAIN OUTCOME MEASURES: Primary: day 1 mean pain relief (0- to 5-point verbal response scale). Secondary: muscle stiffness (101-point numeric rating scale), lateral trunk flexibility (fingertip-floor distance), and Roland-Morris Disability Questionnaire over 3 days of treatment and 2 days of follow-up. RESULTS: Heatwrap therapy was shown to provide significant therapeutic benefits when compared with placebo during both the treatment and follow-up period. On day 1, the heatwrap group had greater pain relief (1.76+/-.10 vs 1.05+/-.11, P <.001), less muscle stiffness (43.1+/-1.21 vs 47.6+/-1.21, P=.008), and increased flexibility (18.6+/-.44 cm vs 16.5+/-.45 cm, P=.001) compared with placebo. Disability was also reduced in the heatwrap group (5.3 vs 7.4, P=.0002). Adverse events were mild and infrequent. CONCLUSION: Continuous low-level heatwrap therapy was shown to be effective for the treatment of acute, nonspecific LBP. Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Man Ther. 2003 Feb;8(1):46-51.
Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations.
Harvey E, Burton AK, Moffett JK, Breen A; UK BEAM trial team.
Department of Health Sciences, Alcuin College, University of York, York, UK. e.l.harvey@leeds.ac.uk

Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trial--a national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is 'pragmatic', in that it represents what happens to most people undergoing manipulation, and 'explanatory' in that it excludes discipline-specific variations and other ancillary treatments.

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Muscle Nerve. 2003 Mar;27(3):265-84.
Evaluation and treatment of low back pain: an evidence-based approach to clinical care.
Atlas SJ, Nardin RA.
General Medicine Division, Medical Services, Massachusetts General Hospital, Harvard Medical School, 50 Staniford Street, Boston, Massachusetts 02114, USA. satlas@partners.org

Low back pain is a common reason for patient visits to a health care provider. For most patients, low back symptoms are nonspecific, meaning that the pain is localized to the back or buttocks and is due to a presumed musculoligamentous process. For patients with radicular leg symptoms, a precise etiology is more commonly identified. The history and physical examination usually provide clues to the uncommon but potentially serious causes of low back pain, as well as to those patients at risk for prolonged recovery. Diagnostic testing should not be a routine part of the initial evaluation, but used selectively based upon the history, examination, and initial treatment response. For patients without significant neurological impairment, initial treatments should include activity modification, nonnarcotic analgesics, and education. For patients whose symptoms are not improving over 2 to 4 weeks, referral for physical treatments is appropriate. A variety of therapeutic options of limited or unproven benefit are available for patients with radicular leg symptoms or chronic low back pain. Patients with radicular pain and little or no neurological findings should receive conservative treatment, but elective surgery is appropriate for those with nerve root compression who are unresponsive to conservative therapy.

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Scand J Work Environ Health. 2003 Feb;29(1):27-34.
A shorter workday as a means of reducing the occurrence of musculoskeletal disorders.
Wergeland EL, Veiersted B, Ingre M, Olsson B, Akerstedt T, Bjornskau T, Varg N.
Institute of General Practice and Community Health, Oslo University, Oslo, Norway. ebba.wergeland@samfunnsmed.uio.no

OBJECTIVES: The study examined the relation between daily workhours and the occurrence of neck-shoulder or back pain in physically demanding care work. METHODS: Unpublished data were obtained from three intervention projects in care institutions. The projects had been conducted independently in Oslo (46 participants, 175 referents before and 158 referents after the intervention), Helsingborg (60 participants, 89 referents) and Stockholm (41 participants, 22 referents) between 1995 and 1998. The intervention was a reduction of daily workhours from > or = 7 to 6 hours (or 30 hours weekly). Full-time salary was retained, and extra personnel were employed to compensate for the reduction in workhours. Data were collected by self-administered questionnaires before and during the intervention periods, lasting from 12 to 22 months. RESULTS: The prevalence of neck-shoulder pain decreased from 40.9% to 25.6% in Oslo and from 57.1% to 39.1% in Helsingborg after 1.5 years with a 6-hour workday; for Stockholm the decrease was from 81.6% to 68.3% after 1 year. No decrease was observed in the reference groups. The prevalence of back pain did not show the same consistent pattern. CONCLUSIONS: The shortening of regular workdays from > or = 7 hours to 6 hours may considerably reduce the prevalence of neck-shoulder pain among persons with physically demanding care work. The potential health benefits should encourage intervention studies also in other occupations with increased risk of work-related musculoskeletal disorders.

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Lasers Surg Med. 2003;32(3):233-8.
Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain.
Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ, Karakoc M.
Physical Medicine and Rehabilitation, School of Medicine, Dicle University, Diyarbakir, Turkey. alig@dicle.edu.tr

BACKGROUND AND OBJECTIVES: The aim of this study was to determine whether low power laser therapy (Gallium-Arsenide) is useful or not for the therapy of chronic low back pain (LBP). STUDY DESIGN/MATERIALS AND METHODS: This study included 75 patients (laser + exercise-25, laser alone-25, and exercise alone-25) with LBP. Visual analogue scale (VAS), Schober test, flexion and lateral flexion measures, Roland Disability Questionnaire (RDQ) and Modified Oswestry Disability Questionnaire (MODQ) were used in the clinical and functional evaluations pre and post therapeutically. A physician, who was not aware of the therapy undertaken, evaluated the patients. RESULTS: Significant improvements were noted in all groups with respect to all outcome parameters, except lateral flexion (P < 0.05). CONCLUSIONS: Low power laser therapy seemed to be an effective method in reducing pain and functional disability in the therapy of chronic LBP. Copyright 2003 Wiley-Liss, Inc.

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Br J Radiol. 2003 Jan;76(901):69-75.
Percutaneous vertebroplasty: indications, contraindications, and technique.
Peh WC, Gilula LA.
Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore 169608.

Percutaneous vertebroplasty is an emerging interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a vertebral body under imaging guidance. This technique provides increased strength and pain relief in vertebrae weakened by a variety of bone diseases. The current indication for vertebroplasty is intractable non-radicular pain caused by compression fractures due to osteoporosis, myeloma, metastases and aggressive vertebral haemangioma. Contraindications include bleeding disorder, unstable fracture and lack of definable vertebral collapse. Our technique of percutaneous vertebroplasty is illustrated in this pictorial review.

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Eur Spine J. 2003 Feb;12(1):41-7. Epub 2002 Sep 19.
Temporary external pedicular fixation versus definitive bony fusion: a prospective comparative study on pain relief and function.
Axelsson P, Johnsson R, Stromqvist B, Andreasson H.
Department of Orthopedics, Lund University Hospital, 221 85 Lund, Sweden.

Temporary external pedicular fixation is used as a prognostic instrument when treating degenerative conditions with spinal fusion. We studied the validity of the method and whether a functional test could improve the prognostic value of such fixation. Twenty-six patients with long-standing lumbar pain had an external temporary fixation. Pain levels were registered before fixation on a visual analogue scale at rest, as a mean for the previous week, and at seven different standardized activities. Walking capacity and walking speed for a standardized distance were also measured. Identical evaluations were then repeated during the external fixation and 1 year after definitive fusion. Based on the outcome of the temporary fixation, 20 patients were recommended for definitive surgical fusion. In six cases, the option of fusion surgery was rejected due to an unfavourable pain response or insufficient pain relief during the test fixation period, and this group was not further followed within the study. One year after surgery, 14 of 20 patients reported a good outcome. Solid bony fusion assessed by conventional radiography was seen in 19 patients. One patient with a poor clinical outcome had a pseudarthrosis. The mean values for pain level at rest, during last week and at the seven different activities in the functional test tended to decrease after fusion compared to the situation with temporary external fixation. In no activity did the external fixator overestimate the mean positive pain-relieving effect after definitive fusion. The walking capacity significantly increased, while the walking speed did not alter at the three different measurements. We conclude that with a good outcome ratio of 14 patients out of 19 having a solid fusion, the external frame improved patient selection and can be used as a valid prognostic instrument. The pain relief and function after definitive fusion can not be quantified by the external fixation, probably due to the fact that the stabilisation with an external frame is partial. The value of the functional test design presented is moderate, and an outcome evaluation comprising pain relief at rest and mean pain level during a week in fixation seems adequate.

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Eur Spine J. 2003 Feb;12(1):22-33. Epub 2002 Oct 23.
Predictors of outcome in fusion surgery for chronic low back pain. A report from the Swedish Lumbar Spine Study.
Hagg O, Fritzell P, Ekselius L, Nordwall A; Swedish Lumbar Spine Study.
Department of Orthopedic Surgery, Sahlgren University Hospital, 413 45 Gothenburg, Sweden. ollehagg@hotmail.com

Despite the continuous development of surgical techniques and implants, a substantial number of patients still undergo surgery for chronic low back pain (CLBP) without any benefit, or even become worse. With the aim of finding predictors of functional and work status outcome, 264 patients with severe CLBP of long duration, randomised to surgical or non-surgical treatment, were characterized by socio-demographic, clinical, radiological and psychological variables. The variables were estimated as predictors of outcome at the 2-year follow-up. Univariate and multiple logistic regression analyses were used in both treatment groups. We found that a personality characterized by low neuroticism and low disc height were significant predictors of functional improvement after surgical treatment. Depressive symptoms predicted functional improvement after non-surgical treatment. Work resumption was predicted by low age and short sick leave in the surgical group, and by short sick leave in the non-surgical group. We conclude that improved selection of successful surgical candidates with CLBP seems to be promoted by attention to severe disc degeneration, evaluation of personality traits and shortening of preoperative sick leave.

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Arch Phys Med Rehabil. 2003 Jan;84(1):23-8.
Treatment of chronic lumbar diskogenic pain with intradiskal electrothermal therapy: a prospective outcome study.
Lutz C, Lutz GE, Cooke PM.
Physiatry Service, Hospital for Special Surgery, New York, NY 10021, USA.

OBJECTIVE: To determine the clinical efficacy of intradiskal electrothermal annuloplasty in treating patients with chronic constant lumbar diskogenic pain who have not responded to at least 6 months of aggressive nonoperative care. DESIGN: Prospective case series. SETTING: Academic-affiliated private physiatry practice. PARTICIPANTS: Thirty-three patients with chronic constant lumbar diskogenic pain of more than 6 months in duration diagnosed with history and physical examination, with concordant pain on provocative pressure-controlled lumbar diskography, and with symptomatic annular tears and/or protrusions less than 5mm, who did not respond to aggressive nonoperative care. INTERVENTION: Intradiskal electrothermal annuloplasty. MAIN OUTCOME MEASURES: Visual analog scale (VAS) pain scores for the back and for the lower extremity, the Roland-Morris Disability Questionnaire (RMDQ), and the North American Spine Society Patient Satisfaction Index. RESULTS: A total of 33 patients, with mean age of 40 years and a mean duration of symptoms of 46 months, were observed with a mean follow-up of 15 months. Relief of pain and improvement in physical function were associated with a mean change in the VAS score of 3.9 (P<.001), a mean change in the lower-extremity VAS score of 3.7 (P<.001), and a mean change in the RMDQ of 7.3 (P<.001). For patient satisfaction, 75.7% reported that they would undergo the same procedure for the same outcome. Complete pain relief was achieved in 24% of the patients, and partial pain relief in 46% of the patients. CONCLUSIONS: Intradiskal electrothermal annuloplasty offers a safe, minimally invasive treatment option for carefully selected patients with chronic lumbar diskogenic pain who have not responded to aggressive nonoperative care. Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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J Pain Symptom Manage. 2003 Feb;25(2 Suppl):S21-31.
Strategies in pain management: new and potential indications for COX-2 specific inhibitors.
Ruoff G, Lema M.
Department of Family Practice, Michigan State University College of Medicine, East Lansing, MI, USA.

The role of the coxibs in the management of osteoarthritis and rheumatoid arthritis has been widely discussed, but there are other potential applications for the coxibs that have received less attention. Here we consider the use of the coxibs in acute pain syndromes such as primary dysmenorrhea and the pain associated with dental extraction, as well as considering their application in chronic low back pain and cancer pain. Another area where the coxibs may prove particularly beneficial is in the management of post-surgical pain. Traditional post-surgical analgesia has involved the use of non-selective NSAIDs and opioids, but these agents can be associated with side effects such as post-operative bleeding, gastrointestinal problems, nausea, and constipation. Because the coxibs do not inhibit COX-1 dependent platelet aggregation like traditional NSAIDs, the risk of post-surgical bleeding is reduced. The careful application of coxibs as part of a multi-modal approach to pain management in the perioperative period can reduce the requirement for opioid medications and thus reduce the risk of post-operative complications such as ileus. In the future, coxibs are likely to play an important role in multi-modal perioperative analgesic regimens with the aim of reducing post-operative periods of convalescence.

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Cochrane Database Syst Rev. 2003;(1):CD004058.
Radiofrequency denervation for neck and back pain. A systematic review of randomized controlled trials.
Niemisto L, Kalso E, Malmivaara A, Seitsalo S, Hurri H.
Rehabilitation Unit of Orton Orthopaedic Hospital, Orton Orthopaedic Hospital, Invalid Foundation, Tenholantie 10, Helsinki, Finland, 00280. leena.niemisto@invalidisaatio.fi

BACKGROUND: The diagnosis of cervical or lumbar zygapophyseal joint pain can only be made by using local anesthesia to block the nerves supplying the painful joint. There is a lack of effective treatment for chronic zygapophyseal joint pain or discogenic pain. Radiofrequency denervation appears to be an emerging technology, with substantial variation in its use between countries. OBJECTIVES: To assess the effectiveness of radiofrequency denervation for the treatment of musculoskeletal pain disorders. SEARCH STRATEGY: We searched MEDLINE, PsycLIT, and EMBASE from start to February 2002, plus the Cochrane Library 2002, Issue 2. The references of identified articles were checked and three experts in the field of radiofrequency treatment were consulted to identify studies we might have missed. SELECTION CRITERIA: Randomized controlled trials (RCTs) of radiofrequency denervation for musculoskeletal pain disorders, with no language or date restrictions. DATA COLLECTION AND ANALYSIS: Two reviewers selected RCTs that met predefined inclusion criteria, extracted the data, and assessed the main results and methodological quality of the selected trials, using standardized forms. Qualitative analysis was conducted to evaluate the level of scientific evidence. MAIN RESULTS: We found only nine articles, reporting on seven relevant RCTs. Six of the seven were considered to be high-quality. The selected trials included 275 randomized patients, 141 of whom received active treatment. One study examined cervical zygapophyseal joint pain, two cervicobrachial pain, three lumbar zygapophyseal joint pain, and one discogenic low-back pain. The study sample sizes were small, follow-up times short, and there were some deficiencies in patient selection, outcome assessments, and statistical analyses. The level of scientific evidence for the short-term effectiveness of radiofrequency denervation was limited for cervical zygapophyseal joint and cervicobrachial pain, and conflicting for lumbar zygapophyseal joint pain. There was limited evidence suggesting that intradiscal radiofrequency thermocoagulation was not effective for discogenic low-back pain. REVIEWER'S CONCLUSIONS: The selected trials provide limited evidence that radiofrequency denervation offers short-term relief for chronic neck pain of zygapophyseal joint origin and for chronic cervicobrachial pain; conflicting evidence on the short-term effect of radiofrequency lesioning on pain and disability in chronic low-back pain of zygapophyseal joint origin; and limited evidence that intradiscal radiofrequency thermocoagulation is not effective for chronic discogenic low-back pain. There is a need for further high-quality RCTs with larger patient samples and data on long-term effects, for which current evidence is inconclusive. Furthermore, RCTs are needed in non-spinal indications where radiofrequency denervation is currently used without any scientific evidence.

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Rheumatology (Oxford). 2003 Jan;42(1):141-8.
A randomized double-blind pilot study comparing Doloteffin and Vioxx in the treatment of low back pain.
Chrubasik S, Model A, Black A, Pollak S.
Department of Forensic Medicine, University of Freiburg, 79104 Freiburg, Germany. sigrun.chrubasik@klinikum.uni-freiburg.de

OBJECTIVE: This randomized, double-dummy, double-blind pilot study of acutely exacerbated low back pain was aimed to inform a definitive comparison between Doloteffin, a proprietary extract of Harpagophytum, and rofecoxib, a selective inhibitor of cyclo-oxygenase-2 (COX-2). METHODS: Forty-four patients (phyto-anti-inflammatory drug-PAID-group) received a daily dose of Doloteffin containing, inter alia, 60 mg of harpagoside for 6 weeks and 44 (non-steroidal anti-inflammatory drug-NSAID-group) received 12.5 mg/day of rofecoxib. All were allowed rescue medication of up to 400 mg/day of tramadol. Several outcome measures were examined at various intervals to obtain estimates of effect size and variability that might be used to decide the most suitable principal outcome measure and corresponding numbers required for a definitive study. RESULTS: Forty-three PAID and 36 NSAID patients completed the study. Ten PAID and 5 NSAID patients reported no pain without rescue medication for at least 5 days of the 6th week of treatment. Eighteen PAID and 12 NSAID patients had more than a 50% reduction in the week's average of their pain scores between the 1st and 6th weeks. The mean percentage decrease from baseline in the pain component of the Arhus Index was 23 (S.D. 52) in PAID and 26 (S.D. 43) in NSAID. The corresponding measures for the overall Arhus Index were 11 (31) and 16 (24) and, for the Health Assessment Questionnaire, 7 (8) and 6 (7). Tramadol was used by 21 PAID patients and 13 NSAID patients. Fourteen patients in each group experienced 39 adverse effects, of which 28 (13 in PAID) were judged to some degree attributable to the study medications. CONCLUSION: Though no significant intergroup differences were demonstrable, large numbers will be needed to show equivalence.

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Clin Rehabil. 2002 Dec;16(8):811-20.
Systematic review of conservative interventions for subacute low back pain.
Pengel HM, Maher CG, Refshauge KM.
School of Physiotherapy, University of Sydney, Sydney, NSW, Australia. hpen1533@mail.usyd.edu.au

OBJECTIVE: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. DESIGN: Systematic review of randomized controlled trials. MAIN OUTCOME MEASURES: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. RESULTS: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g. manipulation, exercise, TENS) may be effective. CONCLUSIONS: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence.

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Di Yi Jun Yi Da Xue Xue Bao. 2002 Dec;22(12):1057-60.
[Cause-specific treatment for nonspecific low back pain]
[Article in Chinese]
Jin AM.
Department of Orthopedics, Zhujiang Hospital, First Military Medical University, Guangzhou 510282, China.

Nonspecific low back pain has long been a troublesome clinical entity in that the diagnoses are usually hard to define, and the effect of treatment unsure. We have been conducting long-term basic and clinical research in Zhujiang Hospital in an effort to find the exact mechanism for this disease and to explore its causal treatment. On the basis of literature review and treatment result evaluation, we recommend the following approaches for origin-specific diagnosis and treatments: (1) For spinal nerve dorsal ramus syndrome caused by mechanical stimulation on the stem part of the dorsal ramus, freezing the dorsal ramus with liquid-nitrogen may constitute the primary treatment. (2) In cases of low back pain originated from the lumbar disc due to degeneration of discs, treatment may be implemented through disc resection with or without arthrodesis. (3) Facet syndrome, a condition with low back pain that is seldom caused by pathological changes in the facet itself, but mostly by the pulling of the dorsal ramus due to the dislocation of the facet, should be attributed to the dorsal ramus syndrome. (4) Lumbar vertebra instability arising from loosened intervertebral conjunction calls for arthrodesis as the primary choice. (5) Interspinal ligaments injury can be most effectively treated by the combination of blocking and needle knife loosing. (6) Low back pain with underlying causes in the internal organs is often caused by diseases in the pelvic organs, and only these diseases are cured can the back pain be relieved. These origin-specific diagnosis and treatments we proposed here await further investigation and comments from our peers interested in this problem.

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Drugs. 2002;62(18):2637-51; discussion 2652-3.
Etoricoxib.
Cochrane DJ, Jarvis B, Keating GM.
Adis International Limited, Mairangi Bay, Auckland, New Zealand. demail@adis.co.nz

Etoricoxib is a cyclo-oxygenase (COX)-2-selective NSAID with a higher COX-1 to COX-2 selectivity ratio than the other COX-2-selective NSAIDs rofecoxib, valdecoxib or celecoxib. In patients with rheumatoid arthritis, improvements in tender and swollen joint counts and patient and investigator global assessment of disease activity were significantly greater in etoricoxib than in placebo recipients in two studies. Etoricoxib was also significantly more effective than naproxen in one of these studies. In patients with osteoarthritis of the hip or knee, etoricoxib was significantly more effective than placebo and had similar efficacy to naproxen with regards to improvements in pain and physical function scores and patient global assessment of disease status scores in two studies. Etoricoxib had similar efficacy to diclofenac in patients with osteoarthritis of the knee. Single-dose etoricoxib relieved pain in patients with postoperative dental pain in two studies. Similar scores assessing total pain relief over 8 hours (TOPAR8) were reported in etoricoxib and naproxen sodium or ibuprofen recipients, and higher TOPAR8 scores were reported with etoricoxib than with paracetamol (acetaminophen)/codeine. Pain relief was significantly better with etoricoxib than placebo in two studies in patients with chronic low back pain. Etoricoxib had similar efficacy to indomethacin in a study in patients with acute gout, and single-dose etoricoxib had similar efficacy to naproxen sodium in a study in women with primary dysmenorrhoea. Compared with non-COX-selective NSAIDs, etoricoxib was associated with significantly fewer upper gastrointestinal (GI) perforations, ulcers or bleeds, and was significantly less likely to result in treatment discontinuation because of NSAID-type GI symptoms or any GI symptoms.

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Aust J Physiother. 2002;48(4):297-302.
Combined physiotherapy and education is efficacious for chronic low back pain.
Moseley L.
The University of Queensland and Royal Brisbane Hospital, Australia. l.moseley@mailbox.uq.edu.au

Manual therapy, exercise and education target distinct aspects of chronic low back pain and probably have distinct effects. This study aimed to determine the efficacy of a combined physiotherapy treatment that comprised all of these strategies. By concealed randomisation, 57 chronic low back pain patients were allocated to either the four-week physiotherapy program or management as directed by their general practitioners. The dependent variables of interest were pain and disability. Assessors were blind to treatment group. Outcome data from 49 subjects (86%) showed a significant treatment effect. The physiotherapy program reduced pain and disability by a mean of 1.5/10 points on a numerical rating scale (95% CI 0.7 to 2.3) and 3.9 points on the 18-point Roland Morris Disability Questionnaire (95% CI 2 to 5.8), respectively. The number needed to treat in order to gain a clinically meaningful change was 3 (95% CI 3 to 8) for pain, and 2 (95% CI 2 to 5) for disability. A treatment effect was maintained at one-year follow-up. The findings support the efficacy of combined physiotherapy treatment in producing symptomatic and functional change in moderately disabled chronic low back pain patients.

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Aust J Physiother. 2002;48(4):277-84.
Does spinal manipulative therapy help people with chronic low back pain?
Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG.
The University of Sydney, Australia. mfer5142@mail.usyd.edu.au

A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain.

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Spine. 2002 Nov 15;27(22):2621-6.
Intradiscal electrothermal therapy used to manage chronic discogenic low back pain: new directions and interventions.
Wetzel FT, McNally TA, Phillips FM.
Section of Orthopaedic Surgery and Rehabilitation and Anesthesia and Critical Care, University of Chicago Spine Center, Chicago, Illinois 60640, USA. twetzel@mcis.bsd.uchicago.edu

STUDY DESIGN: Retrospective literature review. OBJECTIVES: To review the data on the clinical efficacy of intradiscal electrothermal annuloplasty found at this writing in the peer-reviewed literature to date, to discuss the methodologic strengths and flaws of the studies, to discuss the pitfalls of clinical study designs, to emphasize the need for prospective randomized studies and for increased basic science investigation. SUMMARY OF BACKGROUND DATA: Studies published or presented at peer-reviewed societies concerning the clinical efficacy of intradiscal electrothermal annuloplasty are reviewed, including background studies on deafferentation and application of thermal energy to alter biomechanical and structural properties. A proposal for future investigations is presented. METHODS: Background data from intracapsular annuloplasty highlighting the safety and efficacy of intradiscal electrothermal annuloplasty are presented. Current studies on this procedure, including those in the National Registry are reviewed. All the studies share a common study design: prospective cohort with historical or noninterventional groups used as controls. The patients reviewed are similar. All have nonradicular low back pain of at least 3 months duration, failed conservative care, normal neurologic examination, and MRI showing only nondegenerative disc disease and positive concordant discography. All the patients underwent intradiscal electrothermal annuloplasty lesion at one or two levels according to standard protocols. Follow-up evaluation was performed at various intervals up to 2 years. All the studies used data from a visual analog scale, with most using the Short Form 36 (SF-36) as outcome instruments. RESULTS: The reported follow-up periods for the studies ranged from 6 months to 2 years. Three published studies, one with a 6-month follow-up period and two with a 1-year follow-up period, were published in the peer-reviewed literature. Two recent reports presented to the North American Spine Society were reviewed: a study of patients on a manufacturer-sponsored registry with a 1-year follow-up period and a multicenter prospective cohort study of 75 patients in an intent-to-treat group, with a 1-year follow-up period. Using the 7-point criteria of Deyo et al, all the studies suggested a positive effect of treatment, with a decrease in visual analog scale ratings and improvement in SF-36 scales, particularly those for physical function and bodily pain. CONCLUSIONS: The studies published so far suggest that the pain resulting from lumbar disc disease may be diminished by intradiscal electrothermal annuloplasty. All these studies project a positive therapeutic effect. However, all the studies suffer from the same methodologic flaws. A prospective cohort design or a nonrandomized prospective design is used with a biased control. The scientific validity of various study designs is discussed, and a randomized prospective study is recommended. Additionally, more investigation into the basic science of the action of intradiscal electrothermal annuloplasty is required.

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Spine. 2002 Nov 15;27(22):2584-91; discussion 2592.
Spinal cord stimulation for chronic pain of spinal origin: a valuable long-term solution.
North RB, Wetzel FT.
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA. rnorth@jhmi.edu

STUDY DESIGN: A literature review was conducted. OBJECTIVE: To review the indications and efficacy of spinal cord stimulation, particularly in reference to chronic pain of spinal origin. SUMMARY OF BACKGROUND DATA: The first spinal cord stimulation was implanted by Shealy in 1967 via a subarachnoid route. Early systems were plagued with a high rate of complications and technical problems. With the evolving technology, especially the advent of multichannel programmable systems and more precise epidural placement, the ability of spinal cord stimulation to treat various pain syndromes improved. This article reviews the literature on spinal cord stimulation from 1967 to the present. METHODS: The literature is reviewed, with a particular focus on recent studies investigating the efficacy of spinal cord stimulation for low back pain. RESULTS: Most studies are limited by the same flaws, namely, retrospective study design. At this writing, the few published randomized prospective studies have suggested that spinal cord stimulation may be superior to repeat surgery. Complication rates have declined to approximately 8%, and reoperation is necessary in approximately 4% of patients. When current percutaneous techniques are used, a lead migration rate lower than 3% may be achieved. For certain topographies, laminotomy leads may be superior, particularly with regard to low back pain. CONCLUSIONS: The ultimate efficacy of spinal cord stimulation remains to be determined, primarily because of limitations associated with the published literature. However, on the basis of the current evidence, it may represent a valuable treatment option, particularly for patients with chronic pain of predominantly neuropathic origin and topographical distribution involving the extremities. The potential treatment of other pain topographies and etiologies by spinal cord stimulation continues to be studied.

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Br J Nurs. 2002 Nov 28-Dec 11;11(21):1395-403.
Acupuncture: evidence for its use in chronic low back pain.
Henderson H.
Pain Clinic, Belfast City Hospital, Belfast.

Back pain is a major economic burden in the UK, with increasing numbers of patients seeking complementary therapies, such as acupuncture, as a means to supplement traditional medical treatments. Studies to date have produced conflicting results relating to the efficacy of acupuncture and thus this systematic review will provide a concise summary of the clinical scenario in Western countries. A search of various electronic databases identified 11 articles consisting of three case studies, five randomized controlled trials, and two cross-over trials. Systematic examination of these articles did not provide definitive evidence to support or refute the use of acupuncture in the treatment of low back pain. In an era of increasing demands for evidence-based practice and professional accountability, the absence of irrefutable scientific evidence places nurses and medics in a vulnerable position.

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Acupunct Med. 2002 Dec;20(4):175-80.
Randomised controlled trial comparing the effectiveness of electroacupuncture and TENS for low back pain: a preliminary study for a pragmatic trial.
Tsukayama H, Yamashita H, Amagai H, Tanno Y.
Tsukuba College of Technology Clinic, Tsukuba City, Japan. tsukayama@k.tsukuba-tech.ac.jp

The objective of this study was to compare the effectiveness of electroacupuncture and TENS for low back pain when the electroacupuncture is applied in a clinically realistic manner. The study was designed as an evaluator-blinded randomised controlled trial (RCT). The study was performed at the Tsukuba College of Technology Clinic in Japan. Twenty subjects, who suffered from low back pain (LBP) without sciatica, were recruited, using leaflets in Tsukuba city. Subjects were allocated to either an electroacupuncture (EA) group (10 patients) or a transcutaneous electrical nerve stimulation (TENS) group (10 patients). The procedure for EA was in accordance with standard practice at our clinic. The main outcome measures were a pain relief scale (100 mm visual analogue scale: VAS) and a LBP score recommended by the Japanese Orthopaedic Association (JOA Score). Mean VAS value during the 2-weeks experimental period of the EA group was significantly smaller than that of the TENS group (65 mm vs 86 mm; 95% CI, 4.126 - 37.953). JOA Score in the EA group improved significantly while that in the TENS group showed no change. Although some placebo effect may be included, EA appeared more useful than TENS in the short-term effect on low back pain. We suggest that more realistic acupuncture interventions based on standard practice should be employed in pragmatic RCTs.

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Clin J Pain. 2002 Nov-Dec;18(6 Suppl):S155-62.
A focused review of the use of botulinum toxins for low back pain.
Difazio M, Jabbari B.
Department of Neurology, Uniformed Services University, Bethesda, Maryland 20814, USA.

Chronic low back pain is the second most common illness reported by patients in the United States and accounts for substantial morbidity and health-care resource utilization. Many back and spine stressors can contribute to tissue injury, resulting in acute or chronic pain. In response to injury, biochemical processes that cause inflammation and nerve sensitization increase pain levels and contribute to a cycle of reactivity that further heightens patients' sensitivity to pain stimuli. Treatment of back pain depends on its severity, duration, and underlying cause. Traditional therapeutic options include exercise, oral anti-inflammatory or analgesic medication, antidepressants, physical therapy and, in severe cases, surgery. Unfortunately, dissatisfaction with treatment of back pain is common. Oral medications may not completely alleviate symptoms, and opioid analgesics must be used with caution because of their addictive properties. Surgery does not always produce relief and, in some cases, may even exacerbate the problem. Botulinum toxin, which has already been shown to alleviate pain associated with cervical dystonia and other conditions characterized by muscle spasticity, is now being studied for the treatment of back pain. Preliminary evaluations have shown that this treatment is safe and has the advantage of providing local relief directly to the site of injury or pain, without causing systemic side effects. Initial data from small trials also suggest that botulinum toxin is effective, alleviating back pain in selected patients. On the basis of these promising results, additional study in larger trials is warranted.

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Tech Vasc Interv Radiol. 2002 Dec;5(4):201-6.
Facet blocks and sacroiliac joint injections.
Stallmeyer MJ, Ortiz AO.
Interventional and Diagnostic Neuroradiology, University of Maryland Medical Center, Baltimore, MD, USA.

Facet and sacroiliac joint pathology are not an uncommon cause of back or neck pain. Imaging-guided techniques provide ready access to these synovial joints. Percutaneous injection of the facet or sacroiliac joints yields important diagnostic information as to whether or not the interrogated joint is involved in the patient's pain syndrome. The injection of a steroid-anesthetic mixture into these joints is capable of providing significant, albeit temporary, pain relief. Copyright 2002, Elsevier Science (USA). All rights reserved.

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Tech Vasc Interv Radiol. 2002 Dec;5(4):194-200.
Selective nerve root blocks.
Wagner AL, Murtagh FR.
Department of Radiology, Rockingham Memorial Hospital, Harrisonburg, VA, USA.

Selective nerve root blocks are an effective way of diagnosing and treating radicular pain in many patients. Although traditionally performed under fluoroscopic guidance, computed tomography (CT) and CT fluoroscopy have been increasingly used to direct needle placement. This article discusses the indications and technique of selective nerve root blocks in the cervical, thoracic, and lumbar spine, as well as the evidence supporting their use in the treatment of patients with radiculopathy and/or back pain. Copyright 2002, Elsevier Science (USA). All rights reserved.

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Tech Vasc Interv Radiol. 2002 Dec;5(4):186-93.
Image-guided epidural steroid injections.
Watanabe AT, Nishimura E, Garris J.
Deparment of Radiology, Long Beach Memorail Medical Center, Long Beach Memorial Hospital, Long Beach, CA 90806, USA,

Epidural steroid injection has been proven to be useful in the treatment of acute lumbosacral radicular pain syndromes. The use of image guidance significantly increases accuracy and decreases complication rates. The technique of performing these injections, including translaminar approach, is described in this article. Necessary precautions and potential risks are also described. Copyright 2002, Elsevier Science (USA). All rights reserved.

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J Nippon Med Sch. 2002 Dec;69(6):588-92.
[Mechanism of intractable low back pain and neural blockade]
[Article in Japanese]
Sakamoto A.
Department of Anesthesiology, Nippon Medical School, Tokyo, Japan. nol-saka@nms.ac.jp

Low back pain is one of the most prevalent complaints in clinical medicine. Sensations from the axial skeleton and the surrounding tissues are only vaguely somatotopic and are non-specific in quality. The diagnosis of the mechanism or source of low back pain is therefore very challenging. The treatment of low back pain that recurs, persists or intensifies is also formidable, because there has been no evidence of various therapies for chronic back pain. From the prophylactic viewpoint of chronic pain, the most considerable matter is early elimination of severe pain under certain diagnosis. In this article, the mechanisms of passing into the chronic state, especially the development of neuropathic pain, and the utilities of diagnostic and therapeutic neural blockade for low back pain are discussed.

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Bratisl Lek Listy. 2002;103(12):467-72.
Efficacy and tolerability of piroxicam-beta-cyclodextrin in the outpatient management of
chronic back pain.
Pijak MR, Turcani P, Turcaniova Z, Buran I, Gogolak I, Mihal A, Gazdik F.
Department of Clinical Immunology, Institute of Preventive and Clinical Medicine, Bratislava, Slovakia. pijak@upkm.sk

BACKGROUND: Piroxicam-beta-cyclodextrin (PBC) is the first nonsteroidal anti-inflammatory drug (NSAID), in which the active substance is complexed with the cyclic oligosaccharide cyclodextrin, which acts as an artificial receptor. This complex allows single molecules of the NSAID to be released adjacent to the gastrointestinal mucosa, instead of crystals. Since the piroxicam is immediately bioavailable in this formulation, the onset of action is similar to that of a parenteral drug. Since the time contact with gastric mucosa is reduced, the risk of direct-contact gastric irritation is also reduced. There is good evidence that PBC is beneficial in managing acute non-specific back pain (BP) but sufficient evidence on chronic BP is lacking. METHODS: Thirty-one eligible patients aged 18-85 years, resistant to previous therapy with different NSAIDs, were treated with PBC 20 mg once daily in a 40-day open-label noncomparative study. The patients experienced chronic BP defined as pain between the occipital region and gluteal fold, lasting for at least 6 weeks but not more than 6 months. Efficacy was assessed by changes in pain intensity, paravertebral tonus, functional impairment and morning stiffness using a 4-point numerical rating scale. Patients also self-assessed nocturnal and diurnal pain using the visual analogue scale. Tolerability was assessed by adverse events and routine laboratory evaluations. Global assessment of efficacy and tolerability by physician and patients was performed at the last visit. RESULTS: Using intention-to-treat analysis, all efficacy assessments demonstrated statistically significant improvements over baseline at each follow-up. 90.3% of the patients evaluated the efficacy of PBC as improved or greatly improved, and investigators rated the treatment as improved or greatly improved in 87.1% of patients. Remission was achieved in 19.3% of the patients. Tolerability was also rated highly, with 83.9% of the patients characterizing PBC treatment as good or very good, and the investigators rated the treatment as good or excellent in 87.1% of the patients. Drug related adverse events were reported in 9.7% of patients and prompted discontinuation of the study medication in 3.2% of patients. No serious adverse events were reported. CONCLUSION: These results suggest that the newly developed dosage form of piroxicam is effective and well tolerated in the treatment of patients with chronic BP. Thus, PBC, may be an important new treatment option in this condition. (Tab. 3, Fig. 3, Ref. 36.).

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