Low Back Pain

A Systematic Review on the Effectiveness of Physical and Rehabilitation Interventions for Chronic Non-specific Low Back Pain

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SOURCE:   European Spine Journal 2011 (Jan); 20 (1): 19–39

Marienke van Middelkoop • Sidney M. Rubinstein • Ton Kuijpers • Arianne P. Verhagen • Raymond Ostelo •
Bart W. Koes • Maurits W. van Tulder

Department of General Practice,
Erasmus MC, University Medical Center,
Rotterdam, The Netherlands.

Low back pain (LBP) is a common and disabling disorder in western society. The management of LBP comprises a range of different intervention strategies including surgery, drug therapy, and non-medical interventions. The objective of the present study is to determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioural treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy) for chronic LBP. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to 22 December 2008.

Existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria. The search strategy outlined by the Cochrane Back Review Groups (CBRG) was followed. The following were included for selection criteria: (1) randomized controlled trials, (2) adult (≥ 18 years) population with chronic (≥ 12 weeks) non-specific LBP, and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias, and outcomes at short, intermediate, and long-term follow-up. The GRADE approach was used to determine the quality of evidence.

In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6).

Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function.

Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls.

Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls.

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Impact of Musculoskeletal Pain on Balance and Concerns of Falling in Mobility-limited, Community-dwelling Danes over 75 Years of Age: A Cross-sectional Study

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SOURCE:   Aging Clin Exp Res. 2018 (Aug);   30 (8):   969–975

Julie C. Kendall, Lars G. Hvid, Jan Hartvigsen,
Azharuddin Fazalbhoy, Michael F. Azari,
Mathias Skjødt, Stephen R. Robinson, Paolo Caserotti

School of Health and Biomedical Sciences,
RMIT University,
PO Box 71,
Bundoora, Melbourne, 3083, VIC, Australia.

BACKGROUND:   In older adults, musculoskeletal pain is associated with increased concerns of falling, reduced balance and increased occurrence of falls. In younger adults, the intensity of neck pain and low back pain is associated with increased postural sway. It is not known if pain further impairs balance and concerns of falling in mobility-limited older adults, and if so, whether this is associated with different intensities of pain.

OBJECTIVE:   This study examined whether mobility-limited older adults with mild or intense neck pain and/or low back pain have significantly increased postural sway as measured by centre of pressure (COP) changes and concerns of falling compared to those without pain.

METHODS:   48 older adults with a gait speed of < 0.9 m/s from Odense, Denmark were recruited through the public health service. Self-reported neck pain, low back pain, and concerns of falling were recorded on questionnaires. Sway range, velocity and area were recorded on a force plate in a comfortable standing stance. Pain intensity was rated on an 11 point numerical rating scale (0-10). Participants were sub-grouped into mild (0-4) and intense (> 5) neck pain or low back pain.

RESULTS:   Intense neck pain was associated with increased anterior-posterior sway range and area of sway. Intense low back pain was associated with increased concerns of falling.

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Feeling Stiffness in the Back: A Protective Perceptual Inference in Chronic Back Pain

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SOURCE:   Sci Rep. 2017 (Aug 29);   7 (1):   9681

Tasha R. Stanton, G. Lorimer Moseley,
Arnold Y. L. Wong & Gregory N. Kawchuk

The Sansom Institute for Health Research,
School of Health Sciences & Pain Adelaide Consortium,
The University of South Australia,
Adelaide, SA, Australia.

Does feeling back stiffness actually reflect having a stiff back? This research interrogates the long-held question of what informs our subjective experiences of bodily state. We propose a new hypothesis: feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back.

This has far-reaching implications for treatment of pain/stiffness but also for our understanding of bodily feelings. Over three experiments, we challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine, yet are better at detecting changes in this force than those who do not report feeling stiff.

This perceptual error can be manipulated: providing auditory input in synchrony to forces applied to the spine modulates prediction accuracy in both groups, without altering actual stiffness, demonstrating that feeling stiff is a multisensory perceptual inference consistent with protection. Together, this presents a compelling argument against the prevailing view that feeling stiff is an isomorphic marker of the biomechanical characteristics of the back.

From the FULL TEXT Article:

Introduction

Bodily feelings constitute a fundamental aspect of self-awareness and provide critical homeostatic functions – e.g., feeling cold makes one seek warmth [1]; feeling pain makes one seek protection [2]; feeling parched makes one drink. [3] We assume that these bodily feelings reflect the biological state of our body tissues – a ‘read-out’, so to speak, of somatosensory and visceral input – particularly when the feeling is located somewhere in the body, as it is for pain or stiffness. There is growing evidence for pain however, that it is highly modulated by a wide range of cognitive and contextual variables. [4, 5] For example, visually manipulating the perceived size of one’s hand alters the pain experienced in experimental contexts [6] and during movement of a chronically painful limb [7], and illuminating a blue or red light in synchrony with delivering a noxious cold stimulus can transform the feeling evoked from uncomfortably cold to painfully hot. [5]

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Looking Ahead: Chronic Spinal Pain Management

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SOURCE:   Journal of Pain Research 2017 (Aug 30); 10: 2089–2095

Gregory F Parkin-Smith, Stephanie J Davies,
Lyndon G Amorin-Woods

School of Health Professions,
Murdoch University,
Perth, WA, Australia

The other day, we oversaw a seminar on pain management for a local consumer pain group, where all consumers (patients) in attendance were experiencing chronic, persistent spinal pain. Each person had a unique story, and their experience and perceived cause of their pain differed. The quality of life in all these consumers was markedly reduced, which was the only clear similarity, confirming that there may be some similarities in the pain experience, but the pain experience was more often unique and individual. These consumers’ criticisms of care services were consistent, however, with dissatisfaction with their access to care and overall management of their pain. They described variable and often difficult access, limited continuity of care, they were often not taken seriously by health care providers, they received scant information about chronic pain and its prognosis and there were often noteworthy variations in the treatment they received. We agree that these criticisms are commonplace and a frequent gripe directed at health care practitioners about the “system.” [1] Moreover, the problems associated with care delivery are confounded by a number of patient/consumer factors, such as lifestyle habits, nutrition, body weight, depression, health literacy, geographical isolation and poor socioeconomic conditions, making the management of persistent pain even more complicated. [2] There is no doubt that, in the future, matching the care service and treatment with the individual patient will become an essential component of care services, as has been implied in published research. [3-6]

Health care practitioners involved in the triage and management of patients with persistent spinal pain will need to become more vigilant about individualizing and coordinating care for each patient, to achieve the best possible outcomes. For example, Cecchi et al concluded that patients with chronic (persistent) lower baseline pain (LBP)-related disability predicted “nonresponse” to standard physiotherapy, but not to spinal manipulation (an intervention commonly employed by chiropractors [7-9]), implying that spinal manipulation should be considered as a first-line conservative treatment. [9] We note that spinal manipulation is now suggested as the first-line intervention by Deyo, [10] since not a single study examined in a recent systematic review found that spinal manipulation was less effective than conventional care. [11]

Garcia et al, [12] conversely, showed that high pain intensity may be an important treatment effect modifier for patients with chronic low back pain receiving Mckenzie therapy (a treatment frequently used by physiotherapists). These examples demonstrate the importance of matching treatments with the characteristics of the patient.

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