Diagnosis and Characters of Non-Specific Low Back Pain in Japan: The Yamaguchi Low Back Pain Study

Effects of instrument-assisted manipulation and mobilization with movement in chronic non-specific low back pain: A randomized controlled trial

BackgroundLow back pain is the third most reported complaint after headache and chronic fatigue, and more than 80% of the population will experience low back pain at some point in their lives.ObjectıveWe conducted this study to investigate the effects of instrument-assisted manipulation (IAM) and mobilization with movement (MWM) on joint range of motion (ROM), pain, proprioception, endurance, back awareness, and disability in individuals with chronic nonspecific low back pain (CNSLBP).Methods51 participants with CNSLBP were randomized to one of three groups: (1) MWM; (2) IAM; or (3) core exercise. Joint ROM, pain, proprioception, endurance, back awareness, and disability were assessed at baseline, week 2 and 6.ResultsJoint ROM and activity pain scores increased in all groups (p < 0.05). Both activity and resting pain improved in the MWM group (p < 0.001; p = 0.004). Most measures related to proprioception improved in the MWM group (p = 0.005; p = 0.016; p = 0.016). Endurance increased in all groups, but the flexor endurance increase was higher in the MWM group (p < 0.05). Back awareness and disability increased in all groups (p < 0.05), but disability increased most in MWM group (p = 0.022).ConclusıonsMWM could effectively improve pain, proprioception, endurance, and disability.

Screening system for assessing suitability of cognitive behavioral therapy for chronic low back pain

An objective method to evaluate patient suitability for cognitive behavioral therapy (CBT) for chronic low back pain (LBP) is currently lacking. Inappropriate application can result in prolonged hospital visits and increased medical costs. Therefore, identifying an objective biomarker for evaluating suitability is crucial. This study focused on electroencephalogram (EEG) complexity as a potential biomarker for evaluating CBT suitability for chronic LBP, assessing its discriminative ability and identifying factors that impede treatment. Complexity was analyzed as multiscale fuzzy sample entropy (MFSE). Fifty patients with suspected psychosocial factors causing LBP along with 20 healthy volunteers were included. The analysis included 25 responders and 25 non-responders for CBT. MFSE showed significant effects of scale factor [F(19,171) = 14.82, p < 0.01, partial η2 = 0.622] and interaction between group and scale factor [F(38,171) = 7.34, p < 0.01, partial η2 = 0.620]. The low-frequency band MFSE score had an odds ratio of 10.768 (95% confidence interval: 8.263-10.044, p < 0.001). The low-frequency band showed a high discriminative ability (area under the curve: 0.825), with a cut-off value of 1.25. The low-frequency FMSE is a superior biomarker for predicting suitability for CBT. This method can quickly evaluate suitability, reducing the burden on medical professionals and patients, and lowering medical costs.

Health-Related Quality of Life in a Slovak Representative Sample: A Validation Study of the Short Form-8 Scale

OBJECTIVES

The Short Form-8 (SF-8) is a widely used 8-item tool for health-related quality of life assessment. This study aimed to evaluate the psychometric properties of the Slovak version of the SF-8 in a population sample.

METHODS

A cross-sectional survey on a Slovak representative sample (n = 1018; mean age 46.24 ± 16.56 years; 51.3% women) monitoring health and well-being was performed in 2019. Exploratory network analysis and confirmatory factor analysis were used to assess the construct validity of the scale. Reliability and sociodemographic differences were evaluated.

RESULTS

A 2-factor model had an adequate fit to the data [χ2(19) = 186.2, P < .001, comparative fit index = 0.998, Tucker-Lewis index = 0.997, root mean square error of approximation = 0.093, standardized root mean of residuals = 0.039], with high reliability (α = 0.93, ω = 0.95). The physical component score and mental component score (MCS) were negatively associated with the presence of chronic health conditions. Lower physical component score and MCS were associated with higher age (P < .001), and lower MCS were associated with female gender (P < .001).

CONCLUSIONS

The Slovak version of the SF-8 represents a valuable tool for measuring health-related quality of life in the Slovak population in both practice and research.

Magnetic resonance imaging (MRI) vs. computed tomography (CT) in the diagnosis and classification of spondylolysis and spondylolisthesis-a narrative review

Background and Objective

Spondylolysis is a lysis of the pars interarticularis, a component of the posterior arch of the vertebral body, in the face of repeated overuse and stress phenomena generally associated with sports in children and adolescent patients. This entity is one of the most common causes of low back pain in this age group. The diagnosis can be made using various imaging techniques, with computed tomography (CT) being considered the gold standard, as it provides the best visualization of the fracture, its extension and orientation, as well as an assessment of the entire bony skeleton. It is essential to understand the physiopathology and natural evolution of the disease as well as to know the typical findings of this disease in each imaging technique in order to be able to make a diagnosis in early stages of the disease. In this paper, we will review the clinical manifestations and typical radiologic findings of spondylolisthesis and spondylolisthesis, which allow a correct and early diagnosis.

Methods

The literature available in English from 1976 (when the first publications on the diagnosis of this pathology appeared) up to the present day has been used for this review.

Key Content and Findings

In this review we will review the etiology, etiopathogenesis and natural evolution of spondylolysis and spondylolisthesis, we will place special emphasis on the radiological findings in magnetic resonance imaging with a view to an early diagnosis that allows us to slow down the evolution of the disease in its initial stages and we will look at the advantages and disadvantages of each technique.

Conclusions

Spondylolysis is an increasingly frequent entity due to the increase in sporting activity at younger and younger ages, so radiologists should consider its existence in patients with low back pain and know the radiological signs that allow us to make an early diagnosis.

Development of a novel animal model of lumbar vertebral endplate lesion by intervertebral disk injection of monosodium iodoacetate in rats

PURPOSE

Vertebral endplate lesions (EPLs) caused by severe disk degeneration are associated with low back pain. However, its pathophysiology remains unclear. In this study, we aimed to develop a vertebral EPL rat model mimicking severe intervertebral disk (IVD) degeneration by injecting monosodium iodoacetate (MIA) into the IVDs and evaluating it by assessing pain-related behavior, micro-computed tomography (CT) findings, and histological changes.

METHODS

MIA was injected into the L4-5 and L5-6 IVDs of Sprague-Dawley rats. Their behavior was examined by measuring the total distance traveled and the total number of rearing in an open square arena. Bone alterations and volume around the vertebral endplate were assessed using micro-CT. Safranin-O staining, immunohistochemistry, and tartrate-resistant acid phosphatase (TRAP) staining were performed for histological assessment.

RESULTS

The total distance and number of rearing times in the open field were significantly reduced in a time-dependent manner. Micro-CT revealed intervertebral osteophytes and irregularities in the endplates at 12 weeks. The bone volume/tissue volume (BV/TV) around the endplates significantly increased from 6 weeks onward. Safranin-O staining revealed severe degeneration of IVDs and endplate disorders in a dose- and time-dependent manner. Calcitonin gene-related peptide-positive nerve fibers significantly increased from 6 weeks onward. However, the number of osteoclasts decreased over time.

CONCLUSION

Our rat EPL model showed progressive morphological vertebral endplate changes in a time- and concentration-dependent manner, similar to the degenerative changes in human IVDs. This model can be used as an animal model of severe IVD degeneration to better understand the pathophysiology of EPL.

Association Between Lumbar Spine Disorder and Genovarum: A Population-Based Cross-Sectional Study

Background

It is becoming increasingly important to study pathology at the knee and spine because of their role in causing pain and deformity in one another. Compression of the lumbar nerve root can disrupt innervation to the thigh muscles, cause an imbalance of muscle and result in varus deformity. In this study, we try to figure out the relation between lumbar spine disorders and genu varum and realize if lumbar spine disorders can cause varus deformity in a patient.

Methods

In this cross-sectional study, the number of 53 patients with knee varus greater than 20 degrees who visited the orthopedic clinics of Rasoul Akram and Moheb Mehr hospitals affiliated to Iran University of Medical Sciences between 2020 and 2022 were investigated in terms of association with lumbar disorders. The demographic characteristics and clinical findings of the patients were recorded and collected using a checklist by referring to the patient's medical profiles. Radiographic findings were evaluated by referring to the imaging department and using the Pacs system. The diagnosis of the patients was based on the history and findings of the knee graph, which was measured with a goniometer to measure the knee angle. The frequency of lumbar disorders caused by pressure on the lumbar nerves in patients with genu varum deformity including canal stenosis, osteoarthritis, spondylolisthesis, and disc herniation was investigated. To investigate lumbar problems, patients' history and radiographic images as well as lumbosacral and knee MRI of patients were used.

Results

The mean age was 66.3 ± 7.66 years. 40 (75.5%) cases were female and 13 (24.5%) cases were male. Lumbar canal stenosis with 28(52.8%) and disc herniation with 32(60.4%) were the most common lumbar disorders in patients with knee varus more than 20 degrees. The mean age of patients with varus of more than 20 degrees with lumbar disorders was significantly higher than that of patients without lumbar disorders. (P: 0.001) There was no significant difference between gender distribution and lumbar disorders in patients with varus more than 20 degrees. Significant positive correlation between genu varum with lumbar canal stenosis (r: 0.53, P: 0.001), osteoarthritis (r: 0.38, P: 0.004), spondylolisthesis (r: 0.39, P: 0.002) and disc herniation (r: 0.46, P: 0.001) was reported2.

Conclusion

An association between lumbar disorders and varus more than 20 degrees was found to be considerable.

Acute back pain: Clinical and radiologic diagnosis: WFNS spine committee recommendations

Objective

To formulate the most current, evidence-based recommendations for the clinical and radiologic diagnosis of acute low back pain lasting <4 weeks.

Methods

A systematic literature search in PubMed and Google Scholar databases was performed from 2012 to 2022 using the search terms "acute back pain AND clinical diagnosis" and "acute back pain AND radiologic diagnosis". Screening criteria resulted in a total of 97 papers analyzed. Using the Delphi method and two rounds of voting, the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated ten final consensus statements.

Results

Ten final consensus statements address the clinical diagnosis of acute LBP, including which clinical conditions cause acute LBP and how we can distinguish between the different causes of LBP, including discogenic, facet joint, sacroiliac joint, and myofascial pain. The most important step for the radiologic diagnosis of acute LBP is to evaluate the necessity of radiologic investigation, as well as its timing and the most appropriate type of imaging modality. Importantly, imaging should not be a routine diagnostic tool, unless red flag signs are present. In fact, routine imaging for acute LBP can actually have a negative effect as it may reveal incidental radiographic findings that exacerbate patient fear and anxiety.

Conclusion

Overall, the quality of evidence is not high for most of our consensus statements, and further studies are needed to validate the WFNS Spine Committee recommendations on the clinical and radiographic diagnosis of acute LBP.

Paralumbar Spine Disease as a Cause of Low Back Pain in Older Adults

Introduction Low back pain (LBP) is a major contributor to decreases in the ability to perform activities of daily living (ADL) in older adults. Paralumbar spine disease (PLSD) is a common cause of LBP. We aimed to investigate the causes of LBP, including PLSD, among older adults. Methods Among 744 consecutive patients with LBP, 75 patients (10.1%) aged >80 years (25 males and 50 females) were included. The average patient age was 83.9 years. All patients were evaluated using lumbar magnetic resonance imaging (MRI) and radiography to diagnose the causes of LBP. PLSD was diagnosed based on clinical symptoms, palpation, and the effects of the block. Results Eleven patients (11/75, 14.7%) had acute osteoporotic vertebral fractures. Twenty-eight of the remaining 64 patients exhibited decreased LBP with oral medication, and six (6/75, 8.0%) exhibited lumbar spinal canal stenosis on MRI. PLSD was suspected in 19 of the remaining 30 cases based on clinical symptoms and palpation. Blocks were effective in 16 patients with PLSD, which involved superior cluneal nerve entrapment (SCN-E) in eight patients (10.7%), middle cluneal nerve entrapment (MCN-E) in nine patients (12.0%), sacroiliac joint (SIJ) pain in five patients (6.7%), and gluteus medius muscle (GMeM) pain in three patients (4.0%). The average numerical rating scale (NRS) scores for pain changed from 7.5 ± 1.5 before treatment to 1.3 ± 0.9 at discharge (p < 0.05). Conclusion Osteoporotic acute vertebral fracture (14.7%) was identified as the cause of LBP in older adults. Block therapy for PLSD may aid in the diagnosis and treatment of non-specific LBP.

Ultrasound-guided disc pain induction test for diagnosis of discogenic lumbar pain: a cross-sectional study

BACKGROUND

Several methods can be used to diagnose discogenic pain, but only discoblock can diagnose discogenic pain definitively. This study aimed to examine the usefulness of an ultrasound-guided disc pain induction test for a simple and accurate diagnosis of the culprit lesion.

METHODS

We included 41 patients with lumbar pain in whom pain was induced by an ultrasound-guided disc pain induction test. All patients had confirmed pain at L1/2 to L5/S1 based on an ultrasound-guided disc pain induction test and underwent X-ray photography and magnetic resonance imaging. Seventeen patients who required injection due to severe pain underwent discoblock procedures for discs with the most intense pain, and visual analogue scale (VAS) scores were obtained before and after the procedure for these patients. We analysed the association between painful discs and radiological findings.

RESULTS

Pain induction was noted in a total of 65 discs, and the pain was induced in 23 patients in only one disc. All patients had disc degeneration of Pfirrmann classification grade 1 or higher, with more significant disc degeneration in painful discs than in painless discs. There was no significant relationship between the presence or absence of pain and Modic type. The average VAS measurements improved significantly from 9.5 (pre-procedure) to 2.5 (post-procedure). These results suggest that the most painful discs were the causes of discogenic lumbar pain.

CONCLUSIONS

Our ultrasound-guided disc pain induction test may help diagnose disc degeneration and identify culprit lesions, even when multiple discs exhibit findings of degeneration.

Modic changes as seen on MRI are associated with nonspecific chronic lower back pain and disability

BACKGROUND

Estimating the contribution of endplate oedema known as Modic changes to lower back pain (LBP) has been the subject of multiple observational studies and reviews, some of which conclude that the evidence for an association of Modic change with LBP is uncertain while others demonstrate a clear link. The clinical trials demonstrating the benefit of basivertebral nerve ablation, a therapeutic intervention, in a tightly defined homogenous patient group with chronic LBP and Modic changes type 1 or type 2, provides further evidence for the contribution of Modic changes to LBP and shows that in these subjects, nerve ablation substantially reduces pain and disability. These interventional studies provide direct evidence that Modic changes can be associated with lower back pain and disability. This review set out to explore why the literature to date has been conflicting.

METHODS

A narrative, forensic, non-systematic literature review of selected articles to investigate why the published literature investigating the association between Modic imaging changes and chronic low back pain is inconsistent.

RESULTS

This review found that previous systematic reviews and meta-analyses included both heterogeneous study designs and diverse patient syndromes resulting in an inconsistent association between Modic changes and nonspecific chronic lower back pain. Re-analysis of literature data focussing on more homogenous patient populations provides clearer evidence that Modic changes are associated with nonspecific chronic lower back pain and that type 1 Modic changes are more painful than type 2.

CONCLUSIONS

Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. Clinical benefit of basivertebral nerve ablation observed in randomised controlled trials further supports the association between type 1 and type 2 Modic changes with pain and disability.

Expression of GADD45G and CAPRIN1 in Human Nucleus Pulposus: Implications for Intervertebral Disc Degeneration

Marked cellular changes occur in human intervertebral disc (IVD) degeneration during disc degeneration with biochemical changes. Genome-wide analysis of the DNA methylation profile has identified 220 differentially methylated loci associated with human IVD degeneration. Among these, two cell-cycle-associated genes, growth arrest and DNA damage 45 gamma (GADD45G) and cytoplasmic activation/proliferation-associated protein-1 (CAPRIN1), were focused on. The expression of GADD45G and CAPRIN1 in human IVDs remains unknown. We aimed to examine the expression of GADD45G and CAPRIN1 in human nucleus pulposus (NP) cells and evaluate those in human NP tissues in the early and advanced stages of degeneration according to Pfirrmann magnetic resonance imaging (MRI) and histological classifications. Human NP cells were cultured as monolayers after isolation from NP tissues by sequential enzyme digestion. Total RNA was isolated, and the mRNA expression of GADD45G and CAPRIN1 was quantified using real-time polymerase chain reaction. To examine the effects of pro-inflammatory cytokines on mRNA expression, human NP cells were cultured in the presence of IL-1β. Protein expression was evaluated using Western blotting and immunohistochemistry. GADD45G and CAPRIN1 expression was identified in human NP cells at both mRNA and protein levels. The percentage of cells immunopositive for GADD45G and CAPRIN1 significantly increased according to the Pfirrmann grade. A significant correlation between the histological degeneration score and the percentage of GADD45G-immunopositive cells was identified, but not with that of CAPRIN1-immunopositive cells. The expression of cell-cycle-associated proteins (GADD45G and CAPRIN1) was enhanced in human NP cells at an advanced stage of degeneration, suggesting that it may be regulated during the progression of IVD degeneration to maintain the integrity of human NP tissues by controlling cell proliferation and apoptosis under epigenetic alteration.

Revisiting chronic low back pain: evidence that it is not non-specific

CONTEXT

There is a common symptom pattern with most chronic low back pain (CLBP), suggesting that there is a common underlying etiology, belying the term "nonspecific." Many studies of CLBP and its treatment have been conducted with the assumption of nonspecificity, and as a result, treatment has not been focused, thus there has not been a significant change in CLBP prevalence over the past several decades. It is the thesis of this study to show that there is an underlying, specific cause of CLBP and that the presumption that CLBP is nonspecific is misdirected. The lumbosacropelvic (LSP) region, including the sacroiliac joint (SIJ), is part of a neuromusculoskeletal (NMSK) feedback system, and it is proposed here that CLBP is the result of a change in the feedback (afferent) aspect in that system.

OBJECTIVES

The objectives of this study are to show that CLBP presents as a pattern of symptoms that actually represents the final common pathway for a dysfunctional LSP joint system. Rather than being "nonspecific," the majority of CLBP has an underlying cause that is quite specific and predictable.

METHODS

A total of 252 patients were seen for CLBP, 67% of whom were diagnosed with an SIJ dysfunction. The presence of pain was recorded from seven structures most closely associated with CLBP. The conditional probabilities of having each pain generator given a SIJ dysfunction and an SIJ dysfunction given the presence of the pain generator were estimated, and associations were analyzed utilizing chi-square tests. Phi coefficients and odds ratios were utilized to quantify the strength of the association. The multivariable logistic regression model was fit to relate the presence or absence of the SIJ dysfunction to the seven pain generators.

RESULTS

The associations between SIJ dysfunction and each pain generator were statistically significant. Phi coefficients indicated moderate strengths of these bivariate associations. Iliolumbar ligament (ILL) and psoas muscle (PSM) were significant predictors of SIJ dysfunction in the multivariable model.

CONCLUSIONS

Seven pain generators had a strong association with SIJ dysfunction. This empirical clinical evidence supports our hypothesis that LSP system dysfunction, as evidenced by SIJ dysfunction, is a common source of symptom patterning associated with CLBP and is most likely the causal element. This is evidence that most CLBP is not "nonspecific" but rather the result of changes made by the NMSK control system for the LSP region.

Localization diagnosis of low back pain in a population-based study of a Japanese mountain village

PURPOSE

The purposes of this study were to investigate 1) the location of low back pain (LBP) and 2) the relationships between the location of LBP and the LBP intensity or the quality of life (QoL) in a population-based study.

METHODS

The location of LBP was categorized into four areas using palpation: midline of the lumbar region, paravertebral muscles, upper buttock, and sacroiliac joint. The extent of LBP in the situations/positions was assessed. The relationships between the location of LBP and the extent of LBP on the QoL were statistically analyzed.

RESULTS

174 participants (average age: 72.3 years-old) were analyzed in this study. 93 participants (53.4% of the total) who had experienced LBP in the past three months were included in the LBP-positive group. Numerical rating scale (NRS) scores of the LBP-positive group were highest in the standing position. 51.6% of the LBP-positive group had LBP at the midline of the lumbar region, 40.9% at the paravertebral muscles, 28.0% at the upper buttock, and 15.1% at the sacroiliac joint. In the standing position, NRS scores of LBP at the upper buttock were significantly higher than those at the midline of the lumbar region and the paravertebral muscles (P<0.05). The Oswestry Disability Index scores of participants who had pain at the upper buttock were significantly higher than those at the midline of the lumbar region or paravertebral muscles (P<0.05).

CONCLUSION

Our study was the first report to investigate the location of LBP using palpation in a population-based study. LBP localization was significantly associated with LBP intensity and LBP-related QoL.

Transcatheter Arterial Embolization for Alleviating Chronic Musculoskeletal Pain and Improving Physical Function: A Narrative Review

Chronic musculoskeletal pain imposes immense suffering and diminishes the quality of life for millions of patients worldwide; the pain persists despite the use of standard conservative treatments. Increases in our understanding of the pathophysiological mechanisms underlying musculoskeletal disorders indicate the involvement of inappropriate angiogenesis. Accordingly, the resulting neovessels are the target of emerging treatments for chronic musculoskeletal pain, including transarterial embolization. The use of this noninvasive procedure to treat pain refractory to standard therapy in a variety of musculoskeletal conditions is the focus of numerous recent investigations. Here, we describe the pathophysiological indications for the use of transarterial embolization and summarize the findings of studies investigating its use in a variety of histopathological conditions and anatomical sites.

Prevalence of chronic non-specific low back pain among caregivers of stroke survivors in Kano, Nigeria and factors associated with it: A cross-sectional study

Purpose

Low back pain (LBP) may have a specific or non-specific cause such as abnormal posture or repetitive tasks. For instance, lifting and transferring patients during caregiving for stroke survivors may predispose the caregivers to LBP.

Objectives

The aim of this study is to determine the prevalence of chronic non-specific LBP and factors associated with it in caregivers of stroke survivors.

Method

The research design used is cross-sectional study design. Participants of the study were caregivers of stroke survivors in Kano, Nigeria who were at least 18 years old. They were included if they had at least one-month experience with caregiving for at least 1 h per day. Presence of LBP and level of disability were assessed using participants' self-report and Rolland Morris Low Back Pain Disability Questionnaire respectively. The data collected was analyzed using descriptive, Chi-square statistics and Binary Logistics Regression.

Result

Three hundred caregivers with mean age, 33.24 ± 10.32 years in which 207 and 93 were males and females respectively, participated in the study. The results showed that, there was a high prevalence (64.7%) of LBP among the caregivers. The prevalence was significantly associated with gender (p < 0.001), age (p = 0.029), occupation (p < 0.001) and duration of caregiving (p < 0.001) of the study participants. In addition, the result of the regression model showed that, being a female (p = 0.001), a civil servant (p = 0.031), a trader (p = 0.013), and a complete caregiver (0.001); and caregiving for a duration of 5 h or more per day (p = 0.024) are significant predictors of having LBP. Similarly, level of disability due to the presence of LBP among the study participants was significantly associated with gender (p < 0.001), occupation (p < 0.001), duration of caregiving (p = 0.025), and the nature of the caregiving (p < 0.001).

Conclusion

Informal caregiving for stroke survivors may result in developing chronic non-specific LBP, especially among females, Civil servants, traders, complete caregivers and those with long duration of caregiving. This can add an additional burden on the family in terms of cost of care, result in reduced quality of caregiving and cause psychological stress. Thus, it is important the health of the caregivers of stroke survivors is considered during stroke rehabilitation.

Improvement in Disability Mediates the Effect of Self-Efficacy on Pain Relief in Chronic Low Back Pain Patients with Exercise Therapy

Background. The biopsychosocial mechanism by which exercise leads to improvement in chronic low back pain (CLBP) remains unstudied. This prospective cohort study was performed to examine the effectiveness of exercise on pain, disability, and psychological status for CLBP. We also tested path analytic models in which changes in these variables were included. Methods. CLBP patients who visited the Interdisciplinary Pain Center of Keio University Hospital from July 2018 to April 2020 were included. The propensity score matching was performed between patients who underwent exercise (the exercise group) and those who did not (the control group). At the first visit and at the 3-month follow-up, pain (Numerical Rating Scale (NRS)), disability (Pain Disability Assessment Scale (PDAS)), and psychological status (Pain Self-Efficacy Questionnaire (PSEQ), and Pain Catastrophizing Scale (PCS)) were assessed. Changes in pain and disability at the follow-up were compared between the groups. The relationships between changes in pain, disability, and psychological variables were examined using Pearson’s correlation and mediation analysis. Results. A significantly larger decrease in the PDAS was observed in the exercise group (N = 49) than in the control (N = 49) ( $p<0.05$ ). Increased PSEQ scores were significantly correlated with decreased NRS scores in both groups. In the exercise group, decreased PDAS fully mediated the relationship between increased PSEQ and decreased NRS ( $P<0.05$ ). Conclusion. Exercise improved disability, and the improved disability by exercise mediated the effect of increased self-efficacy on pain relief in CLBP patients.

New treatment strategy for chronic low back pain with alpha wave neurofeedback

The lifetime prevalence of low back pain is 83%. Since there is a lack of evidence for therapeutic effect by cognitive behavioral therapy (CBT) or physical therapy (PT), it is necessary to develop objective physiological indexes and effective treatments. We conducted a prospective longitudinal study to evaluate the treatment effects of CBT, PT, and neurofeedback training (NFT) during alpha wave NFT. The early-chronic cases within 1 year and late-chronic cases over 1 year after the diagnosis of chronic low back pain were classified into six groups: Controls, CBTs, PTs, NFTs, CBT-NFTs, PT-NFTs. We evaluated the difference in EEG, psychosocial factors, scores of low back pain before/after the intervention. Therapeutic effect was clearly more effective in the early-chronic cases. We found that the intensity of alpha waves increased significantly after therapeutic intervention in the NFT groups, but did not have the main effect of reducing low back pain; the interaction between CBT and NFT reduced low back pain. Factors that enhance therapeutic effect are early intervention, increased alpha waves, and self-efficacy due to parallel implementation of CBT/PT and NFT. A treatment protocol in which alpha wave neurofeedback training is subsidiarily used with CBT or PT should be developed in the future.

Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait

Unilateral knee extension restriction might change trunk alignment and increase mechanical load on the lumbar region during walking. We aimed to clarify lumbar region mechanical load during walking with restricted knee extension using a musculoskeletal model simulation. Seventeen healthy adult males were enrolled in this study. Participants walked 10 m at a comfortable velocity with and without restricted right knee extension of 15° and 30° using a knee brace. L4-5 joint moment, joint reaction force, and muscle forces around the lumbar region during walking were calculated for each condition. Peaks of kinetic data were compared among three gait conditions during 0%-30% and 50%-80% of the right gait cycle. Lumbar extension moment at early stance of the bilateral lower limbs was significantly increased in the 30° restricted condition (p ≤ 0.021). Muscle force of the multifidus showed peaks at stance phase of the contralateral side during walking, and the erector spinae showed force peaks at early stance of the bilateral lower limb. Muscle force of the multifidus and erector spinae increased with increasing degree of knee flexion (p ≤ 0.010), with a large effect size (η ² = 0.273-0.486). The joint force acting on L4-5 showed two peaks at early stance of the bilateral lower limbs during the walking cycle. The anterior and vertical joint force on L4-5 increased by 14.2%-36.5% and 10.0%-23.0% in walking with restricted knee extension, respectively (p ≤ 0.010), with a large effect size (η ² = 0.149-0.425). Restricted knee joint extension changed trunk alignment and increased the muscle force and the vertical and anterior joint force on the L4-5 joint during walking; this tendency became more obvious with increased restriction angle. Our results provide important information for therapists engaged in the rehabilitation of patients with knee contracture.

Development of a rat model with lumbar vertebral endplate lesion

PURPOSE

Vertebral endplate lesion (EPL) caused by severe disc degeneration is associated with low back pain. However, there is no suitable animal model to elucidate the pathophysiology of EPL. This study aimed to develop a rat model of EPL and evaluate rat behavior and imaging and histological findings.

METHODS

The L4-5 intervertebral discs of Sprague-Dawley rats were transperitoneally removed, except for the outer annulus fibrosus and cartilage endplate, in the EPL group. The L4-5 discs were not removed and simply exposed in the sham group. Changes around the vertebral endplate on magnetic resonance imaging (MRI) and computed tomography (CT) were evaluated. Additionally, pain-related behavioral and histological assessments were performed.

RESULTS

In the EPL group, a low-signal area around the vertebral endplate was observed on T1-weighted and T2-weighted fat-saturated MRI at 8 weeks or later after surgery. In the same group, CT showed osteosclerosis around the vertebral endplate at 12 weeks after surgery. The sham group did not show abnormal imaging features on the MRI and CT. Behavioral evaluation showed that the EPL group had a significantly longer grooming time than the sham group. Conversely, the 12-week postoperative locomotion time and the 1- and 12-week postoperative standing times were significantly shorter in the EPL group than in the sham group. Histological evaluation showed a high degree of vertebral endplate degeneration and an increased number of osteoclasts and proportion of nerve fibers expressing calcitonin gene-related peptide in the EPL group compared to those in the sham group.

CONCLUSION

Our rat EPL model showed pain-related behavioral patterns and an increased expression of pain-related neuropeptide. This model could contribute to the study of the pathophysiology of EPL and will help in the treatment of low back pain in the future.

A High Body Mass Index and the Vacuum Phenomenon Upregulate Pain-Related Molecules in Human Degenerated Intervertebral Discs

Animal studies suggest that pain-related-molecule upregulation in degenerated intervertebral discs (IVDs) potentially leads to low back pain (LBP). We hypothesized that IVD mechanical stress and axial loading contribute to discogenic LBP’s pathomechanism. This study aimed to elucidate the relationships among the clinical findings, radiographical findings, and pain-related-molecule expression in human degenerated IVDs. We harvested degenerated-IVD samples from 35 patients during spinal interbody fusion surgery. Pain-related molecules including tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, calcitonin gene-related peptide (CGRP), microsomal prostaglandin E synthase-1 (mPGES1), and nerve growth factor (NGF) were determined. We also recorded preoperative clinical findings including body mass index (BMI), Oswestry Disability Index (ODI), and radiographical findings including the vacuum phenomenon (VP) and spinal instability. Furthermore, we compared pain-related-molecule expression between the VP (−) and (+) groups. BMI was significantly correlated with the ODI, CGRP, and mPGES-1 levels. In the VP (+) group, mPGES-1 levels were significantly higher than in the VP (−) group. Additionally, CGRP and mPGES-1 were significantly correlated. Axial loading and mechanical stress correlated with CGRP and mPGES-1 expression and not with inflammatory cytokine or NGF expression. Therefore, axial loading and mechanical stress upregulate CGRP and mPGES-1 in human degenerated IVDs, potentially leading to chronic discogenic LBP.

Endplate defects, not the severity of spinal stenosis, contribute to low back pain in patients with lumbar spinal stenosis

BACKGROUND CONTEXT

It is controversial whether lumbar spinal stenosis (LSS) itself contributes to low back pain (LBP). Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to LBP. However, whether these factors cause LBP in patients with LSS is unclear.

PURPOSE

To identify factors associated with LBP in patients with LSS.

STUDY DESIGN/SETTING

Cross-sectional design.

PATIENT SAMPLE

A total of 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication caused by LSS, as confirmed by magnetic resonance imaging (MRI).

OUTCOME MEASURES

Ratings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-Item Short Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including slippage and lumbopelvic alignment. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were assessed on MRI.

METHODS

The presence of LBP was defined as an NRS score ≥3. The demographic data, patient-reported outcomes, and radiological and MRI findings were compared between patients with and without LBP. Multivariate logistic regression analysis was used to identify the factors that were independently associated with the presence of LBP.

RESULTS

There were significant differences between patients with and without LBP for buttock and leg pain and numbness on the NRS, general health on the SF-36, presence of endplate defects, presence of Modic changes, disc degeneration grading, and disc height grading (all p < .05). Multivariate logistic regression analysis showed significant associations between LBP and diabetes (OR 2.43; 95% CI 1.07-5.53), buttock and leg numbness on the NRS (OR 1.34; 95% CI 1.17-1.52), general health on the SF-36 (OR 0.97; 95% CI 0.95-0.99), and the presence of erosive endplate defects (OR 3.04; 95% CI 1.51-6.11) (all p < .05).

CONCLUSIONS

These results suggest that LBP in patients with LSS should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.

Intermittent pain in patients with chronic low back pain is associated with abnormalities in muscles and fascia

We investigated the relationship between paravertebral muscles and perimuscular connective tissues of the thoracolumbar fascia region and the four types of pain in patients suffering from chronic low back pain. A total of 17 patients with chronic low back pain participated in this study. Ultrasound imaging method was used to measure the thickness and echogenicity of the paravertebral muscles and perimuscular connective tissues. The measurement site considered in this study was located lateral to the midpoint between L2-3 and L4-5 spines. In addition, age, gender, BMI, numerical rating scale and the short-form McGill pain questionnaire 2 (includes questions with respect to continuous pain, intermittent pain, neuropathic pain and affective descriptors) were used for assessment. Statistical analysis was performed using correlation analysis and multiple regression analysis. A significant association was observed between paravertebral muscle echogenicity at L2-3 and the numerical rating scale (r = 0.499), between paravertebral muscle echogenicity at L4-5 with numerical rating scale (r = 0.538) and intermittent pain (r = 0.594), and between perimuscular connective tissue thickness at L2-3 and numerical rating scale (r = 0.762). We observed that the factor influencing perimuscular connective tissue thickness at L2-3 and L4-5 was intermittent pain (β = 0.513, β = 0.597, respectively). It was also observed that some of the imaging findings were associated with age and BMI. In conclusion, we observed that paravertebral muscle echogenicity and perimuscular connective tissue thickness in patients with chronic low back pain were associated with pain, especially intermittent pain.

Is radiographic lumbar spinal stenosis associated with the quality of life?: The Wakayama Spine Study

Objectives

This prospective study aimed to determine the association between radiographic lumbar spinal stenosis (LSS) and the quality of life (QOL) in the general Japanese population.

Methods

The severity of radiographic LSS was qualitatively graded on axial magnetic resonance images as follows: no stenosis, mild stenosis with ≤1/3 narrowing, moderate stenosis with a narrowing between 1/3 and 2/3, and severe stenosis with > 2/3 narrowing. Patients less than 40 years of age and those who had undergone previous lumbar spine surgery were excluded from the study. The Oswestry Disability Index (ODI), which includes 10 sections, was used to assess the QOL. One-way analysis of variance was performed to determine the statistical relationship between radiographic LSS and ODI. Further, logistic regression analysis adjusted for gender, age, and body mass index was performed to detect the relationship.

Results

Complete data were available for 907 patients (300 men and 607 women; mean age, 67.3±12.4 years). The prevalence of severe, moderate, and non-mild/non-radiographic were 30%, 48%, and 22%, respectively. In addition, the mean values of ODI in each group were 12.9%, 13.1%, and 11.7%, respectively, and there was no statistically significant difference between the three groups in logistic analysis (P = 0.55). In addition, no significant differences in any section of the ODI were observed among the groups. However, severe radiographic LSS was associated with low back pain in the "severe" group as determined by logistic analysis adjusted for gender, age, and body mass index (odds ratio: 1.53, confidence interval: 1.13–2.07) compared with the non-severe group.

Conclusion

In this general population study, severe radiographic LSS was associated with low back pain (LBP), but did not affect ODI.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Intradiscal injection of monosodium iodoacetate induces intervertebral disc degeneration in an experimental rabbit model

Background

Establishing an optimal animal model for intervertebral disc (IVD) degeneration is essential for developing new IVD therapies. The intra-articular injection of monosodium iodoacetate (MIA), which is commonly used in animal models of osteoarthritis, induces cartilage degeneration and progressive arthritis in a dose- and time-dependent manner. The purpose of this study was to determine the effect of MIA injections into rabbit IVDs on the progression of IVD degeneration evaluated by radiographic, micro-computerized tomography (micro-CT), magnetic resonance imaging (MRI), and histological analyses.

Methods

In total, 24 New Zealand White (NZW) rabbits were used in this study. Under general anesthesia, lumbar discs from L1–L2 to L4–L5 had a posterolateral percutaneous injection of MIA in contrast agent (CA) (L1–L2: CA only; L2–L3: MIA 0.01 mg; L3–L4: 0.1 mg; L4–L5: 1.0 mg; L5–L6: non-injection (NI) control). Disc height was radiographically monitored biweekly until 12 weeks after injection. Six rabbits were sacrificed at 2, 4, 8, and 12 weeks post-injection and processed for micro-CT, MRI (T2-mapping), and histological analyses. Three-dimensional (3D) disc height in five anatomical zones was evaluated by 3D reconstruction of micro-CT data.

Results

Disc height of MIA-injected discs (L2–L3 to L4–L5) gradually decreased time-dependently (P < 0.0001). The disc height of MIA 0.01 mg-injected discs was significantly higher than those of MIA 0.1 and 1.0 mg-injected discs (P < 0.01, respectively). 3D micro-CT analysis showed the dose- and time-dependent decrease of 3D disc height of MIA-injected discs predominantly in the posterior annulus fibrosus (AF) zone. MRI T2 values of MIA 0.1 and 1.0 mg-injected discs were significantly decreased compared to those of CA and/or NI controls (P < 0.05). Histological analyses showed progressive time- and dose-degenerative changes in the discs injected with MIA (P < 0.01). MIA induced cell death in the rabbit nucleus pulposus with a high percentage, while the percentage of cell clones was low.

Conclusions

The results of this study showed, for the first time, that the intradiscal injection of MIA induced degenerative changes of rabbit IVDs in a time- and dose-dependent manner. This study suggests that MIA injection into rabbit IVDs could be used as an animal model of IVD degeneration for developing future treatments.

Repeated standing back extension exercise: Influence on muscle shear modulus change after lumbodorsal muscle fatigue

BACKGROUND

In low back pain, multifidus muscle fibers reportedly exhibit increased stiffness. Low back pain was associated with lumbodorsal muscle fatigue. There is no report of using shear modulus to verify the mechanism of an immediate effect of exercise on low back pain. Here, temporary lumbodorsal muscle fatigue was created, simulating fatigue-related nonspecific low back pain.

OBJECTIVE

To assess the effect of standing back extension exercise on fatigued lumbodorsal muscle based on the results of multifidus muscle elasticity measured using shear wave elastography.

METHODS

Thirty-three healthy subjects were randomly divided into three groups. The subjects performed the Biering-Sorensen test as the fatigue-task of the lumbodorsal muscle before the standing back extension exercise. The fatigue-exercise group exercised five sets after completing the fatigue-task. The fatigue-non-exercise group remained standing for the same duration as the fatigue-exercise group without doing the exercise after the fatigue-task. The non-fatigue-exercise group exercised five sets of without performing the fatigue-task. As intra-group and inter-group factors, the shear modulus of the multifidus muscle was compared before and after the exercise.

RESULTS

The shear modulus of the multifidus muscle after the standing back extension exercise was significantly lower in the fatigue-exercise group, and no significant decrease was observed in the fatigue-non-exercise and non-fatigue-exercise group.

CONCLUSIONS

The standing back extension exercise improved the shear modulus of the fatigued multifidus muscle. Therefore, it was suggested that the change in the elasticity of fatigued muscle might lead to the prevention of low back pain caused by muscle fatigue.

Background factors for chronic low back pain resistant to cognitive behavioral therapy

This study examined the factors that inhibit the therapeutic effects of cognitive behavioral therapy (CBT) and clarify the adaptation judgment criteria of CBT. We included patients with chronic low back pain and allocated them to the adaptation (with visual analog scale [VAS] improvement) or non-adaptation group (without VAS improvement). The patients were analyzed using various psychological tests. CBT improved depressive symptoms and catastrophic thinking; however, they were not correlated with the VAS and did not directly affect low back pain improvement. The non-adaptation group showed an unexplainable/vague sense of anxiety; an excessive focus on searching for pain; a strong intimacy desire; a strong tendency of medical dependency; and fantasy or distortion of the actual experience, especially self-image. Moreover, the patients showed a low ability to objectively express or attribute meaning to pain due to poor language skills, attention-deficit hyperactivity disorder, and emotional value judgment. Individuals with the aforementioned characteristics of pre-CBT psychological tests should select a different treatment approach given the high poor-adaption possibility. Even patients with depressive or anxious symptoms are not necessarily adaptable for CBT. Therefore, pre-CBT tests for treatment suitability are necessary. Future studies should establish a protocol for psychotherapy suitable for the non-adaptation group.

Ultrasound-guided total dorsal ramus block for the treatment of chronic low back pain

Background:

To reduce the risk of radiation exposure, we explored whether the total dorsal ramus block can be performed under ultrasound guidance. We evaluated the accuracy and effect of ultrasound-guided total dorsal ramus block for chronic low back pain.

Methods:

Accuracy of ultrasound guidance after total dorsal ramus block to the L4–L5 level was evaluated using fluoroscopy ( n = 5). A second group was assigned into two groups: ultrasound-guided group ( n = 19) or fluoroscopy-guided group ( n = 18). The effects and adverse events were compared.

Results:

In all cases, the fluoroscopic findings revealed an accurate injection at the L5 level. Significant alleviation of pain was observed after ultrasound-guided total dorsal ramus block, and comparable effectiveness was observed with both ultrasound guidance and fluoroscopic guidance. There were no complications.

Conclusions:

The ultrasound-guided total dorsal ramus block may sufficiently block all three branches of the lumbar dorsal ramus at the targeted level resulting in significant pain reduction.

Magnetic Resonance Spectroscopic Analysis of Multifidus Muscle Lipid Contents and Association with Nociceptive Pain in Chronic Low Back Pain

Study Design

Cross-sectional study.

Purpose

This study aimed to analyze the differences in the lipid contents in chronic low back pain (CLBP) patients with nociceptive pain (NocP) and neuropathic pain (NeP) using magnetic resonance spectroscopy (MRS) of the multifidus muscle (Mm).

Overview of Literature

Early identification of the pain characteristics with CLBP is important because specific treatment approaches are required, depending on NocP and NeP.

Methods

The participants were 50 patients with CLBP (23 men and 27 women; mean age, 63.1±17.8 years; range, 41–79 years). We compared the Visual Analog Scale (VAS) scores, intramyocellular lipids (IMCLs) and extramyocellular lipids (EMCLs) of the Mm in NocP and NeP groups, as evaluated with the Japanese NeP screening questionnaire.

Results

The patients were categorized into the NocP (n=32) and NeP (n=18) groups. The mean VAS score of the NocP group was 59.3±3.1 mm and that of the NeP group was 73.6±4.6 mm. The mean VAS score was significantly higher in the NeP group as compared to that in the NocP group (p<0.01). As per the analysis of covariance for the VAS score, the mean IMCL levels of the Mm in the NocP and NeP groups were 722.3 mmol/L (95% confidence interval [CI], 611.4–833.1) and 484.8 mmol/L (95% CI, 381.1–588.5), respectively. The mean IMCL level was significantly higher in the NocP group than in the NeP group (p<0.05). The mean EMCL levels of the Mm for the NocP and NeP groups were 6,022.9 mmol/L (95% CI, 4,510.6–7,535.2) and 5,558.1 mmol/L (95% CI, 4,298.3–6,817.9), respectively; however, the difference was not significant (p=0.72).

Conclusions

The results indicated an association between the IMCL level of the Mm and NocP. Our results suggest that MRS of the Mm might be beneficial for the assessment of CLBP as well as appropriate targeted analgesic therapies.

Quality of life effects of pain from para-lumbar- and lower extremity entrapment syndrome and carpal tunnel syndrome and comparison of the effectiveness of surgery

INTRODUCTION

We compared the preoperative quality of life (QOL) of patients with carpal tunnel syndrome, lower extremity-, and para-lumbar entrapment syndrome, and the effect of surgery on their QOL.

PATIENTS AND METHODS

We prospectively enrolled 66 consecutive patients who underwent surgery for carpal tunnel syndrome (group 1, n = 23), lower extremity entrapment syndrome (group 2, n = 22), and para-lumbar entrapment syndrome (group 3, n = 21). Their pre- and postoperative overall health status was assessed on the Medical Outcomes Study Short-Form 36 Health Survey, v2 (SF-36).

RESULTS

Except for the mental component summary, the preoperative score for items rated on the SF-36 was significantly lower in group 3 than in groups 1 and 2 (p < 0.05). In all 66 patients, the scores for bodily pain (BP) and the physical component summary (PCS) were significantly lower (p < 0.05) than the national standard, as was the score for physical functioning (PF) in groups 2 and 3. After surgery, PF of group 2 and PF, BP, and PCS of group 3 improved significantly (p < 0.05).

CONCLUSION

The detrimental QOL effects are stronger in patients with para-lumbar- or lower extremity entrapment syndrome than in patients with carpal tunnel syndrome.

Meta-Analysis of Integrated Therapeutic Methods in Noninvasive Lower Back Pain Therapy (LBP): The Role of Interdisciplinary Functional Diagnostics

Introduction. Lower back pain (LBP) is almost a problem of civilizations. Quite often, it is a consequence of many years of disturbed distribution of tension within the human body caused by local conditions (injuries, hernias, stenoses, spondylolisthesis, cancer, etc.), global factors (postural defects, structural integration disorders, lifestyle, type of activity, etc.), or systemic diseases (connective tissue, inflammation, tumours, abdominal aneurysm, and kidney diseases, including urolithiasis, endometriosis, and prostatitis). Therefore, LBP rehabilitation requires the use of integrated therapeutic methods, combining the competences of interdisciplinary teams, both in the process of diagnosis and treatment. Aim of the Study. Given the above, the authors of the article conducted meta-analysis of the literature in terms of integrated therapeutic methods, indicating the techniques focused on a holistic approach to the patient. The aim of the article is to provide the reader with comprehensive knowledge about treating LBP using noninterventional methods. Material and Methods. An extensive search for the materials was conducted online using PubMed, the Cochrane database, and Embase. The most common noninterventional methods have been described, as well as the most relevantly updated and previously referenced treatment of LBP. The authors also proposed noninvasive (measurable) diagnostic procedures for the functional assessment of the musculoskeletal system, including initial, systematic, and cross-sectional control. All figures and images have been prepared by the authors and are their property.

Results

This review article goes beyond combining a detailed description of each procedure with full references, as well as a comprehensive discussion of this very complex and troublesome problem.

Conclusions

Lower back pain is a serious health problem, and this review article will help educate physicians and physiotherapists dealing with LBP in the options of evidence-based treatment. Ultimately, the article introduces and postulates the need to systematize therapeutic procedures in LBP therapy, with a long-term perspective.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

Genome-wide analysis of DNA methylation profile identifies differentially methylated loci associated with human intervertebral disc degeneration

BACKGROUND

Environmental and endogenous factors under genetic predisposition are considered to initiate the human intervertebral disc (IVD) degeneration. DNA methylation is an essential mechanism to ensure cell-specific gene expression for normal development and tissue stability. Aberrant epigenetic alterations play a pivotal role in several diseases, including osteoarthritis. However, epigenetic alternations, including DNA methylation, in IVD degeneration have not been evaluated. The purpose of this study was to comprehensively compare the genome-wide DNA methylation profiles of human IVD tissues, specifically nucleus pulpous (NP) tissues, with early and advanced stages of disc degeneration.

METHODS

Human NP tissues were used in this study. The samples were divided into two groups: early stage degeneration (n = 8, Pfirrmann's MRI grade: I-III) and advanced stage degeneration (n = 8, grade: IV). Genomic DNA was processed for genome-wide DNA methylation profiling using the Infinium MethylationEPIC BeadChip array. Extraction of raw methylation data, clustering and scatter plot of each group values of each sample were performed using a methylation module in GenomeStudio software. The identification of differentially methylated loci (DMLs) and the Gene Ontology (GO) analysis were performed using R software with the ChAMP package.

RESULTS

Unsupervised hierarchical clustering revealed that early and advanced stage degenerated IVD samples segregated into two main clusters by their DNA methylome. A total of 220 DMLs were identified between early and advanced disc degeneration stages. Among these, four loci were hypomethylated and 216 loci were hypermethylated in the advanced disc degeneration stage. The GO enrichment analysis of genes containing DMLs identified two significant GO terms for biological processes, hemophilic cell adhesion and cell-cell adhesion.

CONCLUSIONS

We conducted a genome-wide DNA methylation profile comparative study and observed significant differences in DNA methylation profiles between early and advanced stages of human IVD degeneration. These results implicate DNA methylation in the process of human IVD degeneration.

Height loss but not body composition is related to low back pain in community-dwelling elderlies: Shimane CoHRE study

Background

Low back pain (LBP) is a common complaint in the elderly Japanese population. Although previous studies showed that height loss was associated with LBP, it remains unclear whether LBP is associated with body composition. The objective of the present study was to investigate whether body composition and physical characteristics, including height loss, were associated with LBP.

Methods

The present study is retrospectively registered, and the participants were 2212 community-dwelling Japanese people aged over 60 years who participated in the Shimane CoHRE study in 2016. We investigated the presence of LBP, body composition parameters (muscle, fat, body weight, and bone mass), physical characteristics (body height and height loss), chronic diseases, history of fall, smoking, and drinking habits. We examined the relationships of body composition parameters and physical characteristics with point prevalence of LBP using multivariate logistic regression.

Results

The point prevalence of LBP was 43.2% in women and 39.5% in men. Logistic regression models showed that body height and body composition were not significantly associated with LBP; however, height loss was associated significantly with LBP in women and men (OR: 1.14, 95% CI: 1.08–1.20 and OR: 1.13, 95% CI: 1.06–1.21, respectively). Hypertension (OR: 1.32, 9 5% CI: 1.04–1.69) and chronic heart disease (OR: 1.57, 95% CI: 1.01–2.43) in women and history of fall (OR: 1.70, 95% CI: 1.13–2.56) and cerebrovascular disease (OR: 1.88, 95% CI: 1.05–3.34) in men were significantly associated with LBP. However, body composition was not associated with LBP in either gender.

Conclusions

The present study demonstrated that height loss, but not body composition, was related to LBP in community-dwelling elderly people. To elucidate the cause of LBP, it is important to consider the relationship with height loss.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2580-6) contains supplementary material, which is available to authorized users.

Low Back Pain in Adolescent Athletes: Comparison of Diagnoses Made by General Orthopedic Surgeons and Spine Surgeons

Background

Nonspecific low back pain (NSLBP) is a term used to describe low back pain of unknown origin with no identifiable generators. Over a decade ago, it was reported to account for about 85% of all cases of low back pain, although there is some doubt about the frequency. The purpose of this study was to determine the frequency of NSLBP in adolescent athletes diagnosed by general orthopedic surgeons and by spine surgeons.

Materials and Methods

A total of 69 adolescent athletes consulted our sports spine clinic to seek a second opinion for low back pain. Data on age, sex, type of sport played, the previous diagnosis made by general orthopedic surgeons, and the final diagnosis made by spine surgeons were collected retrospectively from medical records.

Results

The frequency of NSLBP diagnosed by general orthopedic surgeons was 18.9% and decreased to 1.4% after careful imaging and functional nerve block examination by spine surgeons. The final diagnoses made by spine surgeons for those patients previously diagnosed as having NSLBP by general orthopedic surgeons were as follows: early-stage lumbar spondylolysis, discogenic low back pain, facet joint arthritis, lumbar disc herniation, and lumbar apophyseal ring fracture.

Conclusions

In adolescent athletes, the rate of NSLBP diagnosed by general orthopedic surgeons decreased markedly when the diagnosis was made by spine surgeons. A thorough medical interview, careful physical examination, appropriate diagnostic imaging, and selective nerve block examination can effectively identify the cause of low back pain.

Platelet-rich plasma in the management of chronic low back pain: a critical review

Low back pain (LBP) is now regarded as the first cause of disability worldwide and should be a priority for future research on prevention and therapy. Intervertebral disc (IVD) degeneration is an important pathogenesis of LBP. Platelet-rich plasma (PRP) is an autologous blood concentrate that contains a natural concentration of autologous growth factors and cytokines and is currently widely used in the clinical setting for tissue regeneration and repair. PRP has great potential to stimulate cell proliferation and metabolic activity of IVD cells in vitro. Several animal studies have shown that the injection of PRP into degenerated IVDs is effective in restoring structural changes (IVD height) and improving the matrix integrity of degenerated IVDs as evaluated by magnetic resonance imaging (MRI) and histology. The results of this basic research have shown the great possibility that PRP has significant biological effects for tissue repair to counteract IVD degeneration. Clinical studies for evaluating the effects of the injection of PRP into degenerated IVDs for patients with discogenic LBP have been reviewed. Although there was only one double-blind randomized controlled trial, all the studies reported that PRP was safe and effective in reducing back pain. While the clinical evidence of tissue repair of IVDs by PRP treatment is currently lacking, there is a great possibility that the application of PRP has the potential to lead to a feasible intradiscal therapy for the treatment of degenerative disc diseases. Further large-scale studies may be required to confirm the clinical evidence of PRP for the treatment of discogenic LBP.

Effectiveness of active soft tissue release and trigger point block for the diagnosis and treatment of low back and leg pain of predominantly gluteus medius origin: a report of 115 cases

[Purpose] Ineffective and prolonged treatment of low back pain is a major social problem resulting in a huge economic burden. The effectiveness of back pain and/or leg pain treatment using active soft tissue release alone or in combination with a trigger point block was examined. [Participants and Methods] Among 115 patients who underwent medical examination at Senshunkai Hospital during the study period, information on treatment outcomes using active soft tissue release alone or in combination with a trigger point block, location of myofascial trigger points, and duration of treatment were extracted for patients with low back pain, leg pain, or low back pain with leg pain. [Results] Myofascial pain syndrome was diagnosed in 73.4% (36/49) in the low back pain group, 50% (16/32) in the leg pain group, and 85.3% (29/34) in the low back pain with leg pain group. Symptom improvement was noted in all three groups with active soft tissue release alone (90.9%, 20/22; 90.0%, 9/10; and 100%, 14/14, respectively) and active soft tissue release + a trigger point block (90.9%, 10/11; 100%, 1/1; and 92.9%, 13/14, respectively). The gluteus medius was the major myofascial trigger point in all groups. [Conclusion] Manual therapy with active soft tissue release and a trigger point block constitutes an effective treatment combination for low back pain and leg pain, but prolonged treatment is required in chronic cases.

The Impact of Chronic Discogenic Low Back Pain: Costs and Patients' Burden

Introduction

Chronic discogenic low back pain (CDP) is frequently diagnosed in patients referred to specialized pain clinics for their back pain. The aim of this study is to assess the impact of CDP both on the individual patient and on society.

Materials and Methods

Using the baseline records of 80 patients in a randomized trial assessing the effectiveness of a new intervention for CDP, healthcare and societal costs related to back pain are calculated. Furthermore, the impact of the condition on perceived pain, disability, health-related quality of life, Quality of life Adjusted Life Years (QALY), and QALY loss is assessed.

Results

Using the friction costs approach, we found that the annual costs for society are €7,911.95 per CDP patient, 51% healthcare and 49% societal costs. When using the human capital approach, total costs were €18,940.58, 22% healthcare and 78% societal costs. Healthcare costs were mainly related to pain treatment. Mean pain severity was 6.5 (0-10), and 46% suffered from severe pain (≥7/10). Mean physical limitations rate was 43.7; 13.5% of the patients were very limited to disabled. QALY loss compared to a healthy population was 64%.

Discussion

This study shows that in patients with CDP referred to a pain clinic, costs for society are high and the most used healthcare resources are pain therapies. Patients suffer severe pain, are physically limited, and experience a serious loss in quality of life.

Clinical diagnosis scale for pain lumbar of facet origin: systematic review of literature and pilot study

INTRODUCTION

Lumbar pain affects between 60-90% of people. It is a frequent cause of disability in adults. Pain may be generated by different anatomical structures such as the facet joint. However, nowadays pain produced by the facet joint has no clinical diagnosis. Therefore, the purpose of this article is to propose a clinical diagnostic scale for lumbar facet syndrome.

MATERIALS AND METHODS

The study was conducted by means of 6 phases as follows, Phase 1, a systematic review of the literature was performed regarding the clinical diagnosis of facet-based lumbar pain based on the PRISMA checklist; Phase 2, a list of signs and symptoms proposed for diagnosis lumbar pain of facet origin was made. Phase 3, the list of signs and symptoms found was submitted to a committee of experts to discriminate the most significant signs and symptoms, these were linked to general sociodemographic variables to develop an evaluation questionnaire; Phase 4, the evaluation questionnaire was applied, including those selected signs and symptoms to a group of patients with clinical diagnosis of facet disease lumbar pain and who underwent a selective facet block. Phase 5, under standard technique selective facet block and subsequent postoperative clinical control at 1 month. Phase 6, given pre and postsurgical results associated with signs present in the patients we propose a clinical scale of diagnosis scale. Descriptive statistics and Stata 12.0 were used as statistical software.

RESULTS

A total of 36 signs and symptoms were found for the diagnosis of lumbar facet syndrome that were submitted to the group of experts, where a total of 12 (8 symptoms and 4 signs) were included for the final survey. 31 patients underwent selective lumbar facet blockade, mostly women, with an average of 60±11.5 years, analogous visual scale of preoperative pain of 8/10, postoperative of 1.7/10, the signs and symptoms most frequently found included in a diagnostic scale were: 3 symptoms 1) axial or bilateral axial lumbar pain, 2) improvement with rest, 3) absence of root pattern, may have pseudoradicular pattern, however, the pain is greater lumbar than pain in the leg and 3 clinical signs 1) Kemp sign, 2) pain induced in joint or transverse process, 3) facet stress sign or Acevedo sign.

CONCLUSION

The clinical diagnosis of lumbar facet pain is still debated. Few diagnostic scales have been postulated, with little or no external validity, so the present study proposes a diagnostic scale consisting of 3 symptoms and 3 clinical signs.