Do older adults with chronic low back pain differ from younger adults in regards to baseline characteristics and prognosis?

What do older adults want from spine care?

Introduction

Older adults comprise a large portion of back pain (BP) sufferers but are under-represented in the literature. Patients over age 65 present with different clinical characteristics and psychosocial needs than younger patients. Therefore, recommended patient-centered outcomes for BP may not be relevant to older patients.

Research question

What treatment outcomes are most important to adults over 65 years of age?

Materials and methods

We queried older adults seeking treatment for BP using qualitative methods. Participants were asked about their goals and expectations of treatment in an audio-taped interview. Audiotapes were transcribed, coded and analyzed by the investigators. Using thematic analysis, main themes and constructs were extracted and interpreted by the investigators. From there we were able to generate hypotheses about what older patients want from spine treatment.

Results

For all participants, age played a role in their treatment goals as a moderator or motivator. They were most concerned with returning to usual activities and preventing further physical limitations to maintain independence. Goals that reflect important outcomes such as increasing walking tolerance and improving balance were of particular importance. Confidence in the provider acted as a facilitator of goals.

Discussion and conclusion

Unlike their younger cohorts, they did not emphasize work-related outcomes and pain relief. These findings can be tested in future quantitative studies and will help to develop protocols for outcomes assessment in older adults. This study is a first step towards understanding and improving the quality of care for older patients with back pain.

The relationship between chronic diseases and the intensity and duration of low back pain

BACKGROUND

Low back pain (LBP) is a worldwide problem that affects numerous people and limits their mobility. Several factors, including chronic diseases, increase the risk of developing LBP. To date, the information available about the relationship between chronic diseases and the intensity and duration of LBP is quite limited.

AIM

The aim of the present study was to address the relationship between chronic diseases and both the intensity and duration of LBP.

DESIGN

This is an observational cross-sectional study.

SETTING

The study was conducted in the community of Saudi Arabia.

POPULATION

2181 adult participants (aged 18 years or more, mean age of 33 and standard deviation [SD] of ±11, 61% females) from Saudi Arabia with either recent or recurring LBP participated in the study.

METHODS

The participants of this study were surveyed, and their demographic information was obtained. They were asked whether they had LBP during the past year, and if they had, they were asked about their LBP in terms of the pain intensity on a scale that runs from 0 to 10, where 0 indicates no pain and 10 indicates extreme pain. Further, the participants were asked how long their pain lasted (in days). They were also inquired whether they had any of the following chronic diseases: diabetes mellitus, high blood pressure, hypotension, arthritis, cardiopulmonary diseases, kidney diseases, and hypothyroidism. Logistic regression was used to analyze the relationships between both of LBP's intensity and duration, and the presence of chronic diseases, while adjusting for the potential effect of age and gender.

RESULTS

A total of 2181 adults with either new onset of or recurrent LBP during the past 12 months participated in the present study. Of these, 356 (16%), who had LBP, suffered from one or more of the said chronic diseases. It was found that having one or more chronic diseases had statistically significant relationship with increased LBP's intensity (P=0.002), as well as prolonged duration (P=0.001). In particular, hypertension, arthritis, and hypothyroidism have statistically significant relationship with increased the intensity of the pain (P<0.05). Only, hypertension and arthritis have statistically significant relationship with increased the duration of pain (P≤0.001).

CONCLUSIONS

The presence of chronic diseases was associated with a more intense and longer duration of LBP.

CLINICAL REHABILITATION IMPACT

In view of the results of this study, we expect that those who have chronic diseases will have a longer duration of LBP and more intense pain.

Construct validity of movement-evoked pain operational definitions in older adults with chronic low back pain

OBJECTIVE

Movement-evoked pain (MeP) may predispose the geriatric chronic low back pain (LBP) population to health decline. As there are differing operational definitions for MeP, the question remains as to whether these different definitions have similar associations with health outcomes in older adults with chronic LBP.

DESIGN

Cross-sectional analysis of an observational study.

SETTING

Clinical research laboratory.

SUBJECTS

226 older adults with chronic LBP.

METHODS

This secondary analysis used baseline data from a prospective cohort study (n = 250). LBP intensity was collected before and after the repeated chair rise test, stair climbing test, and 6-minute walk test; MeP change scores (ie, sum of pretest pain subtracted from posttest pain) and aggregated posttest pain (ie, sum of posttest pain) variables were calculated. LBP-related disability and self-efficacy were measured by the Quebec Back Pain Disability Scale (QBPDS) and Low Back Activity Confidence Scale (LOBACS), respectively. Physical function was measured with the Health ABC Performance Battery. Robust regression with HC3 standard errors was used to evaluate adjusted associations between both MeP variables and disability, self-efficacy, and physical function.

RESULTS

Greater aggregated posttest MeP was independently associated with worse disability (b = 0.593, t = 2.913, P = .004), self-efficacy (b = -0.870, t = -3.110, P = .002), and physical function (b = -0.017, t = -2.007, P = .039). MeP change scores were not associated with any outcome (all P > .050).

CONCLUSIONS

Aggregate posttest MeP was linked to poorer health outcomes in older adults with chronic LBP, but MeP change scores were not. Future studies should consider that the construct validity of MeP paradigms partially depends on the chosen operational definition.

Movement-Evoked Pain Versus Widespread Pain: A Longitudinal Comparison in Older Adults With Chronic Low Back Pain From the Delaware Spine Studies

It is currently unknown which pain-related factors contribute to long-term disability and poorer perceived health among older adults with chronic low back pain (LBP). This investigation sought to examine the unique influence of movement-evoked pain (MeP) and widespread pain (WP) on longitudinal health outcomes (ie, gait speed, perceived disability, and self-efficacy) in 250 older adults with chronic LBP. MeP was elicited with 3 standardized functional tests, while presence of WP was derived from the McGill Pain Map. Robust regression with HC3 standard errors was used to examine associations between these baseline pain variables and health outcomes at 12-month follow-up. Covariates for these models included age, sex, body mass index, resting and recall LBP intensity, LBP duration, depression, pain catastrophizing, and baseline outcome (eg, baseline gait speed). Greater MeP was independently associated with worse 12-month LBP-related disability (b = .384, t = 2.013, P = .046) and poorer self-efficacy (b = -.562, t = -2.074, P = .039); but not gait speed (P > .05). In contrast, WP and resting and recall LBP intensity were not associated with any prospective health outcome after adjustment (all P > .05). Compared to WP and resting and recall LBP intensity, MeP is most strongly related to longitudinal health outcomes in older adults with chronic LBP. PERSPECTIVE: This article establishes novel independent associations between MeP and worse perceived disability and self-efficacy at 12-months in older adults with chronic LBP. MeP likely has biopsychosocial underpinnings and consequences and may therefore be an important determinant of health outcomes in LBP and other geriatric chronic pain populations.

Is the combination of exercise therapy and health education more effective than usual medical care in the prevention of non-specific back pain? A systematic review with meta-analysis

BACKGROUND

Clinical practice guidelines emphasize the importance of the prevention and treatment of non-specific back pain through exercise therapy and health education. However, it has not yet been confirmed that the combination of exercise plus education is more effective than usual medical care.

OBJECTIVE

The aim of this study was to determine if the combination of exercise plus education is more effective for the prevention of non-specific back pain than usual medical care.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Web of Science and Medline was conducted with the terms Back Pain, Neck Pain, Musculoskeletal Pain, Exercise, Exercise Therapy, Health Education, Cognitive Behavioral Therapy, Primary Prevention, Secondary Prevention and Clinical Trial. The inclusion criteria were: articles published from 2016 to 2021, the intervention included exercise and education, and the sample consisted of non-specific back pain patients.

RESULTS

A total of 4 randomized controlled trials were selected (average PEDro score 6.5 points). The meta-analysis showed statistically significant differences in the pain intensity, standardized mean differences was found to be -0.75 (95% CI = -1.41 to -0.08; p = 0.03); and in disability, standardized mean differences was found to be -0.24 (95% CI = -0.38 to -0.1; p = 0.001).

CONCLUSIONS

Interventions combining exercise and education seem to have a greater preventive effect on non-specific back pain than usual medical care.Key messagesExercise therapy and health education combination prevent better non-specific back pain than usual care.Combining exercise with educational interventions has a higher improvement on disability and kinesophobia than usual care.

Low back pain in the Bangladeshi adult population: a cross-sectional national survey

OBJECTIVE

Low back pain (LBP) is a common musculoskeletal disorder. This study aims to determine the residence-specific and sex-specific prevalence and the factors associated with LBP in Bangladesh.

METHODS

The study subjects (aged ≥18 years) were identified from 20 primary sampling units of the national census following a cross-sectional multistage stratified sampling design. We considered the mechanical type of LBP for this study. A Bangla version of the modified Community Oriented Programme for Control of Rheumatic Disorders questionnaire was used. A team of trained field workers, rheumatology residents and rheumatologists collected the data. Analysis was done using weighted data.

RESULTS

Two thousand subjects were approached, but 1843 could be screened. Among them, 561 had musculoskeletal disorders, and 343 were diagnosed with LBP. The weighted prevalence of LBP was 18.5% (95% CI: 11.8% to 25.2%) and age-standardised prevalence of LBP was 19.4% (95% CI: 14.0% to 24.8%), which was higher in women (27.2%, 19.3% to 35.1%) than men (14.0%, 8.7% to 19.3%). The prevalence persistently increased from age group 18-34 years (10.5%, 5.7 to 15.4) to ≥55 years (27.8%, 16.1% to 39.5%). People with no education had the highest prevalence (31.3%, 22.3% to 40.4%). The prevalence did not differ between urban and rural residential locations. Four factors were significantly associated with LBP: age (adjusted odds ratio: 2.4, 95% CI: 1.7 to 3.4), female sex (2.2, 1.5 to 3.3), absence of formal education (2.3, 1.6 to 3.3) and hypertension (1.7, 1.1 to 2.6).

CONCLUSION

LBP is a common problem in Bangladeshi adults. The factors identified are age, female sex, no formal education and hypertension. These should be addressed adequately to prevent and treat LBP.

Roland-Morris disability questionnaire is bidimensional and has 16 items when applied to community-dwelling older adults with low back pain

PURPOSE

To explore the evidence of the internal structure validity of the Roland-Morris Disability Questionnaire in older adults with low back pain.

METHODS

This was a cross-sectional study of psychometric testing involving 528 older adults with low back pain. Internal structure validity was explored by exploratory factor analysis and semi-confirmatory factor analysis. Reliability was verified using Kuder-Richardson Formula 20, Cronbach's alpha, and McDonald's omega. Replicability was observed by the generalized H index.

RESULTS

Roland-Morris Disability Questionnaire displayed two factors that assess "functional capacity" and "mobility". Eight items were excluded for presenting cross-loading (2 and 10), inadequate loading factors and communalities (18, 24, 13, and 12), or did not relate to the latent construct (15 and 22). Semi-confirmatory factor analysis indicated that the questionnaire had a good fitness model [X² = 153.698 (p = 0.00001); RMSEA = 0.037; RMSR = 0.06; WRMR = 0.04; NNFI = 0.987; GFI = 0.979; AGFI = 0.971]. Reliability was acceptable (KR-20 = 0.79; Cronbach's alpha = 0.86; McDonald's Omega = 0.85), but replicability was poor in both factors (G-H factor 1 = 0.816-0.655; G-H factor 2 = 0.889-0.775).

CONCLUSIONS

The most appropriate version of the Roland-Morris Disability Questionnaire to apply to older adults with low back pain has 16 items and assesses functional capacity and mobility. IMPLICATIONS FOR REHABILITATIONThe RMDQ-16 is the most appropriate version of the RMDQ to use in older adults with LBP;The RMDQ-16 is bidimensional and assesses "functional capacity" and "mobility";The poor replicability of the RMDQ-16 indicates that it will probably not be stable across studies, but it can be useful in a clinical setting.

Feedback on Trunk Movements From an Electronic Game to Improve Postural Balance in People With Nonspecific Low Back Pain: Pilot Randomized Controlled Trial

Background

Postural balance is compromised in people with low back pain, possibly by changes in motor control of the trunk. Augmenting exercising interventions with sensor-based feedback on trunk posture and movements might improve postural balance in people with low back pain.

Objective

We hypothesized that exercising with feedback on trunk movements reduces sway in anterior-posterior direction during quiet standing in people with low back pain. Secondary outcomes were lumbar spine and hip movement assessed during box lift and waiter bow tasks, as well as participant-reported outcomes. Adherence to the exercising intervention was also examined.

Methods

A randomized controlled trial was conducted with the intervention group receiving unsupervised home exercises with visual feedback using the Valedo Home, an exergame based on 2 inertial measurement units. The control group received no intervention. Outcomes were recorded by blinded staff during 4 visits (T1-T4) at University Hospital Zurich. The intervention group performed 9 sessions of 20 minutes in the 3 weeks between T2 and T3 and were instructed to exercise at their own convenience between T3 and T4. Postural balance was assessed on a force platform. Lumbar spine and hip angles were obtained from 3 inertial measurement units. The assessments included pain intensity, disability, quality of life, and fear of movement questionnaires.

Results

A total of 32 participants with nonspecific low back pain completed the first assessment T1, and 27 (84%) participants were randomized at T2 (n=14, 52% control and n=13, 48% intervention). Intention-to-treat analysis revealed no significant difference in change in anterior-posterior sway direction during the intervention period with a specified schedule (T2-T3) between the groups (W=99; P=.36; r=0.07). None of the outcomes showed significant change in accordance with our hypotheses. The intervention group completed a median of 61% (55/90; range 2%-99%) of the exercises in the predefined training program. Adherence was higher in the first intervention period with a specified schedule.

Conclusions

The intervention had no significant effect on postural balance or other outcomes, but the wide range of adherence and a limited sample size challenged the robustness of these conclusions. Future work should increase focus on improving adherence to digital interventions.

Trial Registration

ClinicalTrials.gov NCT04364243; https://clinicaltrials.gov/ct2/show/NCT04364243

International Registered Report Identifier (IRRID)

RR2-10.2196/26982

Comparing Perceived Pain Impact Between Younger and Older Adults With High Impact Chronic Pain: A Cross-Sectional Qualitative and Quantitative Survey

High impact chronic pain (HICP) is a recently proposed concept for treatment stratifying patients with chronic pain and monitoring their progress. The goal is to reduce the impact of chronic pain on the individual, their family, and society. The US National Pain Strategy defined HICP as the chronic pain associated with substantial restrictions on participation in work, social, and self-care activities for at least 6 months. To understand the meaning and characteristics of HICP from the younger (<65 years old) and older adults (≥65 years old) with chronic pain, our study examined patients' perceived pain impact between the two age groups. We also characterize the degree of pain impact, assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI), between adults and older adults with HICP. We recruited patients at a tertiary pain clinic. The survey included open-ended questions about pain impact, the Graded Chronic Pain Scale-Revised to identify patients' meeting criteria for HICP, and the Patient-Reported Outcomes Measurement Information System (PROMIS^®) 8-item PI short form (v.8a). A total of 55 younger adults (65.5% women, 72.7% HICP, mean age = 55.0 with SD of 16.2) and 28 older adults (53.6% women, 64.3% HICP, mean age = 72.6 with SD of 5.4) with chronic pain participated in this study. In response to an open-ended question in which participants were asked to list out the areas of major impact pain, those with HICP in the younger group most commonly listed work, social activity, and basic physical activity (e.g., walking and standing); for those in the older group, basic physical activity, instrumental activity of daily living (e.g., housework, grocery shopping), and participating in social or fun activity for older adults with HICP were the most common. A 2 × 2 ANOVA was conducted using age (younger adults vs. older adults) and HICP classification (HICP vs. No HICP). A statistically significant difference was found in the PROMIS-PI T-scores by HICP status (HICP: M = 58.4, SD = 6.3; No HICP: M = 67.8, SD = 6.3), but not by age groups with HICP. In conclusion, perceived pain impacts were qualitatively, but not quantitatively different between younger and older adults with HICP. We discuss limitations and offer recommendations for future research.

Intrarater and interrater agreement of a 6-item movement control test battery and the resulting diagnosis in patients with nonspecific chronic low back pain

OBJECTIVE

To investigate the intrarater and interrater agreement of a 6-item test battery in nonspecific chronic low back pain (LBP) and investigate the agreement between raters to assign the resulting movement control (MC) diagnoses.

METHODS

Thirty patients with chronic LBP (18-30 years) were included in this study. Six raters were trained and rated the videos of the patients during the execution of the tests. After one week, the raters re-watched the videos and repeated the examination. A diagnosis of MC was assigned for each patient. Agreement was analyzed using weighted kappa and prevalence-adjusted and bias-adjusted kappa (PABAK) coefficients.

RESULTS

We showed an acceptable intrarater agreement for the 6-item test battery for four out of six raters, except for one test: prone knee flexion. The results of the interrater agreement between the three pairs of raters showed acceptable agreement levels (k > 0.4), except for two tests, "rocking on all four backward" and "prone knee flexion test." For the diagnosis of MC impairment, acceptable agreement levels (k > 0.4) were observed for five out of six raters for intrarater agreement. For interrater assessment, we found an acceptable agreement between pairs of raters.

CONCLUSION

We showed acceptable levels of agreement between the intrarater and interrater for a 6-item test battery to identify MC impairment, except for two tests. Agreement in the MC diagnoses achieved acceptable levels for five of the six raters (intrarater) and all three pairs of raters (interrater). Such results support the use of the 6-item test battery to detect MC impairment.

Impaired static postural control correlates to the contraction ability of trunk muscle in young adults with chronic non-specific low back pain: A cross-sectional study

INTRODUCTION

Patients with chronic non-specific low back pain (CNSLBP) were found with impaired postural control in previous studies. Since the trunk muscle take important efforts on core stability, the study aimed to examine the relationships of postural control during stance tasks and the contractility of trunk muscle in young adults with CNSLBP and without.

METHODS

Healthy individuals (n = 25) and individuals with CNSLBP (n = 30) were included. The thickness of the bilateral transversus abdominis (TrA) and lumbar multifidus (MF) was measured during rest and maximal voluntary contraction, and the change percentages (TrA%, MF%) were calculated. Regarding postural control, COP path length and sway area during the stance tasks were measured thrice in each group.

RESULTS

The bilateral TrA% of the CNSLBP group was less than that of the HC group (p < 0.05). The bilateral TrA% of the CNSLBP group was less than that of the HC group (p < 0.05). The bilateral MF% showed no significantly different(p > 0.05) between the two groups. Compared with healthy controls, CNSLBP patients resulted larger path length and sway area of COP during most of static stance tasks. During the EO task in the CNSLBP group, TrA% was found correlate to COP path length (p < 0.05); the right MF% was correlated with COP sway area (p < 0.05). No significant correlations appeared in the healthy controls (p > 0.05).

CONCLUSIONS

Compared with healthy individuals, impaired postural control during static stance with eyes open in patients with CNSLBP was likely to be related to the poor contraction ability of bilateral transversus abdominis and correlated to the normal contraction ability of right lumbar multifidus.

The Use of Virtual Reality in Back Pain Rehabilitation: A Systematic Review and Meta-Analysis

This systematic review aimed to synthesize the existing evidence of extended reality (XR) on pain and motor function outcomes in patients with back pain. Following the Cochrane guidelines, relevant articles of any language were selected by 2 independent reviewers from CINAHL, Cochrane, Embase, Medline and Web of Knowledge databases. Of 2,050 unique citations, 24 articles were included in our review. These studies included a total of 900 back pain patients. Despite broader XR search, all interventions were virtual reality (VR) based and involved physical exercises (n = 17, 71%), hippotherapy (n = 4, 17%), motor imagery (n = 1, 4%), distraction (n = 1, 4%), and cognitive-behavior therapy (n = 1, 4%). Sixteen controlled studies were included in a meta-analysis which suggested that VR provides a significant improvement in terms of back pain intensity over control interventions (Mean Difference: -0.67; 95% CI: -1.12 to -0.23; I² = 85%). Almost all included studies presented high risk of bias, highlighting the need to improve methodology in the examination of VR interventions. While the specific set of studies showed high heterogeneity across several methodological factors, a tentative conclusion could be drawn that VR was effective improving back pain intensity and tends to have a positive effect on improving other pain outcomes and motion function. PERSPECTIVE: Extended reality technologies have appeared as interesting nonpharmacological options for the treatment of back pain, with the potential to minimise the need for opioid medications. Our systematic review summarised existing applications of extended reality for back pain and proposed a few recommendations to direct further studies in the field.

Distinguishing chronic low back pain in young adults with mild to moderate pain and disability using trunk compliance

Chronic low back pain (cLBP) rates among younger individuals are rising. Although pain and disability are often less severe, underlying changes in trunk behavior may be responsible for recurrence. We examine the biomarker capacity of a simple Trunk Compliance Index (TCI) to distinguish individuals with and without cLBP. A random subset (n = 49) of the RELIEF RCT were matched to healthy controls for sex, age, height and weight. We measured TCI (as displacement/ weight-normalized perturbation force) using anthropometrically-matched, suddenly-applied pulling perturbations to the trunk segment, randomized across three planes of motion (antero-posterior, medio-lateral, and rotational). Mean differences between cLBP, sex and perturbation direction were assessed with repeated-measures analysis of variance. Discriminatory accuracy of TCI was assessed using Receiver Operator Characteristic (ROC) analysis. Baseline characteristics between groups were equivalent (x̅ [range]): sex (57% female / group), age (23.0 [18-45], 22.8 [18-45]), height, cm (173.0 [156.5-205], 171.3 [121.2-197], weight, kg (71.8 [44.5-116.6], 71.7 [46.8-117.5]) with cLBP associated with significantly lower TCI for 5 of 6 directions (range mean difference, - 5.35: - 1.49, range 95% CI [- 6.46: - 2.18 to - 4.35: - 0.30]. Classification via ROC showed that composite TCI had high discriminatory potential (area under curve [95% CI], 0.90 [0.84-0.96]), driven by TCI from antero-posterior perturbations (area under curve [95% CI], 0.99 [0.97-1.00]). Consistent reductions in TCI suggests global changes in trunk mechanics that may go undetected in classic clinical examination. Evaluation of TCI in younger adults with mild pain and disability may serve as a biomarker for chronicity, leading to improved preventative measures in cLBP.Trial Registration and Funding RELIEF is registered with clinicaltrials.gov (NCT01854892) and funded by the NIH National Center for Complementary & Integrative Health (R01AT006978).

Effect of Spinal Manipulative and Mobilization Therapies in Young Adults With Mild to Moderate Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

Low back pain (LBP) is one of the most common reasons for seeking medical care. Manual therapy is a common treatment of LBP, yet few studies have directly compared the effectiveness of thrust (spinal manipulation) vs nonthrust (spinal mobilization) techniques.

OBJECTIVE

To evaluate the comparative effectiveness of spinal manipulation and spinal mobilization at reducing pain and disability compared with a placebo control group (sham cold laser) in a cohort of young adults with chronic LBP.

DESIGN, SETTING, AND PARTICIPANTS

This single-blinded (investigator-blinded), placebo-controlled randomized clinical trial with 3 treatment groups was conducted at the Ohio Musculoskeletal and Neurological Institute at Ohio University from June 1, 2013, to August 31, 2017. Of 4903 adult patients assessed for eligibility, 4741 did not meet inclusion criteria, and 162 patients with chronic LBP qualified for randomization to 1 of 3 treatment groups. Recruitment began on June 1, 2013, and the primary completion date was August 31, 2017. Data were analyzed from September 1, 2017, to January 20, 2020.

INTERVENTIONS

Participants received 6 treatment sessions of (1) spinal manipulation, (2) spinal mobilization, or (3) sham cold laser therapy (placebo) during a 3-week period.

MAIN OUTCOMES AND MEASURES

Coprimary outcome measures were the change from baseline in Numerical Pain Rating Scale (NPRS) score over the last 7 days and the change in disability assessed with the Roland-Morris Disability Questionnaire (scores range from 0 to 24, with higher scores indicating greater disability) 48 to 72 hours after completion of the 6 treatments.

RESULTS

A total of 162 participants (mean [SD] age, 25.0 [6.2] years; 92 women [57%]) with chronic LBP (mean [SD] NPRS score, 4.3 [2.6] on a 1-10 scale, with higher scores indicating greater pain) were randomized. Fifty-four participants were randomized to the spinal manipulation group, 54 to the spinal mobilization group, and 54 to the placebo group. There were no significant group differences for sex, age, body mass index, duration of LBP symptoms, depression, fear avoidance, current pain, average pain over the last 7 days, and self-reported disability. At the primary end point, there was no significant difference in change in pain scores between spinal manipulation and spinal mobilization (0.24 [95% CI, -0.38 to 0.86]; P = .45), spinal manipulation and placebo (-0.03 [95% CI, -0.65 to 0.59]; P = .92), or spinal mobilization and placebo (-0.26 [95% CI, -0.38 to 0.85]; P = .39). There was no significant difference in change in self-reported disability scores between spinal manipulation and spinal mobilization (-1.00 [95% CI, -2.27 to 0.36]; P = .14), spinal manipulation and placebo (-0.07 [95% CI, -1.43 to 1.29]; P = .92) or spinal mobilization and placebo (0.93 [95% CI, -0.41 to 2.29]; P = .17).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, neither spinal manipulation nor spinal mobilization appeared to be effective treatments for mild to moderate chronic LBP.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01854892.

BAck complaints in the elders - chiropractic (BACE-C): protocol of an international cohort study of older adults with low back pain seeking chiropractic care

Background

Low back pain is a common condition among older adults that significantly influences physical function and participation. Compared to their younger counterparts, there is limited information available about the clinical course of low back pain in older people, in particularly those presenting for chiropractic care. Improving our understanding of this patient population and the course of their low back pain may provide input for studies researching safer and more effective care than is currently provided.

Objectives

The primary objectives are to examine the clinical course over one year of pain intensity, healthcare costs and pain, functional status and recovery rates of low back pain in people 55 years and older who visit a chiropractor for a new episode of low back pain.

Methods

An international prospective, multi-center cohort study with one-year follow-up. Chiropractic practices are to be recruited in the Netherlands, Sweden, United Kingdom and Australia. Treatment will be left to the discretion of the chiropractor. Inclusion/Exclusion criteria: Patients aged 55 and older who consult a chiropractor for a new episode of low back pain, meaning low back pain for the first time or those patients who have not been to a chiropractor in the previous six months. This is independent of whether they have seen another type of health care provider for the current episode. Patients who are unable to complete the web-based questionnaires because of language restrictions or those with computer literacy restrictions will be excluded as well as those with cognitive disorders. In addition, those with a suspected tumor, fracture, infection or any other potential red flag or condition considered to be a contraindication for chiropractic care will be excluded. Data will be collected using online questionnaires at baseline, and at 2 and 6 weeks and at 3, 6, 9 and 12 months.

Discussion

This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials.

Trial registration

Nederlandse Trial Registrar NL7507.

[Mechanisms of pathogenetic treatment with interstitial electrostimulation for spinal pain syndrome]

BACKGROUND

Interstitial electrostimulation (IES) is used to treat spinal pain syndromes. The phenomena occurring in tissue around the electrode that is connected to a vertebra remain unknown.

AIM

To reveal the mechanisms of action of IES on inflammatory and dystrophic phenomena and blood flow in osseous and paravertebral tissues in low back pain syndrome.

METHODS

Examinations were made in 64 patients with back pain of vertebral genesis in an exacerbation or incomplete remission with intervertebral disc protrusions. Two homogeneous groups of patients treated with different techniques of electrotherapy were identified. A study group was treated with IES, in which the active electrode as a sterile injection needle was brought into the focus of pathology in contact with the diseased vertebra. A control group received a cutaneous procedure with a 50 Hz current with the same physical parameters. Blood flow in the bone and the adjacent tissues and the intensity of pain syndrome were studied. That in the vertebrae was investigated using needle-rheography and polarography.

RESULTS

The intensity of pain depends on circulatory disturbances affecting the vertebral tissues, where a focus of inflammation is formed with signs of free radicals, acidosis, and edema. IES could relieve pain in 90.5% of patients. At the same time, blood circulation in the vertebral tissues considerably improved. Cutaneous electrostimulation was not found to have a substantial effect. The result of the therapeutic effect can be explained by electrochemical phenomena in the plasma from the vessels in the focus of inflammation and by electrophysical processes on the cell membranes of the tissue around its anode introduced.

CONCLUSION

IES is a pathogenetic treatment. In this case, the active anode electrode must be inserted into the focus of pathology, resulting in a contact with the diseased vertebra.

An observational study of pain self-management strategies and outcomes: does type of pain, age, or gender, matter?

Background and aims Acute pain is differentiated from chronic pain by its sudden onset and short duration; in contrast, chronic pain is characterized by a duration of at least several months, typically considered longer than normal healing time. Despite differences in definition, there is little information on how types of self-management strategies or outcomes differ when pain is chronic rather than acute. Additionally, age and gender are thought to be related to types of strategies used and outcomes. However, strategies used and outcomes can be influenced by level of education, socioeconomic status, occupation, and access to the health care system, which can confound associations to type of pain, age or gender. The purpose of this study was to examine the association of strategies used for pain self-management and outcomes with type of pain, acute or chronic, age, or gender in a socioeconomically homogenous population, pharmacists. Methods Pharmacists with acute or chronic pain and a valid email completed an on-line questionnaire on demographic characteristics, pain characteristics, pharmacological and non-pharmacological strategies for managing pain, and outcomes (e.g. pain intensity). Univariate analysis was conducted by stratifying on type of pain (acute or chronic), then stratifying on gender (men vs. women) and age (younger vs. older). The a priori alpha level was 0.05. Results A total of 366 pharmacists completed the questionnaire, 212 with acute pain (average age=44±12.1; 36% men) and 154 with chronic pain (average age=53±14.0; 48% men). The chronic pain group reported substantially higher levels of pain before treatment, level of post-treatment pain, level of pain at which sleep was possible, and goal pain levels (effect sizes [ES's]=0.37-0.61). The chronic pain group were substantially more likely to use prescription non-steroidal anti-inflammatory medications (NSAIDS), opioids, and non-prescription pain relievers (ES's=0.29-0.80), and non-medical strategies (ES's=0.56-0.77). Participants with chronic pain also were less confident (ES=0.54) and less satisfied (ES=0.52). In contrast, there were no differences within either the acute or chronic pain groups related to gender and outcomes. In the acute pain group, there also were no gender differences related to management strategies. However, younger age in the acute pain group was associated with use of herbal remedies and use of rest. Within the chronic pain group, men were more likely to use NSAIDS and women more likely to use hot/cold packs or massage while older participants were more likely to use massage. Variability in post-treatment level of pain and percent relief was high in all groups (coefficient of variation=25%-100%). Conclusions The differences between acute and chronic pain were substantial and included differences in demographic characteristics, pain characteristics, management strategies used, and outcomes. In contrast, few associations between age and gender with either management strategies or outcomes were identified, although the variability was high. Implications When managing or researching pain management, acute pain should be differentiated from chronic pain. Because of the substantial variability within the gender and age groups, an individual approach to pain management irrespective of age and gender may be most useful.