Mechanisms of low back pain: a guide for diagnosis and therapy

An investigation of the mechanism of adjacent segment disease in a porcine spine model

BACKGROUND

Fusion changes the biomechanics of the spine leading to the potential development of adjacent segment disease. Despite many studies on adjacent segment disease, it is largely unknown how spinal fixation affects the mechanical properties of the adjacent disc. The purpose of this study was to assess whether axial compression causes mechanical disruption to the annulus when the caudal spinal level is immobilized or injured.

METHODS

Fifty-two porcine spines were assigned to one of four conditions: 1) control; 2) injured (18.5-gauge needle inserted into the nucleus of cervical 4/5); 3) immobilized (18-gauge steel wire wrapped around the transverse and spinous processes of cervical 4/5); and 4) injured+immobilized. Each specimen was then subjected to 0.5 Hz cyclic compression (300-1200N) for two hours. Post-compression, three annular samples were dissected from the cervical 3/4 disc (adjacent to immobilized and/or injured level) and mechanically tested. The same loading protocol and annular testing was also conducted in eight human cadaveric lumbar spines.

FINDINGS

Immobilization and injury resulted in a reduction in adjacent disc lamellar strength including toe region stress (p < 0.001), initial failure stress (p = 0.03), and ultimate stress (p = 0.004), with immobilization having the greatest impact. Similar findings were observed in the human cadaver samples with reduced toe region strength in the injured+ immobilized samples compared to the control (p = 0.049).

INTERPRETATION

The current study provides empirical evidence of decreased lamellar strength in the disc adjacent to an immobilized and/or injured level following prolonged cyclic axial loading, lending mechanistic insight into the development of adjacent segment disease.

Computed tomography of the equine caudal spine and pelvis. Pathological findings in 56 clinical cases (2018-2023)

BACKGROUND

Computed tomography (CT) of the axial skeleton is increasing across many equine hospitals. CT of the pelvis and caudal spine in a large group of clinical cases has not been reported previously.

OBJECTIVE

To describe the pathological lesions identified in the caudal spine/pelvis in horses and ponies undergoing CT spine of this region.

STUDY DESIGN

A retrospective case series.

METHODS

Horses with CT imaging of the caudal spine/pelvis were included. Horses aged under 6 months and those with CT examinations performed post-mortem were excluded.

RESULTS

Fifty-six horses met the inclusion criteria. Ages ranged from 8 months to 20 years and bodyweights from 85 to 680 kg (mean 488 kg). Horses presented predominantly for lameness (30/56) and poor performance (18/56). Osseous pathology was identified in 41/56 horses; including osteoarthritis of the sacroiliac joint(s) (n: 28), pathology of the intervertebral disc joint(s) (n: 12), pelvic fractures (n: 9), osteoarthritis of the coxofemoral joint(s) (n: 8), ventral spondylosis (n: 6), acetabular rim fracture (n: 2), dislocation of coxofemoral joint(s) (n: 2), and dorsal dermal sinus of the sacrum (n: 1).

MAIN LIMITATIONS

The relationship between CT imaging findings and clinical signs in horses remains unclear. Further work is required to describe the relationship between congenital, developmental, and acquired changes in the caudal spine and pelvis, and clinical signs.

CONCLUSIONS

CT of the caudal spine and pelvis can be utilised in horses and ponies for diagnosing a range of clinical disorders that may be causing 'lumbosacroiliac pain', poor performance, hindlimb lameness, and stiffness. The pathologies we observed were diverse and many patients had multiple lesions.

Development and validation of AI-based automatic measurement of coronal Cobb angles in degenerative scoliosis using sagittal lumbar MRI

OBJECTIVES

Severity of degenerative scoliosis (DS) is assessed by measuring the Cobb angle on anteroposterior radiographs. However, MRI images are often available to study the degenerative spine. This retrospective study aims to develop and evaluate the reliability of a novel automatic method that measures coronal Cobb angles on lumbar MRI in DS patients.

MATERIALS AND METHODS

Vertebrae and intervertebral discs were automatically segmented using a 3D AI algorithm, trained on 447 lumbar MRI series. The segmentations were used to calculate all possible angles between the vertebral endplates, with the largest being the Cobb angle. The results were validated with 50 high-resolution sagittal lumbar MRI scans of DS patients, in which three experienced readers measured the Cobb angle. Reliability was determined using the intraclass correlation coefficient (ICC).

RESULTS

The ICCs between the readers ranged from 0.90 (95% CI 0.83-0.94) to 0.93 (95% CI 0.88-0.96). The ICC between the maximum angle found by the algorithm and the average manually measured Cobb angles was 0.83 (95% CI 0.71-0.90). In 9 out of the 50 cases (18%), all readers agreed on both vertebral levels for Cobb angle measurement. When using the algorithm to extract the angles at the vertebral levels chosen by the readers, the ICCs ranged from 0.92 (95% CI 0.87-0.96) to 0.97 (95% CI 0.94-0.98).

CONCLUSION

The Cobb angle can be accurately measured on MRI using the newly developed algorithm in patients with DS. The readers failed to consistently choose the same vertebral level for Cobb angle measurement, whereas the automatic approach ensures the maximum angle is consistently measured.

CLINICAL RELEVANCE STATEMENT

Our AI-based algorithm offers reliable Cobb angle measurement on routine MRI for degenerative scoliosis patients, potentially reducing the reliance on conventional radiographs, ensuring consistent assessments, and therefore improving patient care.

KEY POINTS

• While often available, MRI images are rarely utilized to determine the severity of degenerative scoliosis. • The presented MRI Cobb angle algorithm is more reliable than humans in patients with degenerative scoliosis. • Radiographic imaging for Cobb angle measurements is mitigated when lumbar MRI images are available.

Medical Cannabis and Its Efficacy/Effectiveness for the Treatment of Low-Back Pain: a Systematic Review

PURPOSE OF REVIEW

This systematic review aims to inform the current state of evidence about the efficacy and effectiveness of medical cannabis use for the treatment of LBP, specifically on pain levels and overall opioid use for LBP. Searches were conducted in MEDLINE (PubMed), Embase, and CINAHL. The search was limited to the past 10 years (2011-2021). Study inclusion was determined by the critical appraisal process using the Joanna Briggs Institute framework. Only English language articles were included. Participant demographics included all adult individuals with LBP who were prescribed medical cannabis for LBP and may be concurrently using opioids for their LBP. Study quality and the risk of bias were both evaluated. A narrative synthesis approach was used.

RECENT FINDINGS

A total of twelve studies were included in the synthesis: one randomized controlled trial (RCT), six observational studies (one prospective, four retrospective, and one cross-over), and five case studies. All study results, except for the RCT, indicated a decrease in LBP levels or opioid use over time after medical cannabis use. The RCT reported no statistically significant difference in LBP between cannabis and placebo groups. Low back pain (LBP) affects 568 million people worldwide. In the United States, LBP treatment represents more than half of regular opioid users. With the opioid epidemic, alternative methods, particularly medical cannabis, is now increasingly sought by practicing physicians and patients. Due to its infancy, there is minimal high-quality evidence to support medical cannabis use as a first line treatment for LBP.

Symptom-imaging correlation in lumbar spine pain

Lumbar spine MRI is associated with a high prevalence of morphological abnormalities in both symptomatic and asymptomatic individuals. A difficult challenge, therefore, is distinguishing the relevant findings causing symptoms from incidental findings. The accurate diagnosis of pain generator is important because misdiagnosis can negatively impact patient management and outcome. Spine physicians use clinical symptoms and signs to interpret lumbar spine MRI and make treatment decisions. Symptom-MRI correlation enables the targeted inspection of images for pain generator. Radiologists can also use clinical information to improve diagnostic confidence and the value of dictated reports. Because high-quality clinical information may be difficult to obtain, radiologists often generate lists of lumbar spine abnormalities that are otherwise difficult to rank as pain generators. Based on the literature review, this article attempts to distinguish the MRI abnormalities that may represent incidental findings from the abnormalities that are more commonly associated with lumbar spine-related symptoms.

The Potency of Platelet-Rich Plasma for Chronic Low Back Pain: A Systematic Review and Metaanalysis of Randomized Controlled Trial

Low back pain is one of the leading causes of disability in the world. Regenerative medicine can be one of the novel treatment breakthroughs in patients with low back pain, yet its use is still debatable. We performed a systematic evaluation and meta-analysis to determine the efficacy of platelet-rich plasma (PRP) treatment for patients with chronic low back pain. Comprehensive database searches were performed in four databases. This study was conducted and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses Guideline and registered to PROSPERO. We included and examined randomized controlled trials that looked into research employing PRP for patients with chronic low back pain. Outcomes of interest include clinical enhancement of pain, which is demonstrated in pain scores. Three studies were included comprising 138 patients with chronic low back pain. After 1, 3, and 6 months after injection, there was a substantial reduction in the pain score difference between the PRP and control groups, demonstrating PRP's superiority over the control group in the treatment of chronic low back pain. PRP injection significantly enhances chronic low back pain in the first, third, and sixth months after injection compared to controls.

Can interoceptive sensitivity provide information on the difference in the perceptual mechanisms of recurrent and chronic pain? Part I. A retrospective clinical study related to multidimensional pain assessment

OBJECTIVES

Although neurobiological research has shown that interoception plays a role in the perception of pain and its chronification, the relationship between interoceptive sensitivity and pain has not been definitively confirmed by clinical studies. The aim of this study was therefore to better understand the relationship between interoceptive sensitivity, somatization, and clinical pain, and to identify any differences in the interoceptive sensitivity of patients with recurrent vs. chronic pain.

METHODS

Scores from 43 Chronic pain subjects, assessed using ICD-11 Criteria; 42 healthy subjects (without pain or psychiatric disorders); and 38 recurrent pain subjects on the Multidimensional Assessment of Interoceptive Awareness (MAIA), Body Perception Questionnaire (BPQ-SF), Somatosensory amplification scale (SSAS), Patient Health Questionnaire (PHQ-15), Symptom Checklist-Revised (SCL-90-R), and Italian Pain Questionnaire (IPQ) were compared.

RESULTS

Negative attention to the body was indicated by higher scores of psychosomatic dimensions as SSAS, SCL90R somatization, and PHQ-15 in recurrent, but especially chronic pain (p<0.000 for all). An increase in psychosomatic dimension scores (i.e., somatization, somatosensory amplification) was associated with an increase in both autonomic nervous system reactivity (ANSR) dimension scores and the negative influence of the Not-worrying, attention regulation and trusting of the MAIA. In contrast, the presence of pain and scores for its dimensions with associated with lower supra-diaphragmatic activity as per the BPQ.

CONCLUSIONS

Pain chronification might depend on both the impairment of interoceptive sensitivity and an increase on psychosomatic dimensions via modification of ANSR hyperactivity and a reduction of the MAIA Not-worrying dimension.

Effectiveness of Local Cryotherapy Treatment with the Use of Carbon Dioxide and Liquid Nitrogen Among Patients with Low Back Pain Syndrome

Introduction: Low back pain syndromes (LBPS) are common. One of the methods of treating LBPS is local cryotherapy, which can be based on various cooling substances. In the available literature, it is suggested that effective cold treatment may depend on the type and temperature of the cooling substance used. Research objective: The aim of the study was to evaluate the effectiveness of 2 local cryotherapy (Carbon Dioxide and Liquid Nitrogen) types among patients with low back pain syndrome (LBPS). Materials and methods: The study included 60 patients diagnosed with chronic LBPS of discopathic origin. Patients were randomised into 2 study groups. Local cryotherapy treatment with Carbon Dioxide was used in the 1st group (G1), while in the 2nd (G2), cryotherapy treatment with applied Liquid Nitrogen. Two measurements were taken, before and after 2 weeks treatment. The following were used for assessment: centralisation of symptoms (Pain Drawings), pain intensity (Numeral Rating Scale), duration of the current pain episode (Quebec Task Force Classification), level of disability (Roland-Morris Disability Questionnaire), quality and intensity of subjective pain (McGill Pain Questionnaire), patients’ emotional state (Adjectival Scale for Testing Emotions) and self-efficacy related to pain (Pain Self-Efficacy Questionnaire). Statistical analysis was performed via the Student’s t-test for dependent and independent samples. Results: In both study groups, the perceived pain was either completely eliminated or centralised to the spine, hip joint and buttock. The level of pain, disability and pain-related self-efficacy decreased significantly, regardless of the therapy used. In terms of these variables, no greater therapeutic efficacy was demonstrated with either cryostimulation treatment. Qualitative assessment of pain and emotions (especially anxiety and anger) decreased significantly in G1 and G2. However, in the nitrogen-treated group, a significantly greater improvement was noted for WOB:OC, anger and anxiety scores (for these variables, the G2 group started from a higher level prior to therapy). Conclusions: Both analysed treatments are equally effective in terms of variables such as: centralisation of symptoms, level of pain intensity, disability, joy, self-efficacy related to pain, as well as the majority of the analysed MPQ indicators. Cryostimulation with liquid nitrogen may be more effective, but only in improving the WOB: OC index of the MPQ questionnaire and the level of anger and anxiety. Nonetheless, the obtained results do not allow for definitive confirmation of these results. The use of both cryostimulation treatment methods may assist in the treatment process of LBPS.

Low back pain expert systems: Clinical resolution through probabilistic considerations and poset

OBJECTIVE

Proper diagnosis of Low Back Pain (LBP) is quite challenging in especially the developing countries like India. Though some developed countries prepared guidelines for evaluation of LBP with tests to detect psychological overlay, implementation of the recommendations becomes quite difficult in regular clinical practice, and different specialties of medicine offer different modes of management. Aiming at offering an expert-level diagnosis for the patients having LBP, this paper uses Artificial Intelligence (AI) to derive a clinically justified and highly sensitive LBP resolution technique.

MATERIALS AND METHODS

The paper considers exhaustive knowledge for different LBP disorders (classified based on different pain generators), which have been represented using lattice structures to ensure completeness, non-redundancy, and optimality in the design of knowledge base. Further the representational enhancement of the knowledge has been done through construction of a hierarchical network, called RuleNet, using the concept of partially-ordered set (poset) with respect to the subset equality (⊆) relation. With implicit incorporation of probability within the knowledge, the RuleNet is used to derive reliable resolution logic along with effective resolution of uncertainties during clinical decision making.

RESULTS

The proposed methodology has been validated with clinical records of seventy seven LBP patients accessed from the database of ESI Hospital Sealdah, India over a period of one year from 2018 to 2019. Achieving 83% sensitivity of the proposed technique, the pain experts at the hospital find the design clinically satisfactory. The inferred outcomes have also been found to be homogeneous with the actual or original diagnosis.

DISCUSSIONS

The proposed approach achieves the clinical and computational efficiency by limiting the shortcomings of the existing methodologies for AI-based LBP diagnosis. While computational efficiency (with respect to both time and space complexity) is ensured by inferring clinical decisions through optimal processing of the knowledge items using poset, the clinical acceptability has been ascertained reaching to the most-likely diagnostic outcomes through probabilistic resolution of clinical uncertainties.

CONCLUSION

The derived resolution technique, when embedded in LBP medical expert systems, would provide a fast, reliable, and affordable healthcare solution for this ailment to a wider range of general population suffering from LBP. The proposed scheme would significantly reduce the controversies and confusion in LBP treatment, and cut down the cost of unnecessary or inappropriate treatment and referral.

Prevalence of Self-Reported Work-Related Lower Back Pain and Its Associated Factors in Ethiopia: A Systematic Review and Meta-Analysis

Introduction

Low back pain is the commonest musculoskeletal disorder affecting every socioeconomic group of the world's population. The lifetime risk of developing low back pain is about 60%–80%. The pooled prevalence and associated factors of low back pain have not yet been determined in Ethiopia. Thus, this study was aimed at assessing the overall prevalence of low back pain and its associated factors in Ethiopia.

Methods

A systematic search of PubMed, Scopus, Science Direct, and Google Scholar for observational studies reporting data on the prevalence and associated factors of low back pain was conducted. Relevant data were extracted with a standardized data extraction excel form. Stata 14 was employed for the meta-analysis. Heterogeneity was assessed by Cochran's Q test and I² values of a forest plot. Publication bias was checked using a funnel plot and Egger's test. A random-effects model was used in the analysis.

Result

A total of thirty-two studies were included for the systematic review. Twenty-four and sixteen studies were used to pool the overall low back pain prevalence and associated factors, respectively. The overall pooled annual prevalence of low back pain in Ethiopia was estimated to be 54.05% (95% CI: 48.14–59.96). Age, sex, body mass index, work experience, working hours, lack of safety training, awkward working posture, work shift, prolonged standing, lifting heavy objects, sleeping disturbance, history of back trauma, previous medical history of musculoskeletal disorder, and lack of adequate rest interval at work were significantly associated with low back pain.

Conclusion

The current systematic review and meta-analysis revealed a higher prevalence of lower back pain in Ethiopia. Most of the low back pain epidemiological studies conducted in Ethiopia focused on specific occupational settings, making pooling of data and comparison with other countries challenging. Thus, further general population studies are recommended.

A Role for Superficial Heat Therapy in the Management of Non-Specific, Mild-to-Moderate Low Back Pain in Current Clinical Practice: A Narrative Review

Low back pain (LBP) is a leading cause of disability. It significantly impacts the patient's quality of life, limits their daily living activities, and reduces their work productivity. To reduce the burden of LBP, several pharmacological and non-pharmacological treatment options are available. This review summarizes the role of superficial heat therapy in the management of non-specific mild-to-moderate LBP. First, we outline the common causes of LBP, then discuss the general mechanisms of heat therapy on (LBP), and finally review the published evidence regarding the impact of superficial heat therapy in patients with acute or chronic non-specific LBP. This review demonstrates that continuous, low-level heat therapy provides pain relief, improves muscular strength, and increases flexibility. Therefore, this effective, safe, easy-to-use, and cost-effective non-pharmacological pain relief option is relevant for the management of non-specific mild or moderate low back pain in current clinical practice.

Characteristics affecting cervical sagittal alignment in patients with chronic low back pain

BACKGROUND

Sagittal spino-pelvic malalignment in patients with chronic low back pain (CLBP) have been reported in the past, which may also affect cervical spine lesions. The purpose of this study is to investigate the cervical alignment in patients with CLBP.

METHOD

Of the patients who visited an orthopedic specialist due to low back pain lasting more than three months, 121 cases (average 71.5-years-old, 46 male and 75 female) with whole standing spinal screening radiographs were reviewed (CLBP group). Cervical parameters included cervical lordosis (CL), C2-C7 sagittal vertical axis (C2-7 SVA), and the T1 slope minus CL (T1S-CL). Cervical spine deformity was defined as C2-7 SVA >4 cm, CL <0°, or T1S-CL ≧20°. We compared the cervical alignment of these patients with 121 age and gender matched volunteers (control group).

RESULTS

The prevalence of cervical spine deformity was significantly higher in the CLBP group than in the control group (20.7% vs. 10.7%, P = 0.034). The mean CL was smaller in the CLBP group than in the control group (16.1° vs. 21.4°, P = 0.002). The mean C2-7 SVA was 17.6 mm vs. 18.7 mm in the CLBP group and in the control group, respectively (P = 0.817). The mean T1S-CL was larger in the CLBP group than in the control group (9.1° vs. 3.5°, P < 0.001). Multivariate analysis showed that people with CLBP were more likely to have cervical deformities than people without CLBP (odds ratio 2.16, 95% confidence interval 1.006 to 4.637).

CONCLUSIONS

This study results suggest that people with CLBP present with worse cervical sagittal alignment and higher prevalence of cervical spine deformities than age and gender matched volunteers with no CLBP. This means CLBP impacts cervical spine lesions negatively.

LEVEL OF EVIDENCE

Ⅳ.

[The efficacy of the combination of diclofenac and orphenadrine in the treatment of dorsalgia]

The high prevalence of dorsalgia and dorsopathy among the adult population makes a significant contribution to the structure of the financial burden of health care systems. The use of non-steroidal anti-inflammatory drugs (NSAIDs) as the basis for the pharmacotherapy of dorsopathy is recommended by most international clinical guidelines. The pharmacodynamic effects of NSAIDs underlie the clinical efficacy of this group of drugs in patients with pain of musculoskeletal origin, while monotherapy is not always accompanied by the rapid development of a persistent analgesic effect. An urgent direction in the therapy of dorsopathies may include combination of NSAIDs with analgesic drugs of other pharmacological groups capable of additive action. The fixed combination of diclofenac, 75 mg, and orphenadrine, 50 mg, allows achieving an effective analgesic effect in patients with lower back pain of various etiologies. It was demonstrated in a series of clinical cases that included 4 patients with dorsopathy who were treated at the City Clinical Hospital No. 24, Moscow in 2020.

Efficacy and safety of fasinumab in patients with chronic low back pain: a phase II/III randomised clinical trial

OBJECTIVES

To study the efficacy and safety of fasinumab in moderate-to-severe, chronic low back pain (CLBP).

METHODS

In this phase II/III, double-blind, placebo-controlled study, patients with CLBP aged ≥35 years with inadequate pain relief/intolerance to acetaminophen, non-steroidal anti-inflammatory drugs and opioids were randomised to fasinumab 6 or 9 mg subcutaneous every 4 weeks (Q4W), 9 mg intravenous every 8 weeks (Q8W) or placebo. Primary endpoint was change from baseline to week 16 in average daily low back pain intensity (LBPI) numeric rating score. Key secondary efficacy variables included Roland-Morris Disability Questionnaire (RMDQ) and Patient Global Assessment (PGA). The results are based on a modified intent-to-treat analysis of 563/800 planned patients when enrolment was stopped early given emerging signals of joint risk in other osteoarthritis (OA) studies at doses being tested here.

RESULTS

Significant placebo-adjusted LBPI reductions at week 16 were observed for fasinumab 9 mg Q4W and Q8W (least squares mean (standard error) -0.7 (0.3); both nominal p<0.05), but not 6 mg (-0.3 (0.3); p=0.39). RMDQ and PGA improvements to week 16 were greatest for fasinumab 9 mg intravenous. Numerically greater efficacy occurred in patients with, versus those without, peripheral OA (pOA) over 16 weeks. Treatment-emergent adverse events (AEs) occurred in 274/418 (65.6%) patients in the combined fasinumab groups and 94/140 (67.1%) placebo patients. Joint AEs, mostly rapid progressive OA type 1, were more frequent in the combined fasinumab groups (19 events in 16 patients (3.8%) vs 1 event in 1 patient (0.7%) for placebo); all except one occurred in pOA patients.

CONCLUSIONS

Fasinumab highest doses, but not lower dose, improved both CLBP pain and function. Most joint AEs occurred in pOA patients, consistent with earlier findings in symptomatic OA. Further study is needed of patients with CLBP with and without pOA to determine optimal benefit-risk.

Medical expert system for low back pain management: design issues and conflict resolution with Bayesian network

The paper focuses on the development of a reliable medical expert system for diagnosis of low back pain (LBP) by proposing an efficient frame-based knowledge representation scheme and a suitable resolution logic with conflicts in outcomes being resolved using Bayesian network. Considering that LBP is classified into many diseases based on different pain generators, the proposed methodology infers non-conflicting LBP diseases sorted according to their chances of occurrence. A satisfactory clinical efficacy (average relative error - 0.09, recall 74.44%, precision 76.67%, accuracy 71.11%, and F1-score 73.88%) of the proposed methodology has been found after validating the design with empirically selected thirty LBP patient cases. Constraining that an inferred disease having chance of occurrence, prior to pathological investigations, below 0.75 (as set by four pain specialists) is not accepted clinically; the design can correctly identify, on average, 74.44% of actual diagnosis; and 76.67% of inferred diagnosis is included in actual diagnosis. With the predicted chance of occurrence being lower than 0.75 by a fraction of 0.09 on average, the proposed design performs well for 73.88% cases detecting 71.11% inferred outcomes as accurate. The design offers homogeneity to the actual outcomes, with the chi-squared static being calculated as 11.08 having 12 as degree of freedom. Graphical abstract.

RELATIONSHIP ANALYSIS OF WHOLE BODY VIBRATION (WBV) WITH MUSCULOSKELETAL DISORDER (MSDS) COMPLAINTS ON HEAVY EQUIPMENT OPERATORS AT THE TRANS SU-MATRA TOLL ROAD CONSTRUCTION PROJECT AT PT. ADHI KARYA TBK

The use of heavy equipment in the construction field is very helpful in the process of a project. Heavy equipment operators exposed to the Whole Body Vibration due to a machine that can be transmitted through a seat or on the floor. These vibrations at certain intensities can lead to Musculoskeletal Disorder. This study aimed to analyze the relationship of Whole Body Vibration with the occurrence of Musculoskeletal Disorder complaints on Heavy Equipment Operators. Methods this study used cross sectional design, with a measuring instrument in the form of an accelerometer type 100A svantek and a Nordic Body Map questionnaire. The research sample was 45 operators with heavy equipment consisting of excavators, bulldozers, motorgrade, vibro compactors and dump trucks. WBV data retrieval is done when the operator works,, the tool is placed in the seat where the operator sits. Results of the study can be obtained through exposure to WBV based on ISO 2631: 1 15 heavy equipment operators (33.3%) were in the low WBV exposure category, while 30 operators (66.6%) in the Moderate and High category. Parts of the body which can be categorized as belonging to Work-related is part of Lower Back 99.35% (P Value 0.043; NK_R2 0.304) with BMI (OR 0.925) as the confounding variable. It can be concluded that the complaints Musculoskeletal Disorder (MSDs) in the Lower back may come from the presence of vibration exposure Whole Body Vibration generated from his job as a heavy equipment operator. Advised the company's management can reduce complaint rates by reducing operator exposure received.Keywords: Secondary metabolites, Trichoderma harzianum, Colletotrichum capsici, tannin

Association between serum 25-hydroxyvitamin D levels and self-reported chronic pain in older adults: A cross-sectional analysis from the ViDA study

Chronic pain is a major contributor to the global burden of disability. Prior studies on the association between serum 25-hydroxyvitamin D (25(OH)D) levels and chronic pain have yielded mixed results. The Vitamin D Assessment study, a large randomized controlled trial from New Zealand, offered the opportunity to examine this association in data collected at baseline in all participants, and among those with arthritis or depression. A total of 5110 participants aged 50-84 years were recruited from community general practices. Chronic pain (lasting ≥6 months) and other baseline characteristics were collected at baseline interview. Serum 25(OH)D concentration was measured by liquid chromatography-tandem mass spectrometry. Associations between 25(OH)D levels and chronic pain were explored using multivariable log-binomial regression to estimate relative risks (RRs). Out of 5049 participants with complete data, 871 (17%) reported having this clinical outcome, and 1254 (25%) had a 25(OH)D concentration <50 nmol/L. There was no significant association between 25(OH)D and chronic pain, with vitamin D status categorized in four groups: <25.0, 25.0-49.9, 50.0-74.9, and ≥75.0 nmol/L (the highest group as reference). The unadjusted RRs were 1.09, 1.10, and 1.08, respectively (P_trend = 0.24). Adjustment for demographics, lifestyle, BMI, medical history, prescription of analgesics and vitamin D supplements did not change this finding. Similar non-significant results were observed in participants with arthritis (n = 1732) or depression (n = 528). In this multi-ethnic, community-selected sample of older adults in New Zealand, serum 25(OH)D levels were not associated with chronic pain. These results do not support a role for low vitamin D status in the prevalence of chronic pain in older adults.

The approach of physiatrists to low back pain across Europe

BACKGROUND

Low back pain (LBP) is the most common type of musculoskeletal pain, thus it is one of the most commonly encountered conditions in Physical and Rehabilitation Medicine. The physicians who are primarily responsible for the nonsurgical management of LBP are physiatrists.

OBJECTIVE

The present study aimed to investigate the approaches of physiatrists to low back pain across Europe. Preferences, tendencies, and priorities in the diagnosis, management, and treatment of LBP, as well as the epidemiological data pertaining to LBP in PRM practice were evaluated in this Europe-wide study.

METHODS

The study was conducted under the control of the European Society of Physical and Rehabilitation Medicine (ESPRM) Musculoskeletal Disorders Research Committee. A total of 576 physiatrists from most European countries participated in the survey.

RESULTS

The results show that physiatrists frequently deal with patients with LBP in their daily practice. Most patients are not referred to other departments and are treated with various conservative methods. Less than one-fifth of patients are primarily referred for surgery. The physiatrists believe that a clear diagnosis to account for cases of low back pain is rarely established. The most common diagnosis is discopathy. History and physical examination remain the most valuable clinical evaluation tools for low back pain according to physiatrists. Less than half the patients require a magnetic resonance imaging. Non-steroidal anti-inflammatory drugs are the most commonly prescribed drugs for low back pain. Exercise, back care information, and physical therapy are the preferred conservative treatments. More than half of the physiatrists offer interventional treatments to patients with low back pain.

CONCLUSION

The present study is a preliminary report that presents the attitudes of European physiatrists in the management of low back pain. Further researches are warranted to standardize the conservative management of LBP.

Is It Radiculopathy or Referred Pain? Buttock Pain in Spinal Stenosis Patients

Background

Buttock pain is common, and there are no fixed guidelines for its diagnosis and treatment. This study compared a selective nerve root block and a facet joint block for patients with degenerative spinal disease and buttock pain.

Methods

Patients with degenerative spinal disease who presented with buttock pain, received a selective nerve root block (group A) or a facet joint block (group B) from June 2017 to September 2017, and were able to be followed up for more than 3 months were prospectively enrolled. Clinical results were assessed using a visual analog scale for comparative analysis.

Results

One day after the procedure, an excellent response was found in 7% and 6% of groups A and B, respectively; a good response was found in 41% and 13% of groups A and B, respectively. Two weeks later, an excellent response was found in 11% and 4% of groups A and B, respectively; a good response was found in 41% and 20% of groups A and B, respectively. Six weeks later, an excellent response was found in 11% and 7% of groups A and B, respectively, and a good response was found in 41% and 20% of groups A and B, respectively. At the final follow-up, more than 47% and 46% of patients showed a good response in groups A and B, respectively. In group A, the visual analog scale score improved compared to the pre-procedure value of 5.01 to 2.74 on day 1, 2.51 at week 2, 2.38 at week 6, and 2.39 at week 12. In group B, the visual analog scale score improved compared to the preprocedure value of 5.24 to 3.94 on day 1, 3.99 at week 2, 3.24 at week 6, and 2.59 at week 12. On day 1 and at weeks 2 and 6, group A showed a significantly better outcome than group B (p < 0.05).

Conclusions

The selective nerve root block showed superior results up to 6 weeks post-procedure. Considering that the selective nerve root block is effective for treating radiculopathy, the primary cause of buttock pain can be thought to be radiculopathy rather than degenerative changes of the facet joint.

Theory of Bowstring Disease: Diagnosis and Treatment Bowstring Disease

Bowstring disease (BSD) is a new classification of spine disease caused by axial stretched lesion on nerve roots and the spinal cord, which is differentiated from disc herniation and canal stenosis in that it is caused by nerve compression lesions. BSD could be caused by mismatched growth rates between the spine and nerve roots (the juvenile type), or by imbalanced degenerative rates between the spine column and nerve roots (degenerative type). Here, we propose that there are several self-adjust mechanisms to relieve axial nerve tension: (i) nerve growth; (ii) posture adjustment and low back pain; (iii) autogenous degeneration of intervertebral disc; and (iv) idiopathic and degenerative scoliosis. Iatrogenic lesions could also result in BSD, which could be presented as adjacent segment degeneration, leading to adding-on effects and other neurological symptoms. The diagnosis criteria are proposed based on symptoms, physical examination, and radiological presentations. To remove axial tension on nerve roots, lumbar surgery should aim to restore the coordination of spine and cord units. Capsule surgery, shortening the spine column, could decompress cord and nerve roots 3-dimensionally.

Chronic Musculoskeletal Pain, Self-Reported Health and Quality of Life among Older Populations in South Africa and Uganda

Chronic musculoskeletal pain (CMP) is a serious health concern especially among the elderly population and has significant bearing on health and quality of life. Not much is known about the relationship between chronic pain with self-reported health and quality of life among older populations in low-resource settings. Based on sub-national data from South Africa and Uganda, the present study aimed to explore whether the older population living with CMP report health and quality of life differently compared to those with no CMP complaints. This study was based on cross-sectional data on 1495 South African and Ugandan men and women collected from the SAGE Well-Being of Older People Study. Outcome variables were self-reported physical and mental health and quality of life (QoL). Mental health was assessed by self-reported depressive symptoms during the last 12 months. CMP was assessed by self-reported generalised pain as well as back pain. Multivariable logistic regression models were used to measure the association between health and QoL with CMP by adjusting for potential demographic and environmental confounders. The prevalence of poor self-rated health (61.2%, 95% CI = 51.7, 70.0), depression (37.2%, 95% CI = 34.8, 39.6) and QoL (80.5%, 95% CI = 70.8, 87.5) was considerably high in the study population. Mild/moderate and Severe/extreme generalised pain were reported respectively by 34.5% (95% CI = 28.9, 40.5) and 15.7% (95% CI = 12.2, 19.9) of the respondents, while back pain was reported by 53.3% (95% CI = 45.8, 60.4). The prevalence of both types was significantly higher among women than in men (p < 0.001). In the multivariate analysis, both generalised pain and back pain significantly predicted poor health, depression and QoL, however, it varied between the two different populations. Back pain was associated with higher odds of poor self-rated health [OR = 1.813, 95% CI = 1.308, 2.512], depression [1.640, 95% CI = 1.425, 3.964] and poor QoL [1.505, 95% CI = 1.028, 2.202] in South Africa, but not in Uganda. Compared to having no generalised pain, having Mild/Moderate [OR = 2.309, 95% CI = 1.219, 7.438] and Severe/Extreme [OR = 2.271, 95% CI = 1.447, 4.143] generalised pain was associated with significantly higher odds of poor self-rated health in South Africa. An overwhelmingly high proportion of the sample population reported poor health, quality of life and depression. Among older individuals, health interventions that address CMP may help promote subjective health and quality and life and improve psychological health.

Radiculopathy Contralateral to the Side of Disc Herniation -Microendoscopic Observation

INTRODUCTION

There are patients with lumbar disc herniation (LDH) having contralateral sciatic symptoms although the mechanisms of this clinical feature are still not well understood. The purpose of this study was to investigate these mechanisms by microendoscopic findings.

METHODS

Patients were performed microendoscopic surgery using over-the-top approach (ME-OTT), with laminoplasty, extirpation of herniation, and observation of the contralateral nerve root. The over-the-top approach was applied through the same incision from the herniation side. Clinical results were assessed according to the clinical scoring system established by the Japanese Orthopedic Association (JOA) score.

RESULTS

This study consisted of five patients, with the average age of 55.6 years old. The mean preoperative JOA score was 13 points. Three cases were Grade II and two were Grade III degrees of disc herniation. Levels of herniation were one at L3-4 and four at L4-5. Remission of sciatic symptoms was obtained in all cases after surgery. The average and percent improvements (%IP) of JOA scores at 2 months after surgery were 27.8 points and 92%, respectively. By the approach from the herniation side using ME-OTT, image around the contralateral nerve root was obtained without radical intervention. By ME-OTT, redness of the nerve root and fibrosis around the symptomatic nerve root were identified, whereas inflammatory changes were not apparent on the ipsilateral nerve root.

CONCLUSIONS

Operative treatment of LDH with contralateral symptoms by ME-OTT was a useful procedure for decompression and observation of the affected nerve root. Asymptomatic disc herniation, "silent disc herniation," was considered at the herniation side since there were less inflammatory changes around the ipsilateral nerve root. In contrast, compression of dura toward the opposite side by disc herniation could have led to mechanical stress against the contralateral nerve root and triggered inflammation at lateral recess, resulting in radicular pain.

Compensatory strategy between trunk-hip kinematics and reaction time following slip perturbation between subjects with and without chronic low back pain

Compensatory trunk and hip motions following slip perturbations may compromise the control of lumbopelvic movement. However, it is unclear how postural integration of the trunk and hips can be transferred to treadmill-induced slip perturbations in subjects with chronic low back pain (LBP). The purpose of this study was to investigate trunk reaction times and three-dimensional trunk-hip angle changes following a slip perturbation (duration: 0.12 sec, velocity: 1.37 m/sec, displacement: 8.22 cm) with a handheld task between subjects with and without chronic LBP. There were 23 subjects with LBP and 33 control subjects who participated in the study. The trunk reaction time was not significantly different between groups. However, the three-dimensional trunk-hip angle changes were significantly different following the perturbation. There were significant interactions between the body regions and three-dimensional angles between groups. There was a negative correlation between reaction time and trunk flexion in the LBP group. Overall, the LBP group demonstrated significantly reduced trunk flexion, which might be associated with reduced adaptability or a possible fear of avoidance strategy. Clinicians need to consider compensatory strategies to improve trunk flexibility following slip perturbations in subjects with chronic LBP. Mini abstract: Trunk reaction time and three-dimensional trunk-hip motions were compared between subjects with and without chronic low back pain (LBP). The control group demonstrated greater trunk flexion; however, the LBP group reduced trunk flexion to protect against further injuries following the novelty of the slip perturbation.

MAGNETIC RESONANCE IMAGING PATHOLOGICAL EVIDENCE IN PATIENTS WITH LOW BACK PAIN IN SOUTHWEST NIGERIA

BACKGROUND

Low back pain, a condition that affects many individuals worldwide during their lifetime is receiving increasing attention due to the attendant chronic disability, absenteeism from work, loss of earning power, loss of quality of life and finances. Recently focus has been on the rising prevalence and search for steps to address low back pain risk factors now known to be modifiable. For the evaluation of low back pain, magnetic resonance imaging (MRI) has emerged as the imaging modality of choice.

AIM

To determine the prevalence and distribution of lumbosacral spine discs, osseous, ligamentum flavum and facet joint changes evaluated by MRI. And to further understand the lumbosacral spine biomechanics of MRI-related disco-osseous abnormalities among native African population with low back pain.

STUDY DESIGN

This was a retrospective study.

SETTING

University College Hospital, Ibadan, Nigeria.

METHODOLOGY

The Lumbosacral spine T1W and T2W sagittal and axial images and post gadolinium contrast images generated using a low field MRI scanner and body surface coil, in patients with low back pain, were evaluated in line with pre-defined spinal changes.

RESULTS

There were a total of one hundred and eight low back pain patients who had Magnetic resonance imaging between March 2015 and August 2016 in this study with a mean age of 49.9 years and a range of 8 to 77 years. There were 28(25.9%) patients aged 50 - 59 years; this age bracket had the highest number while those aged 20 years and below were 3.7%. In all, 80(74.1%) subjects had chronic low back pain. Abnormal Magnetic resonance findings were reported in 96.3%. Multiple disc affectation was seen in 75.3%; disc bulge (79.8%) was the commonest disc findings followed by dehydration in 74.0%. The L4/5 discs were commonly affected in disc dehydration in 59(76.6%) cases, anterior herniation in 22(61.1%) cases, ventrolateral herniations in 9(81.8%) cases, nerve root compression in 21(60%) cases, facet joint hypertrophy in 17/24(70.8%) cases and spinal canal stenosis in 32/47(68.1%) cases. Vertebral end plate changes occur mostly at L4 and L5 (74% at each level).

CONCLUSION

This study has shown that Magnetic Resonance Imaging changes in low back pain involved multiple discs and multilevel osseous pathologies, however, disc abnormalities are predominant. The L4-5, L5-S1 disc levels and L4 vertebra body were the most commonly affected sites among a native African population.

Correlation of lumbar lateral recess stenosis in magnetic resonance imaging and clinical symptoms

AIM

To assess the correlation of lateral recess stenosis (LRS) of lumbar segments L4/5 and L5/S1 and the Oswestry Disability Index (ODI).

METHODS

Nine hundred and twenty-seven patients with history of low back pain were included in this uncontrolled study. On magnetic resonance images (MRI) the lateral recesses (LR) at lumbar levels L4/5 and L5/S1 were evaluated and each nerve root was classified into a 4-point grading scale (Grade 0-3) as normal, not deviated, deviated or compressed. Patient symptoms and disability were assessed using ODI. The Spearman’s rank correlation coefficient was used for statistical analysis (P < 0.05).

RESULTS

Approximately half of the LR revealed stenosis (grade 1-3; 52% at level L4/5 and 42% at level L5/S1) with 2.2% and 1.9% respectively reveal a nerve root compression. The ODI score ranged from 0%-91.11% with an arithmetic mean of 34.06% ± 16.89%. We observed a very weak statistically significant positive correlation between ODI and LRS at lumbar levels L4/5 and L5/S1, each bilaterally (L4/5 left: rho < 0.105, P < 0.01; L4/5 right: rho < 0.111, P < 0.01; L5/S1 left: rho 0.128, P < 0.01; L5/S1 right: rho < 0.157, P < 0.001).

CONCLUSION

Although MRI is the standard imaging tool for diagnosing lumbar spinal stenosis, this study showed only a weak correlation of LRS on MRI and clinical findings. This can be attributed to a number of reasons outlined in this study, underlining that imaging findings alone are not sufficient to establish a reliable diagnosis for patients with LRS.