Relationship between physical activity and disability in low back pain: A systematic review and meta-analysis

The normative score and the cut-off value of the Oswestry Disability Index (ODI)

PURPOSE

The Oswestry Disability Index (ODI) is one of the most common scoring systems used for patients with low back pain (LBP). Although the normative score of the ODI was reported to be 10.19 in a review article, no study has calculated the normative score after adjusting the value based on the age distribution. In addition, none of the previous studies has estimated the cut-off value which separates LBP with disability from LBP without disability. The purpose of this study was to estimate the normative score by adjusting the data for age distribution in Japan, and to determine the cut-off value which separates LBP with disability from LBP without disability.

METHODS

We conducted an internet survey on LBP using the Japanese version of the ODQ. A total of 1,200 respondents, composed of 100 males and 100 females in each age group (from the 20s to 70s), participated in this study. We also asked them to provide information about their backgrounds. We estimated the normative score after correcting for the age distribution of Japan. We also estimated the ODI of those with or without disability, the factors associated with the ODI, and the cut-off value which separates LBP with disability from LBP without disability.

RESULTS

The participants' backgrounds were similar to the national survey. The normative score of the ODI was estimated at 8.73. The ODI of the LBP with disability group was 22.07. Those with sciatica and obese subjects showed higher ODI than those without. The optimal cut-off value was estimated to be 12.

CONCLUSIONS

We defined the normative score and the cut-off value of the ODI.

Psychological therapies for the management of chronic pain (excluding headache) in adults

BACKGROUND

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.

OBJECTIVES

To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.

SEARCH METHODS

We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.

DATA COLLECTION AND ANALYSIS

Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.

MAIN RESULTS

Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

AUTHORS' CONCLUSIONS

Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Assessment of physical activity by movement registration systems in chronic pain: methodological considerations

OBJECTIVES

Physical activity assessments in chronic pain research have mostly been based on self-report. However, earlier research indicated that chronic pain patients have difficulties in estimating their own daily life activity level. Movement registration systems have been introduced to overcome the limitations of self-reported measures. However, no uniform guidelines for researchers on how to analyze and interpret movement registration data in chronic pain exist. The aim of the study was to provide recommendations for physical activity assessment based on movement registration in patients with chronic pain.

METHODS

First, a systematic review of the procedures and data processing techniques used in movement registration for chronic pain patients will be performed. Second, it will be discussed whether the recommendations for physical activity assessment in healthy individuals are applied in chronic pain research. Last, recommendations regarding assessment procedure and data processing for using movement registration systems in future research in patients with chronic pain will be given.

RESULTS

In chronic pain literature, 27 articles on movement registration were identified. According to the recommendations for activity assessment in healthy individuals, the various descriptions of the assessment procedures in these articles were mostly limited. Especially, information regarding the minimal requirements for the assessment period and the method used for calculation of the final outcome variable were often lacking.

DISCUSSION

It is recommended that studies in chronic pain research explicitly apply and report the criteria that have been used to define an assessment day, the total assessment time, and the method for calculating the final test outcome.

Consumers' experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours

Background

Coordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP.

Methods

Fourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes.

Results

Five key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.

Conclusions

Consumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion

PURPOSE

The diagnosis of low back pain pathology is generally based upon invasive image-based assessment of structural pathology, but is limited in methods to evaluate function. The accurate and robust measurement of dynamic function may assist in the diagnosis and monitoring of therapy success. Epionics SPINE is an advanced strain-gauge measurement technology, based on the two sensor strips SpineDMS system, which allows the non-invasive assessment of lumbar and thoraco-lumbar motion for periods of up to 24 h. The aim of this study was to examine the reliability of Epionics SPINE and to collect and compare normative data for the characterisation of spinal motion in healthy subjects. Furthermore, the identification of parameters that influence lumbar range of motion (RoM) was targeted.

METHODS

Spinal shape was measured using Epionics SPINE in 30 asymptomatic volunteers during upright standing, as well as maximum flexion and extension, to check intra-rater reliability. Furthermore, back shape was assessed throughout repeated maximum flexion and extension movements in 429 asymptomatic volunteers in order to collect normative data of the lordosis angle and RoM in different gender and age classes.

RESULTS

The lordosis angle during standing in the healthy collective measured with Epionics SPINE was 32.4° ± 9.7°. Relative to this standing position, the average maximum flexion angle was 50.8° ± 10.9° and the average extension angle 25.0° ± 11.5°. Comparisons with X-ray and Spinal Mouse data demonstrated good agreement in static positions. Age played a larger role than gender in influencing lumbar posture and RoM.

CONCLUSIONS

The Epionics SPINE system allows the practical and reliable dynamic assessment of lumbar spine shape and RoM, and may therefore provide a clinical solution for the evaluation of lower back pain as well as therapy monitoring.

Different level, but a similar day pattern of physical activity in workers and sick-listed people with chronic nonspecific musculoskeletal pain

OBJECTIVE

To investigate whether physical activity (PA) levels and day patterns of sick-listed workers with chronic nonspecific musculoskeletal pain (CMP) admitted for multidisciplinary rehabilitation are different from those of workers with CMP.

DESIGN

Cross-sectional.

SETTING

Outpatient rehabilitation center and general community.

PARTICIPANTS

A convenience sample of sick-listed patients with CMP (n=27) referred for multidisciplinary pain rehabilitation, and a volunteer sample of workers with CMP (n=107; <5% sick leave in year before participation).

INTERVENTION

Participants wore an accelerometer for 5 to 7 consecutive days.

MAIN OUTCOME MEASURE

PA, expressed as activity counts. All analyses were corrected for confounders.

RESULTS

PA levels of workers with CMP were higher than those of sick-listed patients (P=.01). After correction for confounders, work status explained 3.5% of the variance observed in activity counts (F(change)=5.27, P=.024). In the mornings, group status significantly contributed to the variance in mean activity counts (F(change)=5.32, P=.02). In afternoons (F(change)=3.29, P=.07) and evenings (F(change)=2.41, P=.12), the effect of group status on PA level was nonsignificant. No significant interaction was observed between time and group status (Wilks' λ=.92, F(14,104)=.66, P=.80).

CONCLUSIONS

Workers with CMP have a higher PA level compared with sick-listed patients. The PA day pattern did not differ significantly between the 2 groups.

Chronic low back pain is associated with reduced vertebral bone mineral measures in community-dwelling adults

Background

Chronic low back pain (CLBP) experienced in middle-age may have important implications for vertebral bone health, although this issue has not been investigated as a primary aim previously. This study investigated the associations between CLBP and dual energy X-ray absorptiometry (DXA)-derived vertebral bone mineral measures acquired from postero-anterior and lateral-projections, among community-dwelling, middle-aged adults.

Methods

Twenty-nine adults with CLBP (11 male, 18 female) and 42 adults with no history of LBP in the preceding year (17 male, 25 female) were evaluated. Self-reported demographic and clinical data were collected via questionnaires. Areal bone mineral density (aBMD) was measured in the lumbar spine by DXA. Apparent volumetric (ap.v) BMD in the lumbar spine was also calculated. Multiple linear regression models were used to examine associations between study group (CLBP and control) and vertebral DXA variables by gender, adjusting for height, mass and age.

Results

There was no difference between groups by gender in anthropometrics or clinical characteristics. In the CLBP group, the mean (SD) duration of CLBP was 13.3 (10.4) years in males and 11.6 (9.9) years in females, with Oswestry Disability Index scores of 16.2 (8.7)% and 15.4 (9.1)%, respectively. Males with CLBP had significantly lower adjusted lateral-projection aBMD and lateral-projection ap.vBMD than controls at L3 with mean differences (standard error) of 0.09 (0.04) g/cm² (p = 0.03) and 0.02 (0.01) g/cm³ (p = 0.04). These multivariate models accounted for 55% and 53% of the variance in lateral-projection L3 aBMD and lateral-projection L3 ap.vBMD.

Conclusions

CLBP in males is associated with some lumbar vertebral BMD measures, raising important questions about the mechanism and potential clinical impact of this association.

The relationship between low back pain and leisure time physical activity in a working population of cleaners--a study with weekly follow-ups for 1 year

BACKGROUND

Low back pain (LBP) and leisure time physical activity (LTPA) are considered to be closely related, and clinical guidelines for the treatment of acute LBP recommend patients stay physically active. However, the documentation for this recommendation is sparse and based on studies involving patient populations. The purpose of the study was (1) to investigate the correlation between LBP and LTPA on a weekly basis over the course of a year in a high-risk group of cleaners; and (2) to investigate if maintaining LTPA during an episode of acute LBP has a positive effect on LBP intensity in the subsequent 4 weeks.

METHODS

188 cleaners consented to participate in a 52-week text message survey about hours of LTPA and intensity of LBP (from 0 to 9) over the previous 7 days. The correlation between LBP and LTPA was calculated by Pearson correlation coefficient. During an episode of acute LBP, a mixed effect logistic regression model was used to investigate whether cleaners who maintain LTPA have a lower pain intensity and higher probability of returning to initial pain intensity within the following four weeks compared with cleaners who decrease LTPA during acute LBP.

RESULTS

The correlation between weekly LTPA and LBP data was negative, but numerically low (r = -0.069) and statistically insignificant (p = 0.08). Among the 82 cleaners experiencing at least one episode of acute LBP, those maintaining LTPA during an episode of acute LBP did not have a lower pain intensity (average LBP intensity difference between groups of 0.06; 95% confidence interval (95% CI) of -0.417 to 0.539) or higher probability of returning to initial pain level (Odds ratio 1,02; 95% CI of 0.50 to 2.09) in the following four weeks compared with cleaners decreasing LTPA during acute LBP.

CONCLUSIONS

Hours of LTPA and intensity of LBP measured on a weekly basis throughout a year showed no close correlation. Maintaining LTPA during an episode of acute LBP did not result in a positive effect on LBP in the following 4 weeks. Documentation of LTPA recommendations for acute LBP in working populations is still needed.