WITHDRAWN: Lumbar supports for prevention and treatment of low-back pain

Non-Specific Low Back Pain

BACKGROUND

For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition.

METHODS

The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process.

RESULTS

If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible.

CONCLUSION

A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

Preventive aspects regarding back pain

Prevention, as the act of keeping from happening, aims to avert things that would occur if no intervention would be taken. From the epidemiology of back pain, consequences of the disease that are worth preventing can be derived. Biological, psychological, and social factors lead to back pain and chronification and ultimately to various adverse outcomes. The most important preventable consequences of back pain include loss of ability to function in daily life, loss of work productivity, sickness absence, and disability pension, excessive and inappropriate healthcare utilisation, impairments in quality of life, and disturbance of sexual life. The most important tools for prevention of back pain lie within rehabilitation after acute pain treatment and include exercise and physical training as well as health education and increasing health literacy. The bio-psycho-social nature of back pain must be taken into account in all preventive measures.

Identification of barriers to the prevention and treatment of heat-related illness in Latino farmworkers using activity-oriented, participatory rural appraisal focus group methods

BACKGROUND

Heat-related illness (HRI) is an important cause of non-fatal illness and death in farmworkers. We sought to identify potential barriers to HRI prevention and treatment in Latino farmworkers.

METHODS

We conducted three semi-structured focus group discussions with 35 Latino farmworkers in the Central Washington, USA area using participatory rural appraisal techniques. Interviews were audio taped and transcribed in Spanish. Three researchers reviewed and coded transcripts and field notes, and investigator triangulation was used to identify relevant themes and quotes.

RESULTS

Although the majority of participants in our study reported never receiving formal HRI training, most participants were aware that extreme heat can cause illness and were able to accurately describe HRI symptoms, risk factors, and certain prevention strategies. Four main observations regarding farmworkers' HRI-relevant beliefs and attitudes were identified: 1) farmworkers subscribe to varying degrees to the belief that cooling treatments should be avoided after heat exposure, with some believing that such treatments should be avoided after heat exposure, and others encouraging the use of such treatments; 2) the desire to lose weight may be reflected in behaviors that promote increased sweating; 3) highly caffeinated energy drinks are preferred to increase work efficiency and maintain alertness; and 4) the location of drinking water at work (e.g. next to restrooms) and whether water is clean, but not necessarily chemically-treated, are important considerations in deciding whether to drink the water provided at worksites.

CONCLUSIONS

We identified potential barriers to HRI prevention and treatment related to hydration, certain HRI treatments, clothing use, and the desire to lose weight among Latino farmworkers. Strategies to address potential barriers to HRI prevention and treatment in this population may include engineering, administrative, and health education and health promotion strategies at individual, workplace, community, and societal levels. Although farmworkers in our study were able to describe HRI risk factors, reported practices were not necessarily consistent with reported knowledge. Further study of potential knowledge-behavior gaps may uncover opportunities for additional HRI prevention strategies. Farmworkers and employers should be included in the development and evaluation of interventions to prevent HRI.

Intramuscular architecture of the autochthonous back muscles in humans

Many training concepts take muscle properties such as contraction speed or muscle topography into account to achieve an optimal training outcome. Thus far, the internal architecture of muscles has largely been neglected, although it is well known that parameters such as pennation angles or the lengths of fascicles but also the proportions of fleshy and tendinous fascicle parts have a major impact on the contraction behaviour of a muscle. Here, we present the most detailed description of the intramuscular fascicle architecture of the human perivertebral muscles available so far. For this, one adult male cadaver was studied. Our general approach was to digitize the geometry of each fascicle of the muscles of back proper (Erector spinae) - the Spinalis thoracis, Iliocostalis lumborum, Longissimus thoracis and the Multifidus thoracis et lumborum - and of the deep muscles of the abdomen - Psoas minor, Psoas major and Quadratus lumborum - during a layerwise dissection. Architectural parameters such as fascicle angles to the sagittal and the frontal planes as well as fascicle lengths were determined for each fascicle, and are discussed regarding their consequences for the function of the muscle. For example, compared with the other dorsovertebral muscles, the Longissimus thoracis can produce greater shortening distances because of its relatively long fleshy portions, and it can store more elastic energy due to both its relatively long fleshy and tendinous fascicle portions. The Quadratus lumborum was outstanding because of its many architectural subunits defined by distinct attachment sites and fascicle lengths. The presented database will improve biomechanical models of the human trunk by allowing the incorporation of anisotropic muscle properties such as the fascicle direction into finite element models. This information will help to increase our understanding of the functionality of the human back musculature, and may thereby improve future training concepts.

A pilot randomized controlled trial comparing the efficacy of exercise, spinal manipulation, and neuro emotional technique for the treatment of pregnancy-related low back pain

BACKGROUND

This pilot randomized controlled trial evaluated the feasibility of conducting a full scale study and compared the efficacy of exercise, spinal manipulation, and a mind-body therapy called Neuro Emotional Technique for the treatment of pregnancy-related low back pain, a common morbidity of pregnancy.

METHODS

Healthy pregnant women with low back pain of insidious onset were eligible to enroll in the study at any point in their pregnancy. Once enrolled, they remained in the study until they had their babies. Women were randomly allocated into one of three treatment groups using opaque envelopes. The treatment schedule paralleled the prenatal care schedule and women received individualized intervention. Our null hypothesis was that spinal manipulation and Neuro Emotional Technique would perform no better than exercise in enhancing function and decreasing pain. Our primary outcome measure was the Roland Morris Disability Questionnaire and our secondary outcome measure was the Numeric Pain Rating Scale. Intention to treat analysis was conducted. For the primary analysis, regression was conducted to compare groups on the outcome measure scores. In a secondary responder analysis, difference in proportions of participants in attaining 30% and 50% improvement were calculated. Feasibility factors for conducting a future larger trial were also evaluated such as recruitment, compliance to study protocols, cost, and adverse events.

RESULTS

Fifty-seven participants were randomized into the exercise (n = 22), spinal manipulation (n = 15), and Neuro Emotional Technique (n = 20) treatment arms. At least 50% of participants in each treatment group experienced clinically meaningful improvement in symptoms for the Roland Morris Disability Questionnaire. At least 50% of the exercise and spinal manipulation participants also experienced clinically meaningful improvement for the Numeric Pain Rating Scale. There were no clinically meaningful or statistically significant differences between groups in any analysis.

CONCLUSIONS

This pilot study demonstrated feasibility for recruitment, compliance, safety, and affordability for conducting a larger study in the future. Spinal manipulation and exercise generally performed slightly better than did Neuro Emotional Technique for improving function and decreasing pain, but the study was not powered to detect the between-group differences as statistically significant.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT00937365).

Triggers for an episode of sudden onset low back pain: study protocol

Background

Most research on risk factors for low back pain has focused on long term exposures rather than factors immediately preceding the onset of low back pain. The aim of this study is to quantify the transient increase in risk of a sudden episode of low back pain associated with acute exposure to a range of common physical and psychological factors.

Methods/design

This study uses a case-crossover design. One thousand adults with a sudden onset of low back pain presenting to primary care clinicians will be recruited. Basic demographic and clinical information including exposure to putative triggers will be collected using a questionnaire. These triggers include exposure to hazardous manual tasks, physical activity, a slip/trip or fall, consumption of alcohol, sexual activity, being distracted, and being fatigued or tired. Exposures in the case window (0-2 hours from the time when participants first notice their back pain) will be compared to exposures in two control time-windows (one 24-26 hours and another 48-50 hours before the case window).

Discussion

The completion of this study will provide the first-research based estimates of the increase in risk of a sudden episode of acute low back pain associated with transient exposure to a range of common factors thought to trigger low back pain.

A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain

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. Overall, the level of evidence was low. Evidence from randomized controlled trials demonstrates that there is low quality evidence for the effectiveness of exercise therapy compared to usual care, there is low evidence for the effectiveness of behavioural therapy compared to no treatment and there is moderate evidence for the effectiveness of a multidisciplinary treatment compared to no treatment and other active treatments at reducing pain at short-term in the treatment of chronic low back pain. Based on the heterogeneity of the populations, interventions, and comparison groups, we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.

Pharmacotherapy for patellofemoral pain syndrome

BACKGROUND

Patellofemoral pain syndrome (PFPS) is common among adolescents and young adults. It is characterised by pain behind or around the patella and crepitations, provoked by ascending or descending stairs, squatting, prolonged sitting with flexed knees, running and cycling. The symptoms impede function in daily activities or sports. Pharmacological treatments focus on reducing pain symptoms (non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids), or restoring the assumed underlying pathology (compounds containing glucosamine to stimulate cartilage metabolism, anabolic steroids to increase bone density of the patella and build up supporting muscles). In studies, drugs are usually applied in addition to exercises aimed at building up supporting musculature.

OBJECTIVES

This review aims to summarise the evidence of effectiveness of pharmacotherapy in reducing anterior knee pain and improving knee function in people with PFPS.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group and Cochrane Rehabilitation and Related Therapies Field trials registers, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), PEDro (up to January 2004), MEDLINE (1966 to January 2004), EMBASE (1988 to January 2004), and CINAHL (1982 to January 2004).

SELECTION CRITERIA

Controlled trials (randomised or not) comparing pharmacotherapy with placebo, different types of pharmacotherapy, or pharmacotherapy to other therapies for people with PFPS.

DATA COLLECTION AND ANALYSIS

The literature search yielded 780 publications. Eight trials were included, of which three were of high quality. Data were analysed qualitatively using best evidence synthesis, because meta-analysis was impeded by differences in route of administration of drugs, care programs and outcome measures.

MAIN RESULTS

Four trials (163 participants) studied the effect of NSAIDs. Aspirin compared to placebo in a high quality trial produced no significant differences in clinical symptoms and signs. Naproxen produced significant short term pain reduction when compared to placebo, but not when compared to diflunisal. Laser therapy to stimulate blood flow in tender areas led to more satisfied participants than tenoxicam, though not significantly. Two high quality RCTs (84 participants) studied the effect of glycosaminoglycan polysulphate (GAGPS). Twelve intramuscular injections in six weeks led to significantly more participants with a good overall therapeutic effect after one year, and to significantly better pain reduction during one of two activities. Five weekly intra-articular injections of GAGPS and lidocaine were compared with intra-articular injections of saline and lidocaine or no injections, all with concurrent quadriceps training. Injected participants showed better function after six weeks, though only the difference between GAGPS injected participants and non-injected participants was significant. The differences had disappeared after one year. One trial (43 participants) found that intramuscular injections of the anabolic steroid nandrolone phenylpropionate significantly improved both pain and function compared to placebo injections.

REVIEWERS' CONCLUSIONS

There is only limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS. The evidence for the effect of glycosaminoglycan polysulphate is conflicting and merits further investigation. The anabolic steroid nandrolone may be effective, but is too controversial for treatment of PFPS.