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Latest Research on Back Pain
     
Pain Pract. 2008 Mar;8(1):11-7.
Treatment of 94 outpatients with chronic discogenic low back pain with the DRX9000: a retrospective chart review.
Macario A, Richmond C, Auster M, Pergolizzi JV.
Department of Anesthesia and Health Research & Policy, Stanford University School of Medicine, Stanford, California 94305-5640, USA. amaca@stanford.edu

BACKGROUND: This study's goal was a retrospective chart audit of 100 outpatients with discogenic low back pain (LBP) lasting more than 12 weeks treated with a 2-month course of motorized spinal decompression via the DRX9000 (Axiom Worldwide, Tampa, FL, U.S.A.). METHODS: Patients at a convenience sample of four clinics received 30-minute DRX9000 sessions daily for the first 2 weeks tapering to 1 session/week. Treatment protocol included lumbar stretching, myofascial release, or heat prior to treatment, with ice and/or muscle stimulation afterwards. Primary outcome was verbal numerical pain intensity rating (NRS) 0 to 10 before and after the 8-week treatment. RESULTS: Of the 100 initial subjects, three withdrew their protected health information, and three were excluded because their LBP duration was less than 12 weeks. The remaining 94 subjects (63% female, 95% white, age = 55 (SD 16) year, 52% employed, 41% retired, LBP median duration of 260 weeks) had diagnoses of herniated
disc (73% of patients), degenerative disc disease (68%), or both (27%). Mean NRS equaled 6.05 (SD 2.3) at presentation and decreased significantly to 0.89 (SD 1.15) at end of 8-week treatment (P < 0.0001). Analgesic use also appeared to decrease (charts with data = 20) and Activities of Daily Living improved (charts with data = 38). Follow-up (mean 31 weeks) on 29/94 patients reported mean 83% LBP improvement, NRS of 1.7 (SD 1.15), and satisfaction of 8.55/10 (median 9). CONCLUSIONS: This retrospective chart audit provides preliminary data that chronic LBP may improve with DRX9000 spinal decompression. Randomized double-blind trials are needed to measure the efficacy of such systems.

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Anesth Analg. 2008 Feb;106(2):638-44, table of contents.
A prospective evaluation of iodinated contrast flow patterns with fluoroscopically guided lumbar epidural steroid injections: the lateral parasagittal interlaminar epidural approach versus the transforaminal epidural approach.
Candido KD, Raghavendra MS, Chinthagada M, Badiee S, Trepashko DW.
Department of Anesthesiology, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153, USA. kdcandido@yahoo.com

BACKGROUND: Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance. METHODS: Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0-2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at > or = 1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo. RESULTS: One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83-2.0) in the PIL group and 1.46 (95% CI, 1.17-1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9-34.1 s) in the PIL group and 46.25 s (95% CI, 36.27-56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups. CONCLUSIONS: The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.

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Anesth Analg. 2008 Feb;106(2):611-21, table of contents.
Acupuncture analgesia: II. Clinical considerations.
Wang SM, Kain ZN, White PF.
Center for Advancement of Perioperative Health, Department of Anesthesiology, Yale School of Medicine, 333 Cedar St., New Haven, CT 06510, USA. shu-ming.wang@yale.edu

BACKGROUND: Acupuncture and related percutaneous neuromodulation therapies can be used to treat patients with both acute and chronic pain. In this review, we critically examined peer-reviewed clinical studies evaluating the analgesic properties of acupuncture modalities. METHODS: Using Ovid and published medical databases, we examined prospective, randomized, sham-controlled clinical investigations involving the use of acupuncture and related forms of acustimulation for the management of pain. Case reports, case series, and cohort studies were not included in this analysis. RESULTS: Peer-reviewed literature suggests that acupuncture and other forms of acustimulation are effective in the short-term management of low back pain, neck pain, and osteoarthritis involving the knee. However, the literature also suggests that short-term treatment with acupuncture does not result in long-term benefits. Data regarding the efficacy of acupuncture for dental pain, colonoscopy pain, and intraoperative analgesia are inconclusive. Studies describing the use of acupuncture during labor suggest that it may be useful during the early stages, but not throughout the entire course of labor. Finally, the effects of acupuncture on postoperative pain are inconclusive and are dependent on the timing of the intervention and the patient's level of consciousness. CONCLUSIONS: Current data regarding the clinical efficacy of acupuncture and related techniques suggest that the benefits are short-lasting. There remains a need for well designed, sham-controlled clinical trials to evaluate the effect of these modalities on clinically relevant outcome measures such as resumption of daily normal activities when used in the management of acute and chronic pain syndromes.

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Arch Phys Med Rehabil. 2008 Feb;89(2):269-74.
Outcomes after a prone lumbar traction protocol for patients with activity-limiting low back pain: a prospective case series study.
Beattie PF, Nelson RM, Michener LA, Cammarata J, Donley J.
Program in Physical Therapy, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA. pbeattie@gwm.sc.edu

OBJECTIVE: To determine outcomes after administration of a prone lumbar traction protocol. DESIGN: Prospective, longitudinal, case series. SETTING: Suburban, chiropractic practice. PARTICIPANTS: A total of 296 subjects with low back pain (LBP) and evidence of a degenerative and/or herniated intervertebral disk at 1 or more levels of the lumbar spine. We excluded patients involved in litigation and those receiving workers' compensation. INTERVENTION: An 8-week course of prone lumbar traction, using the vertebral axial decompression (VAX-D) system, consisting of five 30-minute sessions a week for 4 weeks, followed by one 30-minute session a week for 4 additional weeks. MAIN OUTCOME MEASURES: The numeric pain rating scale and the Roland-Morris Disability Questionnaire (RMDQ) were completed at preintervention, discharge (within 2 weeks of the last visit), and at 30 days and 180 days after discharge. Intention-to-treat strategies were used to account for those subjects lost to follow-up. RESULTS: A total of 250 (84.4%) subjects completed the treatment protocol. On the 30-day follow-up, 247 (83.4%) subjects were available; on the 180-day follow-up, data were available for 241 (81.4%) subjects. We noted significant improvements for all postintervention outcome scores when compared with preintervention scores (P<.01). CONCLUSIONS: Traction applied in the prone position using the VAX-D for 8 weeks was associated with improvements in pain intensity and RMDQ scores at discharge, and at 30 and 180 days after discharge in a sample of patients with activity-limiting LBP. Causal relationships between these outcomes and the intervention should not be made until further study is performed using randomized comparison groups.

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BMJ. 2008 Jan 31 [Epub ahead of print]
Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review.
Martimo KP, Verbeek J, Karppinen J, Furlan AD, Takala EP, Kuijer PP, Jauhiainen M, Viikari-Juntura E.
Musculoskeletal Disorders Group, Centre of Expertise for Health and Work Ability, Finnish Institute of Occupational Health, Helsinki, Finland.

OBJECTIVES: To determine whether advice and training on working techniques and lifting equipment prevent back pain in jobs that involve heavy lifting. DATA SOURCES: Medline, Embase, CENTRAL, Cochrane Back Group's specialised register, CINAHL, Nioshtic, CISdoc, Science Citation Index, and PsychLIT were searched up to September-November 2005. Review methods The primary search focused on randomised controlled trials and the secondary search on cohort studies with a concurrent control group. Interventions aimed to modify techniques for lifting and handling heavy objects or patients and including measurements for back pain, consequent disability, or sick leave as the main outcome were considered for the review. Two authors independently assessed eligibility of the studies and methodological quality of those included. For data synthesis, we summarised the results of studies comparing similar interventions. We used odds ratios and effect sizes to combine the results in a meta-analysis. Finally, we compared the conclusions of the primary and secondary analyses. RESULTS: Six randomised trials and five cohort studies met the inclusion criteria. Two randomised trials and all cohort studies were labelled as high quality. Eight studies looked at lifting and moving patients, and three studies were conducted among baggage handlers or postal workers. Those in control groups received no intervention or minimal training, physical exercise, or use of back belts. None of the comparisons in randomised trials (17 720 participants) yielded significant differences. In the secondary analysis, none of the cohort studies (772 participants) had significant results, which supports the results of the randomised trials. CONCLUSIONS: There is no evidence to support use of advice or training in working techniques with or without lifting equipment for preventing back pain or consequent disability. The findings challenge current widespread practice of advising workers on correct lifting technique.

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Pain. 2008 Jan 31 [Epub ahead of print]
Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial.
Leeuw M, Goossens ME, van Breukelen GJ, de Jong JR, Heuts PH, Smeets RJ, Köke AJ, Vlaeyen JW.
Department of Clinical Psychological Science, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.

Since pain-related fear may contribute to the development and maintenance of chronic low back pain (CLBP), an exposure in vivo treatment (EXP) was developed for CLBP patients. We examined the effectiveness as well as specific mediating mechanisms of EXP versus operant graded activity (GA) directly and 6 months post-treatment in a multi-centre randomized controlled trial. In total, 85 patients suffering from disabling non-specific CLBP reporting at least moderate pain-related fear were randomly allocated to EXP or GA. It was demonstrated that EXP, despite excelling in diminishing pain catastrophizing and perceived harmfulness of activities, was equally effective as GA in improving functional disability and main complaints, although the group difference almost reached statistical significance favouring EXP. Both treatment conditions did not differ in pain intensity and daily activity levels either. Nor was EXP superior to GA in the subgroup of highly fearful patients. Irrespective of treatment, approximately half the patients reported clinically relevant improvements in main complaints and functional disability, although for the latter outcome the group difference was almost significant favouring EXP. Furthermore, the effect of EXP relative to GA on functional disability and main complaints was mediated by decreases in catastrophizing and perceived harmfulness of activities. In sum, this study demonstrates that up to 6 months after treatment EXP is an effective treatment, but not more effective than GA, in moderately to highly fearful CLBP patients, although its superiority in altering pain catastrophizing and perceived harmfulness of activities is clearly established. Possible explanations for these findings are discussed.

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Phytother Res. 2008 Jan 30;22(2):149-152 [Epub ahead of print]
Systematic review on the safety of Harpagophytum preparations for osteoarthritic and Low back pain.
Vlachojannis J, Roufogalis BD, Chrubasik S.
Department of Orthodontics, Columbia University, 630 W 168th, VC 9, Rm 219 B 10032 NYC, NY, USA.

Harpagophytum products are a treatment option for osteoarthritic and low back pain. The aim of this study was to review the safety of treatment with Harpagophytum procumbens. The databases OVID(MEDLINE), PUBMED and COCHRANE COLLABORATION LIBRARY were searched back to 1985 for studies with Harpagophytum procumbens. Twenty-eight clinical trials were identified of which 20 stated adverse events. In none of the double-blind studies was the incidence of adverse events during treatment with Harpagophytum procumbens higher than during placebo treatment. Minor adverse events occurred in around 3% of the patients, mainly gastrointestinal adverse events. A few reports of acute toxicity were found but there were no reports on chronic toxicity. Since the dosage used in most of the studies is at the lower limit and since long-term treatment with Harpagophytum products is advisable, more safety data are urgently needed. Copyright (c) 2008 John Wiley & Sons, Ltd.

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Spine. 2007 Dec 1;32(25):2905-9.
Comparative charge analysis of one- and two-level lumbar total disc arthroplasty versus circumferential lumbar fusion.
Levin DA, Bendo JA, Quirno M, Errico T, Goldstein J, Spivak J.
From the Department of Orthopaedic Surgery, Spine Division, Hospital for Joint Diseases, New York, NY.

STUDY DESIGN.: This is a retrospective, independent study comparing 2 groups of patients treated surgically for discogenic low back pain associated with degenerative disc disease (DDD) in the lumbosacral spine. OBJECTIVE.: To compare the surgical and hospitalization charges associated with 1- and 2-level lumbar total disc replacement and circumferential lumbar fusion. SUMMARY OF BACKGROUND DATA.: Reported series of lumbar total disc replacement have been favorable. However, economic aspects of lumbar total disc replacement (TDR) have not been published or studied. This information is important considering the recent widespread utilization of new technologies. Recent studies have demonstrated comparable short-term clinical results between TDR and lumbar fusion recipients. Relative charges may be another important indicator of the most appropriate procedure. We report a hospital charge-analysis comparing ProDisc lumbar disc replacement with circumferential fusion for discogenic low back pain. METHODS.: In a cohort of 53 prospectively selected patients with severe, disabling back pain and lumbar disc degeneration, 36 received Synthes ProDisc TDR and 17 underwent circumferential fusion for 1- and 2-level degenerative disc disease between L3 and S1. Randomization was performed using a 2-to-1 ratio of ProDisc recipients to control spinal fusion recipients. Charge comparisons, including operating room charges, inpatient hospital charges, and implant charges, were made from hospital records using inflation-corrected 2006 U.S. dollars. Operating room times, estimated blood loss, and length of stay were obtained from hospital records as well. Surgeon and anesthesiologist fees were, for the purposes of comparison, based on Medicare reimbursement rates. Statistical analysis was performed using a 2-tailed Student t test. RESULTS.: For patients with 1-level disease, significant differences were noted between the TDR and fusion control group. The mean total charge for the TDR group was $35,592 versus $46,280 for the fusion group (P = 0.0018). Operating room charges were $12,000 and $18,950, respectively, for the TDR and fusion groups (P < 0.05). Implant charges averaged $13,990 for the fusion group, which is slightly higher than the $13,800 for the ProDisc (P = 0.9). Estimated blood loss averaged 794 mL in the fusion group versus 412 mL in the TDR group (P = 0.0058). Mean OR minutes averaged 344 minutes for the fusion group and 185 minutes for the TDR (P < 0.05) Mean length of stay was 4.78 days for fusion versus 4.32 days for TDR (P = 0.394). For patients with 2-level disease, charges were similar between the TDR and fusion groups. The mean total charge for the 2-level TDR group was $55,524 versus $56,823 for the fusion group (P = 0.55). Operating room charges were $15,340 and $20,560, respectively, for the TDR and fusion groups (P = 0.0003). Surgeon fees and anesthesiologist charges based on Medicare reimbursement rates were $5857 and $525 for the fusion group, respectively, versus $2826 and $331 for the TDR group (P < 0.05 for each). Implant charges were significantly lower for the fusion group (mean, $18,460) than those for 2-level Synthes ProDisc ($27,600) (P < 0.05). Operative time averaged 387 minutes for fusion versus 242 minutes for TDR (P < 0.0001). EBL and length of stay were similar. CONCLUSION.: Patients undergoing 1- and 2-level ProDisc total disc replacement spent significantly less time in the OR and had less EBL than controls. Charges were significantly lower for TDR compared with circumferential fusions in the 1-level patient group, while charges were similar in the 2-level group.

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Radiographics. 2007 Nov-Dec;27(6):1751-71.
Management of Chronic Low Back Pain: Rationales, Principles, and Targets of Imaging-guided Spinal Injections.
Fritz J, Niemeyer T, Clasen S, Wiskirchen J, Tepe G, Kastler B, Nägele T, König CW, Claussen CD, Pereira PL.
Departments of Diagnostic Radiology, Orthopedic Surgery, and Neuroradiology, Eberhard-Karls-University, Hoppe-Seyler-Str 3, Tübingen, Germany.

If low back pain does not improve with conservative management, the cause of the pain must be determined before further therapy is initiated. Information obtained from the patient's medical history, physical examination, and imaging may suffice to rule out many common causes of chronic pain (eg, fracture, malignancy, visceral or metabolic abnormality, deformity, inflammation, and infection). However, in most cases, the initial clinical and imaging findings have a low predictive value for the identification of specific pain-producing spinal structures. Diagnostic spinal injections performed in conjunction with imaging may be necessary to test the hypothesis that a particular structure is the source of pain. To ensure a valid test result, diagnostic injection procedures should be monitored with fluoroscopy, computed tomography, or magnetic resonance imaging. The use of controlled and comparative injections helps maximize the reliability of the test results. After a symptomatic structure has been identified, therapeutic spinal injections may be administered as an adjunct to conservative management, especially in patients with inoperable conditions. Therapeutic injections also may help hasten the recovery of patients with persistent or recurrent pain after spinal surgery. (c) RSNA, 2007.

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Spine J. 2007 Nov-Dec;7(6):701-7. Epub 2007 Jan 3.
Nonoperatively treated burst fractures of the thoracic and lumbar spine in adults: a 23- to 41-year follow-up.
Moller A, Hasserius R, Redlund-Johnell I, Ohlin A, Karlsson MK.
Department of Orthopaedics, Malmo University Hospital, Malmo SE-205/02, Sweden.

BACKGROUND CONTEXT: Several studies report a favorable short-term outcome after nonoperatively treated two-column thoracic or lumbar burst fractures in patients without neurological deficits. Few reports have described the long-term clinical and radiological outcome after these fractures, and none have, to our knowledge, specifically evaluated the long-term outcome of the discs adjacent to the fractured vertebra, often damaged at injury and possibly at an increased risk of height reduction and degeneration with subsequent chronic back pain. PURPOSE: To evaluate the long-term clinical and radiological outcome after nonoperatively treated thoracic or lumbar burst fractures in adults, with special attention to posttraumatic radiological disc height reduction. STUDY DESIGN: Case series. PATIENT SAMPLE: Sixteen men with a mean age of 31 years (range, 19-44) and 11 women with a mean age of 40 years (range, 23-61) had sustained a thoracic or lumbar burst fracture during the years 1965 to 1973. Four had sustained a burst fracture Denis type A, 18 a Denis type B, 1 a Denis type C, and 4 a Denis type E. Seven of these patients had neurological deficits at injury, all retrospectively classified as Frankel D. OUTCOME MEASURES: The clinical outcome was evaluated subjectively with Oswestry score and questions regarding work capacity and objectively with the Frankel scale. The radiological outcome was evaluated with measurements of local kyphosis over the fractured segment, ratios of anterior and posterior vertebral body heights, adjacent disc heights, pedicle widths, sagittal width of the spinal canal, and lateral and anteroposterior displacement. METHODS: From the radiographical archives of an emergency hospital, all patients with a nonoperatively treated thoracic or lumbar burst fracture during the years 1965 to 1973 were registered. The fracture type, localization, primary treatment, and outcome were evaluated from the old radiographs, referrals, and reports. Twenty-seven individuals were clinically and radiologically evaluated a mean of 27 years (range, 23-41) after the injury. RESULTS: At follow-up, 21 former patients reported no or minimal back pain or disability (Oswestry Score mean 4; range, 0-16), whereas 6 former patients (of whom 3 were classified as Frankel D at baseline) reported moderate or severe disability (Oswestry Score mean 39; range, 26-54). Six former patients were classified as Frankel D, and the rest as Frankel E. Local kyphosis had increased by a mean of 3 degrees (p<.05), whereas the discs adjacent to the fractured vertebrae remained unchanged in height during the follow-up. CONCLUSIONS: Nonoperatively treated burst fractures of the thoracic or lumbar spine in adults with or without minor neurological deficits have a predominantly favorable long-term outcome, and there seems to be no increased risk for subsequent disc height reduction in the adjacent discs.

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Lancet. 2007 Nov 10;370(9599):1638-43.
Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial.
Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH.
Back Pain Research Group, University of Sydney, Sydney, Australia. M.Hancock@usyd.edu.au

BACKGROUND: We aimed to investigate whether the addition of non-steroidal anti-inflammatory drugs or spinal manipulative therapy, or both, would result in faster recovery for patients with acute low back pain receiving recommended first-line care. METHODS: 240 patients with acute low back pain who had seen their general practitioner and had been given advice and paracetamol were randomly allocated to one of four groups in our community-based study: diclofenac 50 mg twice daily and placebo manipulative therapy (n=60); spinal manipulative therapy and placebo drug (n=60); diclofenac 50 mg twice daily and spinal manipulative therapy (n=60); or double placebo (n=60). The primary outcome was days to recovery from pain assessed by survival curves (log-rank test) in an intention-to-treat analysis. This trial was registered with the Australian Clinical Trials Registry, ACTRN012605000036617. FINDINGS: Neither diclofenac nor spinal manipulative therapy appreciably reduced the number of days until recovery compared with placebo drug or placebo manipulative therapy (diclofenac hazard ratio 1.09, 95% CI 0.84-1.42, p=0.516; spinal manipulative therapy hazard ratio 1.01, 95% CI 0.77-1.31, p=0.955). 237 patients (99%) either recovered or were censored 12 weeks after randomisation. 22 patients had possible adverse reactions including gastrointestinal disturbances, dizziness, and heart palpitations. Half of these patients were in the active diclofenac group, the other half were taking placebo. One patient taking active diclofenac had a suspected hypersensitivity reaction and ceased treatment. INTERPRETATION: Patients with acute low back pain receiving recommended first-line care do not recover more quickly with the addition of diclofenac or spinal manipulative therapy.

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Eur Spine J. 2007 Nov 17; [Epub ahead of print]
Diagnosis and conservative management of degenerative lumbar spondylolisthesis.
Kalichman L, Hunter DJ.
Clinical Epidemiology Research and Training Unit, Boston University, 650 Albany Street (X Building), Suite 200, Boston, MA, 02118, USA, leonid@bu.edu.

Degenerative spondylolisthesis (DS) is a disorder that causes the slip of one vertebral body over the one below due to degenerative changes in the spine. Lumbar DS is a major cause of spinal canal stenosis and is often related to low back and leg pain. We reviewed the symptoms, prognosis and conservative treatments for symptoms associated with DS. PubMed and MEDLINE databases (1950-2007) were searched for the key words "spondylolisthesis", "pseudospondylolisthesis", "degenerative spondylolisthesis", "spinal stenosis", "lumbar spine", "antherolisthesis", "posterolisthesis", "low back pain", and "lumbar instability". All relevant articles in English were reviewed. Pertinent secondary references were also retrieved. The prognosis of patients with DS is favorable, however, those who suffer from neurological symptoms such as intermittent claudication or vesicorectal disorder, will most probably experience neurological deterioration if they are not operated upon. Nonoperative treatment should be the initial course of action in most cases of DS, with or without neurologic symptoms. Treatment options include use of analgesics and NSAIDs to control pain; epidural steroid injections, and physical methods such as bracing and flexion strengthening exercises. An up-to-date knowledge on diagnosis and prevention of lumbar DS can assist in determination of future research goals. Additional studies are required to establish treatment protocols for the conservative treatment of DS.

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Ann Intern Med. 2007 Nov 20;147(10):685-92.
Lumbar supports to prevent recurrent low back pain among home care workers: a randomized trial.
Roelofs PD, Bierma-Zeinstra SM, van Poppel MN, Jellema P, Willemsen SP, van Tulder MW, van Mechelen W, Koes BW.
Department of General Practice, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands. p.roelofs@erasmusmc.nl

BACKGROUND: People use lumbar supports to prevent low back pain. Secondary analyses from primary preventive studies suggest benefit among workers with previous low back pain, but definitive studies on the effectiveness of supports for the secondary prevention of low back pain are lacking. OBJECTIVE: To determine the effectiveness of lumbar supports in the secondary prevention of low back pain. DESIGN: Randomized, controlled trial. SETTING: Home care organization in the Netherlands. PATIENTS: 360 home care workers with self-reported history of low back pain. INTERVENTION: Short course on healthy working methods, with or without patient-directed use of 1 of 4 types of lumbar support. MEASUREMENTS: Primary outcomes were the number of days of low back pain and sick leave over 12 months. Secondary outcomes were the average severity of low back pain and function (Quebec Back Pain Disability scale) in the previous week. RESULTS: Over 12 months, participants in the lumbar support group reported an average of -52.7 days (CI, -59.6 to -45.1 days) fewer days with low back pain than participants who received only the short course. However, the total sick days in the lumbar support group did not decrease (-5 days [CI, -21.1 to 6.8 days]). Small but statistically significant differences in pain intensity and function favored lumbar support. LIMITATIONS: Study participants were unblinded, and a substantial amount of missing data required imputation. Objective data on sick days due to low back pain were not available. CONCLUSION: Adding patient-directed use of lumbar supports to a short course on healthy working methods may reduce the number of days when low back pain occurs, but not overall work absenteeism, among home care workers with previous low back pain. Further study of lumbar supports is warranted.

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Spine. 2007 Nov 15;32(24):E713-7.
Low back pain in 15- to 16-year-old children in relation to school furniture and carrying of the school bag.
Skoffer B.
From the Department of Health Services Research, Institute of Public Health, University of Aarhus, Denmark.

STUDY DESIGN.: Cross-sectional sample with longitudinal information. OBJECTIVE.: To estimate the relationship between the occurrence of low back pain (LBP) and various types of school furniture and anthropometric dimensions in schoolchildren, and physical loading by school bag carrying. SUMMARY OF BACKGROUND DATA.: Some types of school furniture may be hypothesized to prevent or cause LBP. Despite strong opinions in the public debate about a possible relationship between use of various types of school furniture and LBP, scientific research on this matter is sparse. METHODS.: Five hundred forty-six schoolchildren aged 14 to 17 years answered a questionnaire about sitting positions during school hours and the presence and severity of LBP. Furthermore, the anthropometric dimensions and the weight of the school bags were measured. The types and dimensions of the school furniture were described and measured. In multivariate analyses was adjusted for physical activity and other possible risk factors. RESULTS.: More than half of the adolescents experienced LBP during the preceding 3 months, and 24.2% reported reduced daily function or care seeking because of LBP. LBP occurrence was not associated with the types or dimensions of the school furniture or body dimensions, but was positively associated with carrying the school bag on 1 shoulder [OR: 2.06 (1.29-3.31)]. CONCLUSION.: The present study does not support the hypothesis of different types of school furniture being a causative or preventing factor for LBP. Carrying the school bag in an asymmetric manner may play a role.

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BJOG. 2007 Nov 12; [Epub ahead of print]
Managing back pain in pregnancy using a support garment: a randomised trial.
Kalus SM, Kornman LH, Quinlivan JA.
Department of Obstetrics and Gynaecology, the University of Melbourne, Parkville, Victoria, Australia.

Objective Large population studies have shown that low back pain affects about 50% of pregnant women. The aim of this study was to determine whether the use of the BellyBra((R)) in pregnant women with back pain is associated with changes in assessments of pain severity, physical activity and satisfaction with life after 3 weeks of intervention compared with tubigrip, a more generic form of support. Design Randomised controlled trial. Setting A tertiary referral hospital in Australia. Population Women between 20 and 36 weeks of pregnancy with lumbar back or posterior pelvic pain. Methods Participants were randomised to the BellyBra((R)) (the study device) or to tubigrip (the control) by means of computer-generated numbered, sealed, opaque envelopes. Main outcome measures The primary outcomes were pain severity and physical activity, and the secondary outcome was satisfaction with life. Results One hundred and fifteen women consented to participate in the trial. Mean visual analogue scale scores of pain severity decreased from 6.1 to 4.5 in the study device group (P= 0.001) and from 6.0 to 4.7 in the control group (P= 0.003). There was no significant difference between the groups in this outcome (P= 0.61). However, the study device group demonstrated a significantly greater reduction in Likert scale assessments of the impact of back pain on sleeping (P= 0.007), getting up from a sitting position (P= 0.02) and walking (P= 0.001) than the control group. There was also a significant reduction in the use of analgesic medication in the study group (P= 0.01). Conclusion The BellyBra((R)) and tubigrip were both associated with a reduction in the severity of pregnancy-related low back pain. The BellyBra((R)) was more effective than tubigrip, however, in alleviating the impact of pain on a number of physical activities that constitute daily life.

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Harefuah. 2007 Oct;146(10):747-50, 815.
[Percutaneous discectomy and intradiscal radiofrequency thermocoagulation for low back pain: evaluation according to the best available evidence]
[Article in Hebrew]
Nezer D, Hermoni D.
Clalit Health Services, Sharon-Shomron District.

Within the framework of evidence-based medicine, high quality randomized trials and systematic reviews are needed for new medical treatment. Clinicians should conscientiously, explicitly and judiciously use the best current evidence in making decisions about the care of individual patients. This paper summarizes the best available evidence from systematic reviews and randomized controlled trials concerning two minimally invasive procedures: percutaneous discectomy and percutaneous intradiscal radiofrequency thermocoagulation. Percutaneous discectomy is a minimally invasive surgical procedure that treats contained, herniated discs. Specific procedures within the class include: manual percutaneous lumbar discectomy, Automated percutaneous lumbar discectomy (APLD) laser discectomy and nucleoplasty percutaneous intradiscal radiofrequency thermocoagulation is a procedure that allows the controlled delivery of heat to the intervertebral disc via an electrode or coil. Results of systematic reviews were retrieved from four leading evidence-based databases: the National Institute for Clinical Excellence--NICE, which is an independent organization responsible for providing national guidance on treatments, the Cochrane Library, which is the largest library world-wide for systematic reviews and randomized controlled trials, the Center for Review and Dissemination (CRD) at the University of York, which undertakes reviews of research about the effects of interventions in health and social care and finally, a search via Medline. The results from those systematic reviews and randomized trials shows that, at present, unless or until better scientific evidence is available, automated percutaneous discectomy and laser discectomy should be regarded as research techniques. Radiofrequency denervation can relieve pain from neck joints, but may not relieve pain originating from lumbar discs, and its impact on low-back joint pain is uncertain.

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Pediatr Exerc Sci. 2007 Aug;19(3):349-59.
The efficacy of exercise as an intervention to treat recurrent nonspecific low back pain in adolescents.
Jones M, Stratton G, Reilly T, Unnithan V.
Sport and Exercise Research Group, Edge Hill University, Ormskirk, UK.

The purpose of this study was to evaluate the efficacy of a specific 8-week exercise rehabilitation program as an intervention to treat recurrent nonspecific low back pain in adolescents. A randomized controlled trial involving 54 adolescents (14.6 +/- 0.6 years) who suffered from recurrent nonspecific low back pain participated in either the exercise rehabilitation program or a control condition. Pre- and postintervention measures of low back pain status and biological risk indicators were taken. Two-way mixed ANOVA was conducted and significance was set at p < .01. Significant improvement was noted in the exercise rehabilitation group for perceived severity of pain (effect size 1.47) and number of occasions missing physical activity (effect size 0.99). Significant improvement in the exercise rehabilitation group for sit-and-reach performance, hip range of motion, lumbar sagittal mobility (modified Schöber), and number of sit-ups in 60 s were also identified. In conclusion, the specific exercise program appeared to provide positive benefits for adolescents suffering from recurrent nonspecific low back pain. Further evaluation is required to evaluate the effectiveness of the exercise rehabilitation program in relation to other interventions and to assess the long-term effectiveness.

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Evid Based Complement Alternat Med. 2007 Jun;4(2):165-79. Epub 2007 Feb 5.
Effectiveness of Massage Therapy for Chronic, Non-malignant Pain: A Review.
Tsao JC.
Pediatric Pain Program, Department of Pediatrics, David Geffen School of Medicine at UCLA, USA.

Previous reviews of massage therapy for chronic, non-malignant pain have focused on discrete pain conditions. This article aims to provide a broad overview of the literature on the effectiveness of massage for a variety of chronic, non-malignant pain complaints to identify gaps in the research and to inform future clinical trials. Computerized databases were searched for relevant studies including prior reviews and primary trials of massage therapy for chronic, non-malignant pain. Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain, but only moderate support for such effects on shoulder pain and headache pain. There is only modest, preliminary support for massage in the treatment of fibromyalgia, mixed chronic pain conditions, neck pain and carpal tunnel syndrome. Thus, research to date provides varying levels of evidence for the benefits of massage therapy for different chronic pain conditions. Future studies should employ rigorous study designs and include follow-up assessments for additional quantification of the longer-term effects of massage on chronic pain.

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Ann Intern Med. 2007 Jun 5;146(11):787-96.
Physiotherapist-directed exercise, advice, or both for subacute low back pain: a randomized trial.
Pengel LH, Refshauge KM, Maher CG, Nicholas MK, Herbert RD, McNair P.
Royal College of Surgeons of England, London, United Kingdom.

BACKGROUND: Advice and exercise are widely recommended for subacute low back pain, but the effectiveness of these interventions is unclear. OBJECTIVE: To investigate the effectiveness of physiotherapist-prescribed exercise, advice, or both for subacute low back pain. DESIGN: Factorial randomized, placebo-controlled trial. SETTING: 7 university hospitals and primary care clinics in Australia and New Zealand. PATIENTS: 259 persons with subacute low back pain (>6 weeks and <3 months in duration). INTERVENTION: Participants received 12 physiotherapist-directed exercise or sham exercise sessions and 3 physiotherapist-directed advice or sham advice sessions over 6 weeks. MEASUREMENTS: Primary outcomes were average pain over the past week (scale, 0 to 10), function (Patient-Specific Functional Scale), and global perceived effect (11-point scale) at 6 weeks and 12 months. Secondary outcomes were disability (Roland-Morris Disability Questionnaire), number of health care contacts, and depression (Depression Anxiety Stress Scales-21). RESULTS: Exercise and advice were each slightly more effective than placebo at 6 weeks but not at 12 months. The effect of advice on the pain scale was -0.7 point (95% CI, -1.2 to -0.2 point; P = 0.011) at 6 weeks and -0.4 point (CI, -1.0 to 0.3 point; P = 0.27) at 12 months, whereras the effect of exercise was -0.8 point (CI, -1.3 to -0.3 point; P = 0.004) at 6 weeks and -0.5 point (CI, -1.1 to 0.2 point; P = 0.14) at 12 months. The effect of advice on the function scale was 0.7 point (CI, 0.1 to 1.3 points; P = 0.014) at 6 weeks and 0.6 point (CI, 0.1 to 1.2 points; P = 0.023) at 12 months, and the effect of exercise was 0.4 point (CI, -0.2 to 1.0 point; P = 0.174) at 6 weeks and 0.5 point (CI, -0.1 to 1.0 point; P = 0.094) at 12 months. The effect of advice on the global perceived effect scale was 0.8 point (CI, 0.3 to 1.2 points; P < 0.001) at 6 weeks and 0.3 point (CI, -0.2 to 0.9 point; P = 0.24) at 12 months, and the effect of exercise was 0.5 point (CI, 0.1 to 1.0 point; P = 0.017) at 6 weeks and 0.4 point (CI, -0.1 to 1.0 point; P = 0.134) at 12 months. When administered together, exercise and advice had larger effects on all outcomes at 6 weeks (effect on pain, -1.5 [CI -2.2 to -0.7 point; P = 0.001], with similar results for other primary outcomes); however, by 12 months, there was a statistically significant effect only for function (effect, 1.1 points [CI, 0.3 to 1.8 points]; P = 0.005). LIMITATION: Physiotherapists were not blinded. CONCLUSIONS: In participants with subacute low back pain, physiotherapist-directed exercise and advice were each slightly more effective than placebo at 6 weeks. The effect was greatest when the interventions were combined. At 12 months, the only effect that persisted was a small effect on participant-reported function. AUSTRALIAN CLINICAL TRIALS REGISTRY REGISTRATION NUMBER: 12605000039684.

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J Spinal Disord Tech. 2007 Jun;20(4):271-7.
Safety and efficacy of implant removal for patients with recurrent back pain after a failed degenerative lumbar spine surgery.
Alanay A, Vyas R, Shamie AN, Sciocia T, Randolph G, Wang JC.
UCLA David Geffen School of Medicine, Comprehensive Spine Center.

The etiology of failed degenerative lumbar spine surgery may include a wide array of conditions. There is a group of patients who have recurrence of back pain despite a solid fusion in the absence of any obvious pain generator. Implant removal in those patients is a controversial optional treatment. The purpose of this study was to evaluate the efficacy and safety of implant removal and to determine the possible predictors of its efficacy. Twenty-five patients (10 M, 15 F) with an average age of 44 (18 to 74) were retrospectively evaluated. All patients had prior titanium posterior pedicle screw instrumentation and fusion for lumbar degenerative disorders. Twenty patients with increase in pain during palpation of the operative side underwent a preoperative anesthetic injection at the site of their trigger points. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the percent Visual Analog Scale (VAS) pain change due to implant removal. Functional improvement was rated on a five-point scale. Predictors of pain relief were analyzed by using bivariate analysis. A P value <0.05 was considered significant. Average follow-up period was 20 (12 to 37) months. The median time after the index operation and the recurrence of pain was 13.5 (1 to 119) months. VAS decrease after implant removal was 50% (P<0.001). Functional improvement was reported by 84% of patients. One patient developed a superficial infection managed successfully. Bivariate analysis showed that percent VAS change after injection, months free of pain after the index operation, and provocation of pain by palpation were significant predictors for pain relief (P<0.05). Removal of the implant may be an efficient and safe procedure for carefully selected patients and the most consistent predictor of its efficacy is the percent pain relief after the diagnostic injection of the painful operative side.

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Pain. 2007 May 31; [Epub ahead of print]
Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study.
Morone NE, Greco CM, Weiner DK.
Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.

The objectives of this pilot study were to assess the feasibility of recruitment and adherence to an eight-session mindfulness meditation program for community-dwelling older adults with chronic low back pain (CLBP) and to develop initial estimates of treatment effects. It was designed as a randomized, controlled clinical trial. Participants were 37 community-dwelling older adults aged 65 years and older with CLBP of moderate intensity occurring daily or almost every day. Participants were randomized to an 8-week mindfulness-based meditation program or to a wait-list control group. Baseline, 8-week and 3-month follow-up measures of pain, physical function, and quality of life were assessed. Eighty-nine older adults were screened and 37 found to be eligible and randomized within a 6-month period. The mean age of the sample was 74.9 years, 21/37 (57%) of participants were female and 33/37 (89%) were white. At the end of the intervention 30/37 (81%) participants completed 8-week assessments. Average class attendance of the intervention arm was 6.7 out of 8. They meditated an average of 4.3 days a week and the average minutes per day was 31.6. Compared to the control group, the intervention group displayed significant improvement in the Chronic Pain Acceptance Questionnaire Total Score and Activities Engagement subscale (P=.008, P=.004) and SF-36 Physical Function (P=.03). An 8-week mindfulness-based meditation program is feasible for older adults with CLBP. The program may lead to improvement in pain acceptance and physical function.

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Orthopedics. 2007 May;30(5):389-92.
Transforaminal lumbar interbody fusion: a retrospective study of long-term pain relief and fusion outcomes.
Chastain CA, Eck JC, Hodges SD, Humphreys SC, Levi P.
Center for Sports Medicine and Orthopaedics, Foundation for Research, Chattanooga, Tenn, USA.

No long-term studies exist on the effectiveness of transforaminal lumbar interbody fusion. This study sought to determine postoperative pain, disability, and fusion status of transforaminal lumbar interbody fusion patients after > or = 4 years to establish long-term outcomes. A retrospective analysis of 42 patients with minimum 4-year follow-up was conducted. Patients completed visual analog pain scale (VAS) and Oswestry functional capacity evaluation pre- and postoperatively. Statistically significant improvement was noted in VAS and Oswestry functional capacity evaluation scores. Transforaminal lumbar interbody fusion is effective in alleviating intractable back pain over an extended time period. Solid radiographic fusion is unnecessary for clinically successful outcomes.

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Pain Physician. 2007 May;10(3):425-40.
Evaluation of Lumbar Facet Joint Nerve Blocks in the Management of Chronic Low Back Pain: Preliminary Report of a Randomized, Double-Blind Controlled Trial: Clinical Trial NCT00355914
.Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD.
Pain Management Center of Paducah, Paducah, KY.

BACKGROUND: The prevalence of persistent low back pain with the involvement of lumbar facet or zygapophysial joints has been described in controlled studies as varying from 15% to 45% based on the criteria of the International Association for the Study of Pain. Therapeutic interventions utilized in managing chronic low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves. OBJECTIVE: To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain of facet joint origin. DESIGN: A prospective, randomized, double-blind trial. SETTING: An interventional pain management setting in the United States. METHODS: In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of 4 groups. Thirty patients were in a non-steroid group consisting of Groups I (control, with lumbar facet joint nerve blocks using bupivacaine ) and II (with lumbar facet joint nerve blocks using bupivacaine and Sarapin); another 30 patients were in a steroid group consisting of Groups III (with lumbar facet joint nerve blocks using bupivacaine and steroids) and IV (with lumbar facet joint nerve blocks using bupivacaine, Sarapin, and steroids). All patients met the diagnostic criteria of lumbar facet joint pain by means of comparative, controlled diagnostic blocks. OUTCOME MEASURES: Numeric Rating Scale (NRS) pain scale, the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake. RSULTS: Significant improvement in pain and functional status were observed at 3 months, 6 months, and 12 months, compared to baseline measurements. The average number of treatments for 1 year was 3.7 with no significant differences among the groups. Duration of average pain relief with each procedure was 14.8 +/- 7.9 weeks in the non-steroid group, and 12.5 +/- 3.3 weeks in the steroid group, with no significant differences among the groups. CONCLUSION: Therapeutic lumbar facet joint nerve blocks with local anesthetic, with or without Sarapin or steroids, may be effective in the treatment of chronic low back pain of facet joint origin.

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Curr Med Res Opin. 2007 May;23(5):981-9.
Efficacy and safety evaluation of once-daily OROS hydromorphone in patients with chronic low back pain: a pilot open-label study (DO-127).
Wallace M, Skowronski R, Khanna S, Tudor IC, Thipphawong J.
University of California, San Diego Medical Center, La Jolla, CA, USA.

OBJECTIVE: To evaluate the safety, tolerability, and efficacy of once-daily osmotic controlled-release oral delivery system (OROS) hydromorphone in patients with chronic low back pain of moderate-to-severe intensity. RESEARCH DESIGN AND METHODS: This was a 6-week, multicenter, nonrandomized, noncomparative, open-label, repeat-dose study of chronic (> or = 6 weeks) low back pain. The study comprised three periods: prior opioid stabilization (2-7 days); OROS hydromorphone conversion, titration, and stabilization (3-14 days); and OROS hydromorphone maintenance (28 days). Patients were evaluated weekly. Baseline pain assessment was performed at the end of prior opioid stabilization. For pain relief rating, endpoint was defined as the mean pain relief score from the last 2 nonmissing days before study termination. For other assessments, endpoint was defined as the last post-baseline evaluation. RESULTS: Of the 207 patients who received the study drug, 131 completed the trial. Scores (mean +/- SD) for Brief Pain Inventory 'worst pain in the last 24 hours' decreased significantly from baseline to endpoint (-0.8 +/- 2.06, p < 0.0001). The proportions of patients and investigators rating the global effectiveness as good, very good, or excellent increased from 31.6% at baseline while patients were on prior opioids to 63.2% at endpoint while patients received OROS hydromorphone, and from 29.8% at baseline while patients were on prior opioids to 65.8% at endpoint while patients received OROS hydromorphone, respectively. Daily pain relief ratings also increased significantly (+0.26 +/- 1.084, p = 0.0008). Significant improvements in health-related quality of life and sleep problems were observed. Adverse events were mild to moderate in severity; the most common of these were constipation, nausea, headache, and somnolence. The limitations of this study include its pilot-type design and the lack of comparison of OROS hydromorphone with a placebo or another drug. Additional comparative and longer-term studies are needed to confirm these findings. CONCLUSIONS: OROS hydromorphone may be an effective treatment for chronic low back pain of moderate-to-severe intensity. Adverse events were typical of those associated with opioid therapy.

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Phys Ther. 2007 Feb 6; [Epub ahead of print]
A pilot study of the effects of high-intensity aerobic exercise versus passive interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain.
Chatzitheodorou D, Kabitsis C, Malliou P, Mougios V.
Department of Physical Therapy, Technological Educational Institute of Thessaloniki, PO Box 141, 57400 Sindos, Greece.

BACKGROUND AND PURPOSE: Given the complex nature of chronic pain, the effects of high-intensity aerobic exercise on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain were investigated. SUBJECTS: Twenty subjects receiving primary health care were randomly allocated into exercise and control groups. METHODS: Subjects in the exercise group received a 12-week high-intensity aerobic exercise program. Subjects in the control group received a conservative physical therapy intervention. RESULTS: Data analysis identified reductions in pain (41%, t(10)=8.51, P<.001), disability (31%, t(10)=7.32, P<.001), and psychological strain (35%, t(10)=7.09, P<.001) in subjects in the exercise group and no changes in subjects in the control group. High-intensity exercise failed to influence serum cortisol concentrations. DISCUSSION AND CONCLUSION: Regular high-intensity aerobic exercise alleviated pain, disability, and psychological strain in subjects with chronic low back pain but did not improve serum cortisol concentrations.

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Cardiovasc Intervent Radiol. 2007 Feb 2; [Epub ahead of print]
Nucleoplasty in the Treatment of Lumbar Diskogenic Back Pain: One Year Follow-Up.
Masala S, Massari F, Fabiano S, Ursone A, Fiori R, Pastore F, Simonetti G.
Department of Diagnostic Imaging and Interventional Radiology, University of Rome "Tor Vergata", Rome, Italy.

PURPOSE: The spine is an important source of pain and disability, affecting two thirds of adults at some time in their lives. Treatment in these patients is mainly conservative medical management, based on medication, physical therapy, behavioral management, and psychotherapy, surgery being limited to elective cases with neurologic deficits. This study was carried out to evaluate the efficacy of percutaneous nucleoplasty in patients affected by painful diskal protrusions and contained herniations. METHODS: From February 2004 to October 2005, 72 patients (48 men, 24 women; mean age 48 years) affected by lumbar disk herniation were treated with nucleoplasty coblation. All patients were evaluated clinically and with radiography and MRI in order to confirm the presence of lumbalgic and/or sciatalgic pain, in the absence of major neurologic deficit and with lack of response after 6 weeks of conservative management. RESULTS: Average preprocedural pain level for all patients was 8.2 (on a visual analog scale of 1 to 10), while the average pain level at 12 months follow-up was 4.1. At the 1 year evaluation, 79% of patients demonstrated a statistically significant improvement in numeric pain scores (p < 0.01): 17% (12 patients) were completely satisfied with complete resolution of symptoms, and 62% (43 patients) obtained a good result. CONCLUSION: Our data indicate that nucleoplasty coblation is a promising treatment option for patients with symptomatic disk protrusion and herniation who present with lumbalgic and/or sciatalgic pain, have failed conservative therapies, and are not considered candidates for open surgery.

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Spine. 2007 Feb 1;32(3):291-8; discussion 299-300.
Multidisciplinary rehabilitation for subacute low back pain: graded activity or workplace intervention or both?: a randomized controlled trial.
Anema JR, Steenstra IA, Bongers PM, de Vet HC, Knol DL, Loisel P, van Mechelen W.
Body@Work, Research Centre Physical Activity, Work and Health, Amsterdam, The Netherlands. h.anema@vumc.nl

STUDY DESIGN: Population-based randomized controlled trial. OBJECTIVE: To assess the effectiveness of workplace intervention and graded activity, separately and combined, for multidisciplinary rehabilitation of low back pain (LBP). SUMMARY OF BACKGROUND DATA: Effective components for multidisciplinary rehabilitation of LBP are not yet established. METHODS: Participants sick-listed 2 to 6 weeks due to nonspecific LBP were randomized to workplace intervention (n = 96) or usual care (n = 100). Workplace intervention consisted of workplace assessment, work modifications, and case management involving all stakeholders. Participants still sick-listed at 8 weeks were randomized for graded activity (n = 55) or usual care (n = 57). Graded activity comprised biweekly 1-hour exercise sessions based on operant-conditioning principles. Outcomes were lasting return to work, pain intensity and functional status, assessed at baseline, and at 12, 26, and 52 weeks after the start of sick leave. RESULTS: Time until return to work for workers with workplace intervention was 77 versus 104 days (median) for workers without this intervention (P = 0.02). Workplace intervention was effective on return to work (hazard ratio = 1.7; 95% CI, 1.2-2.3; P = 0.002). Graded activity had a negative effect on return to work (hazard ratio = 0.4; 95% CI, 0.3-0.6; P < 0.001) and functional status. Combined intervention had no effect. CONCLUSION: Workplace intervention is advised for multidisciplinary rehabilitation of subacute LBP. Graded activity or combined intervention is not advised.

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Clin J Pain. 2007 Feb;23(2):128-35.
Acupuncture for chronic low back pain in routine care: a multicenter observational study.
Weidenhammer W, Linde K, Streng A, Hoppe A, Melchart D.
Department of Internal Medicine II, Center for Complementary Medicine Research, Technische Universitat Munchen, Germany. Wolfgang.Weidenhammer@lrz.tu-muenchen.de

OBJECTIVE: To investigate patient characteristics and outcomes after undergoing acupuncture treatment for chronic low back pain (cLBP) in Germany and to analyze chronification, pain grading, and depression as predictors for treatment outcomes. PATIENTS AND METHODS: Patients with cLBP (ICD-10 diagnoses M54.4 or M54.5) who underwent acupuncture therapy (mean number of sessions 8.7+/-2.9) within the framework of a reimbursement and research program sponsored by German statutory sickness funds were included in an observational study. Patients were asked to complete detailed questionnaires that included questions on intensity and frequency of pain and instruments measuring functional ability, depression, and quality of life (SF-36) before and after treatment and 6 months after beginning acupuncture. Participating physicians assessed pain chronification in patients. RESULTS: A total of 2564 patients (mean age 57.7+/-14.0 y, 78.7% female), who were treated by 1607 physicians, were included in the main analysis. After 6 months (6-mo follow-up), 45.5% of patients demonstrated clinically significant improvements in their functional ability scores. The mean number of days with pain was decreased by half (from 21 to 10 d/mo). Employed patients (employed patient subgroup analysis) reported a 30% decrease from baseline in days of work lost. In all, 8.1% of patients reported adverse events, the majority of which were minor. Subgroup analyses focusing on pain severity, stage of chronification, and depression revealed statistically significant relationships both to baseline measures and to reduction of pain after acupuncture. CONCLUSIONS: Acupuncture treatment is associated with clinically relevant improvements in patients suffering from cLBP of varying degrees of chronification and/or severity.

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Schmerz. 2007 Jan 31; [Epub ahead of print]
[Rehabilitation of non-specific low back pain : Results of a multidisciplinary in-patient program.]
[Article in German]
Wagner E, Ehrenhofer B, Lackerbauer E, Pawelak U, Siegmeth W.
Ludwig-Boltzmann-Forschungsstelle fur Epidemiologie rheumatischer Erkrankungen, Institut fur Rheumatologie der Kurstadt Baden , Sauerhofstrasse 9-15, A-2500, Baden, Osterreich, Ernst.Wagner@noegkk.at.

In this study we documented the effectiveness of a 3-week multidisciplinary rehabilitative intervention in patients with chronic nonspecific low back pain. We compared the therapy group (136 patients: 91 female, 45 male) with a waiting list control group (34 patients: 25 female, 9 male). The patients showed chronic pain grades 1 and 2 (according to the Mainz Pain Staging System) and mild restriction of activity. Pain intensity, activity, participation, and health-related quality of life improved significantly in the intervention group (VAS from 46.34 to 25.91; FFbH-R from 19.79 to 18; PDI from 21.02 to 14.57; NHP from 161.83 to 120.97); the waiting list control group remained unchanged. The improvement was independent of age, gender, duration of disease, work status, or workplace satisfaction.

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Ann Intern Med. 2007 Jan 16;146(2):116-27.
Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.
Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, Fiellin DA.
Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.

BACKGROUND: The prevalence, efficacy, and risk for addiction for persons receiving opioids for chronic back pain are unclear. PURPOSE: To determine the prevalence of opioid treatment, whether opioid medications are effective, and the prevalence of substance use disorders among patients receiving opioid medications for chronic back pain. DATA SOURCES: English-language studies from MEDLINE (1966-March 2005), EMBASE (1966-March 2005), Cochrane Central Register of Controlled Clinical Trials (to 4th quarter 2004), PsychInfo (1966-March 2005), and retrieved references. STUDY SELECTION: Articles that studied an adult, nonobstetric sample; used oral, topical, or transdermal opioids; and focused on treatment for chronic back pain. DATA EXTRACTION: Two investigators independently extracted data and determined study quality. DATA SYNTHESIS: Opioid prescribing varied by treatment setting (range, 3% to 66%). Meta-analysis of the 4 studies assessing the efficacy of opioids compared with placebo or a nonopioid control did not show reduced pain with opioids (g, -0.199 composite standardized mean difference [95% CI, -0.49 to 0.11]; P = 0.136). Meta-analysis of the 5 studies directly comparing the efficacy of different opioids demonstrated a nonsignificant reduction in pain from baseline (g, -0.93 composite standardized mean difference [CI, -1.89 to -0.03]; P = 0.055). The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%. LIMITATIONS: Retrieval and publication biases and poor study quality. No trial evaluating the efficacy of opioids was longer than 16 weeks. CONCLUSIONS: Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (> or =16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24% of cases.

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Curr Med Res Opin. 2007 Jan;23(1):117-28.
A 12-week, randomized, placebo-controlled trial assessing the safety and efficacy of oxymorphone extended release for opioid-naive patients with chronic low back pain.
Katz N, Rauck R, Ahdieh H, Ma T, Gerritsen van der Hoop R, Kerwin R, Podolsky G.
Tufts University School of Medicine, Boston, MA, USA. NKatz@analgesicresearch.com

OBJECTIVE: Determine the efficacy and tolerability of oxymorphone extended release (OPANA ER) in opioid-naive patients with moderate to severe chronic low back pain (CLBP). DESIGN AND METHODS: Patients > or = 18 years of age were titrated with oxymorphone ER (5- to 10-mg increments every 12 h, every 3-7 days) to a well-tolerated, stabilized dose. Patients were then randomized to continue their oxymorphone ER dose or receive placebo every 12 h for 12 weeks. Oxymorphone immediate release was available every 4-6 h, as needed, for the first 4 days and twice daily thereafter. RESULTS: Sixty-three percent of patients (205/325) were titrated to a stabilized dose of oxymorphone ER, most (203/205) within 1 month. During titration, 18% discontinued from adverse events (AEs) and 1% from lack of efficacy. For patients completing titration, average pain intensity decreased from 69.4 mm at screening to 22.7 mm (p < 0.0001). After randomization, 68% of oxymorphone ER and 47% of placebo patients completed 12 weeks of double-blind treatment. Approximately 8% of patients in each group discontinued because of AEs. Placebo patients discontinued significantly sooner from lack of efficacy than those receiving oxymorphone ER (p < 0.0001). Pain intensity increased significantly more in the placebo group (least squares [LS] mean change 26.9 +/- 2.4 [median 28.0]) than in the oxymorphone ER group (LS mean change 10.0 +/- 2.4 [median 2.0]; p < 0.0001). Oxymorphone ER was generally well tolerated without unexpected AEs. Although limitations of a randomized withdrawal study include the potential for unblinding and opioid withdrawal in placebo patients, opioid withdrawal was limited to two patients in the placebo group and one in the oxymorphone ER group. CONCLUSIONS: Stabilized doses of oxymorphone ER were generally safe and effective over a 12-week double-blind treatment period in opioid-naive patients with CLBP.

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Pain Physician. 2007 Jan;10(1):185-212.
Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic Review.
Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, Smith HS, Manchikanti L.
University of Miami, Miller School of Medicine, Miami, FL; Vanderbilt University School of Medicine, Nashville, TN; University of Florida, Gainesville, FL; University of Minnesota Medical School, Minneapolis, MN; Pain Control Associates, Munster, IN; Tristate Pain Management, Loveland, OH; Albany Medical College, Albany, NY; and Pain Management Center of Paducah, KY, and University of Louisville, KY.

Background: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of epidural injections. Consequently, debate continues as to the value of epidural steroid injections in managing spinal pain. Objective: To evaluate the effect of various types of epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions. Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Methods: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome Measures: The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. Results: In managing lumbar radicular pain with interlaminar lumbar epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome. Conclusion: There is moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain.

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Pain Physician. 2007 Jan;10(1):129-46.
Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update.
Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM.
University of FL, Gainesville, FL; Brown Medical School,Pawtucket, RI; University of Miami, Miami, FL; Vanderbilt University School of Medicine, Nashville,TN; and University of Minnesota Medical School, Minneapolis, MN.

Background: Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques used to treat patients with refractory low back pain due to epidural scarring. Standard epidural steroid injections are often ineffective, especially in patients with prior back surgery. Adhesions in the epidural space can prevent the flow of medicine to the target area; lysis of these adhesions can improve the delivery of medication to the affected areas, potentially improving the therapeutic efficacy of the injected medications. Study Design: A systematic review utilizing the methodologic quality criteria of the Cochrane Musculoskeletal Review Group for randomized trials and the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials. Objective: To evaluate and update the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis in managing chronic low back and lower extremity pain due to radiculopathy, with or without prior lumbar surgery, since the 2005 systematic review. Methods: Basic search identified the relevant literature, in the MEDLINE, EMBASE, and BioMed databases (November 2004 to September 2006). Manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years were reviewed. Randomized and non-randomized studies are included in the review based on criteria established. Percutaneous adhesiolysis and endoscopic adhesiolysis are analyzed separately. Outcome Measures: The primary outcome measure was significant pain relief (50% or greater). Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term relief was defined as less than 3 months, and long-term relief was defined as 3 months or longer. Results: Studies regarding the treatment of epidural adhesions for the treatment of low back and lower extremity pain were sought and reviewed. The evidence from the previous systematic review was combined with new studies since November 2004. There is strong evidence for short term and moderate evidence for long term effectiveness of percutaneous adhesiolysis and spinal endoscopy. Conclusion: Percutaneous adhesiolysis and spinal endoscopy may be effective interventions to treat low back and lower extremity pain caused by epidural adhesions.

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Pain Physician. 2007 Jan;10(1):7-111.
Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain.
Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L.
American Society of Interventional Pain Physicians, Paducah, KY, USA. E-mail: asipp@asipp.org.

Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited.The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. Conclusion: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a "standard of care."
 

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