Presence and extent of severe facet joint osteoarthritis are associated with back pain in older adults

OBJECTIVE

To determine whether the presence and extent of severe lumbar facet joint osteoarthritis (OA) are associated with back pain in older adults, accounting for disc height narrowing and other covariates.

DESIGN

Two hundred and fifty-two older adults from the Framingham Offspring Cohort (mean age 67 years) were studied. Participants received standardized computed tomography (CT) assessments of lumbar facet joint OA and disc height narrowing at the L2-S1 interspaces using four-grade semi-quantitative scales. Severe facet joint OA was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intraarticular vacuum phenomenon. Severe disc height narrowing was defined as marked narrowing with endplates almost in contact. Back pain was defined as participant report of pain on most days or all days in the past 12 months. We used multivariable logistic regression to examine associations between severe facet joint OA and back pain, adjusting for key covariates including disc height narrowing, sociodemographics, anthropometrics, and health factors.

RESULTS

Severe facet joint OA was more common in participants with back pain than those without (63.2% vs 46.7%; P = 0.03). In multivariable analyses, presence of any severe facet joint OA remained significantly associated with back pain (odds ratio (OR) 2.15 [95% confidence interval (CI) 1.13-4.08]). Each additional joint with severe OA conferred greater odds of back pain [OR per joint 1.20 (95% CI 1.02-1.41)].

CONCLUSIONS

The presence and extent of severe facet joint OA on CT imaging are associated with back pain in community-based older adults, independent of sociodemographics, health factors, and disc height narrowing.

Randomized trial comparing the effects of one set vs two sets of resistance exercises for outpatients with chronic low back pain and leg pain

AIM

Progressive resistance exercises (PRE) are prescribed to reverse the deconditioning associated with chronic back pain. The spine rehabilitation program has utilized 2 sets of progressive resistance exercises during each session, with increased resistance between sets, and with successive sessions. Exercise literature has challenged the need for multiple sets of resistance exercises, with a single set producing similar functional benefits. The authors studied whether completing 1 versus 2 sets of resistance exercises would affect strength, pain and disability outcomes in subjects with chronic low back pain (CLBP).

METHODS

The study randomly assigned subjects with CLBP to perform either 1 set or 2 sets of progressive resistance exercises during otherwise identical spine rehabilitation programs. The patient sample included 100 subjects (36 male patients, 64 female patients, mean age 46 years) with chronic back pain referred to spine rehabilitation. Primary outcomes were back strength and progressive isoinertial lifting evaluation (PILE) at discharge. Secondary outcomes were Oswestry disability (0-100) and pain scores (0-10). Exercises consisted of Cybex back extension, rotary torso, pull downs, and multi-hip; lifting of crates from floor-to-waist (lumbar) and waist-to-shoulder (cervical) heights. The maximum levels of exercises were determined using a four repetition to maximum protocol, and the PILE.

RESULTS

At discharge, there was no significant difference in strength, disability or pain measures between subjects completing 1 versus 2 sets of resistance exercises.

CONCLUSION

These findings suggest that there were no added benefits for completing a second set of resistance exercises during therapy sessions for patients with CLBP.

Exploration of physicians' recommendations for activities in chronic low back pain

STUDY DESIGN

A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients.

OBJECTIVES

To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations.

SUMMARY OF BACKGROUND DATA

Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations.

METHODS

Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders.

RESULTS

Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms.

CONCLUSIONS

Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.

Long-term exercise adherence after intensive rehabilitation for chronic low back pain

PURPOSE

The purpose of this study was to examine exercise compliance in patients with chronic low back pain (CLBP) after participation in an intensive spine rehabilitation program.

METHODS

Exercise behaviors in 122 consecutive subjects with CLBP who completed a program of quota based exercise were examined. Frequency per week of performance of four exercise activities, Oswestry disability scores, and visual analog scale (VAS) scores were assessed at evaluation, 3-month, and 12-month follow-up by patient-completed questionnaires.

RESULTS

Percentage of patients responding to initial, 3-month, and 12-month questionnaires were 100%, 86%, and 71%, respectively. Frequencies of exercise behaviors were compared by Wilcoxon signed-rank test and were found to increase significantly between evaluation and 3 months (P < 0.000), and evaluation and 12-month follow-up (P < 0.000). The percentages of patients reporting three or more times weekly performance of the following activities at evaluation and at three month follow-up, respectively, were: 1) stretching for the back and legs, 35% and 93%; 2) aerobic exercise, 44% and 87%; 3) back-strengthening exercises, 15% and 82%; and, 4) weight training, 6% and 71%. Evaluation and follow-up Oswestry disability and visual analog scale (VAS) scores for back pain were compared using Student's t-test. Significant improvements (P < 0.000) were noted for each of these scales at 3-month follow-up that were maintained at 12-month follow-up.

CONCLUSION

It is concluded that exercise behaviors can be increased and maintained in CLBP patients without adversely affecting pain or function.

Decreasing disability in chronic back pain through aggressive spine rehabilitation

This paper discusses specific techniques for rehabilitation of chronic low back pain through aggressive physical therapy with behavioral support. The rationale for approaching the outcome dimensions of impairments in back function and pain-related disability as opposed to chronic pain symptoms is explained. This approach requires that impairments in back function are systematically identified through the quantification of trunk flexibility, straight leg raising, back extensor strength, lifting ability, and endurance. The described treatment approach focuses on eliminating those impairments through aggressive, quota-based exercise and is usually completed within 8 weeks. It requires only a modest amount of space and equipment. Useful behavioral techniques for extinguishing pain behaviors, lessening pain beliefs, and for promoting wellness are described. Results from a treatment program using these techniques demonstrate normal back function and reduced disability for a majority of treated persons. Applying such a program to the VA population is an important challenge.

The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain

STUDY DESIGN

In this prospective, observational, cohort study of 192 individuals with chronic low back pain, the group of individuals was divided based on compensation involvement, and their presentation pain and disability, treatment recommendations, and compliance were compared. For 85 of these individuals who completed a spine rehabilitation program, their pain and disability at 3 and 12 months were compared.

OBJECTIVES

To test the theory that individuals with compensation involvement presented with greater pain and disability and would report less change of pain and disability after rehabilitation efforts.

BACKGROUND

Previous studies have produced conflicting results concerning this issue.

METHODS

Individuals were recruited as consecutive patients referred for consultation at a spine rehabilitation center. Pain, depression, and disability were assessed using self-report questionnaires at evaluation and at 3 and 12 months. Rehabilitation services consisted of aggressive, quota-based exercises aimed at correcting impairments in flexibility, strength, endurance, and lifting capacity, identified through quantification of back function. Multifactoral analysis of variance models were used to control for baseline differences between compensation and noncompensation patients during analysis of target variables.

RESULTS

The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and noncompensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow-up visit, pain scores improved for the noncompensation group, but not for the compensation group.

CONCLUSIONS

In chronic low back pain, compensation involvement may have an adverse effect on self-reported pain, depression, and disability before and after rehabilitation interventions.

Low back and cervical spine disorders

Neck and back pain are common work-related complaints. The natural history of these symptoms favors rapid recovery. Medical management of workers with these complaints relies on carefully managing this natural history, while attempting to minimize the resulting disability. Medical advice should focus on decreasing patients' fears and encouraging a rapid return to function (including work) as acute pain symptoms improve. Interventions should be as limited as possible and promote self care. Patients with radicular symptoms may require additional interventions but, there, too, the natural history is favorable. Surgery may be necessary in a small percentage of patients with catastrophic and severe neurologic symptoms or persistent, severe pain. Chronic neck and back pain symptoms are commonly encountered. Medical and reversible causes of pain should be sought in such patients. When none is found, interventions aimed at maximizing back and neck function and improving tolerance for physical activities may be beneficial in returning these workers to productive lifestyles.

Health care providers' attitudes and beliefs about functional impairments and chronic back pain

OBJECTIVE

This study validated a measure entitled the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) for assessing the attitudes and beliefs of health care providers about functional expectation for chronic low back pain patients. HC-PAIRS was developed by modifying the Pain and Impairment Relationship Scale (PAIRS) used to assess the attitudes and beliefs of chronic pain patients.

DESIGN

This study surveyed 150 community health care providers and 66 functional restoration providers using HC-PAIRS. HC-PAIRS consists of 15 items attributing back pain patients' impairment and disability to pain, followed by a seven-point Likert scale anchored with degrees of agreement and disagreement. Reliability of HC-PAIRS was determined using Cronbach's alpha. Factor analysis was performed to explore the dimensions of attitudes and beliefs. Validity was determined by HC-PAIRS accurately measuring the pain attitudes and beliefs of functional restoration providers, who have a stated philosophy concerning this notion.

RESULTS

For the 150 community health care providers, HC-PAIRS revealed a Cronbach's alpha of 0.78. Factor analysis showed four dimensions of attitudes and beliefs measures by HC-PAIRS, which were entitled "functional expectations," "social expectations," "need for cure," and "projected cognition." Community providers showed a mean score of 52 (S.D. = 10). Most respondents were neutral or disagreed somewhat with the notion that chronic back pain should limit functional performance, but a wide range of responses were noted (range 33-80), indicating that diverse pain attitudes and beliefs are held. The 66 functional restoration providers had a mean HC-PAIRS score of 38 (S.D. = 7), and a range of scores from 26 to 52 was found. As expected, these scores corresponded to disagreement with the notion that chronic low back pain justifies impairments and disability. This was accurately measured by HC-PAIRS and is evidence of HC-PAIRS validity. Comparison of HC-PAIRS between community and functional restoration providers revealed a significantly lower score for function restoration providers (t = 12.14, p < 0.000).

CONCLUSION

These results suggested that HC-PAIRS can be used to measure health care providers' attitudes and beliefs about the degree to which chronic low back pain justifies impairments and disability. HC-PAIRS may be useful to health care providers interested in examining this notion.

Correlates of motor unit size, recruitment threshold, and H-reflex jitter

The aim of this research was to study the neurophysiology of the anterior horn cell (AHC) using single-fiber EMG (SFEMG) study of the flexor carpi radialis (FCR) H-reflex. Twelve men and 7 women, ages 20-80 years, were studied. The mean H-jitter was 138 +/- 59 microseconds. H-jitter increased with age (while the M-jitter did not) and was greater in men than in women. There was a direct correlation between the H-jitter and H-latency which was used as an indirect measure of the AHC's size. Given that small AHCs have a higher input resistance than large ones, the H-jitter can be used as an indirect indicator of the AHC's input resistance and therefore its size. When subjects fell asleep, the H-jitter increased over tenfold the baseline value, raising the possibility of an alternative, oligosynaptic pathway. H-reflex jitter studies provide a useful clinical neurophysiological tool for the study of AHC physiology.

Comparison of total lumbosacral flexion and true lumbar flexion measured by a dual inclinometer technique

STUDY DESIGN

This study investigated the interrelationship between total lumbosacral flexion and true lumbar flexion in a population of chronic low back pain sufferers, measured with a dual inclinometer technique. Correlations with self-reported disability also were assessed. Self-reported disability was measured with the Million Visual Analog Scale.

OBJECTIVES

To assess whether total lumbosacral flexion could be substituted for true lumbar flexion in the clinical evaluation of trunk mobility. To determine which measure of flexion is a better predictor of self-reported disability after an intensive rehabilitation program for chronic spinal disorders.

SUMMARY OF BACKGROUND DATA

Eighty-nine consecutive patients with chronic low back pain were evaluated. Fourteen subjects were excluded because of previous surgery. Seventy-five meet inclusion criteria and underwent quantification of lumbar mobility. Sixty-four met literacy criteria and were administered the Million Visual Analog Scale. Thirty-six patients completed rehabilitation and were re-evaluated at program completion for lumbar mobility. Thirty-three were re-evaluated with the Million Visual Analog Scale.

RESULTS

Pearson's correlation coefficients for lumbar versus total flexion were r = 0.88 for initial evaluation and r = 0.84 after treatment. Correlation coefficients also were calculated for lumbar flexion and total flexion with disability scores. Before treatment, both measurements accounted for similar amounts of the variance in disability scores. However, after treatment, total flexion correlated higher with self-reported disability (r = -0.62 versus r = -0.43).

CONCLUSIONS

Our results suggest that total lumbosacral flexion may be as equally relevant as true lumbar flexion in the measurement of trunk mobility in the clinical examination of patients with chronic low back pain. Regarding their relationship to self-reported disability, total flexion seems to be more relevant to outcome after intensive rehabilitation.

Altering beliefs about pain and impairment in a functionally oriented treatment program for chronic low back pain

OBJECTIVE

This study examined pain and impairment beliefs [measured with the Pain and Impairment Relationship Scale, (PAIRS)] of chronic low back pain patients during rehabilitation and hypothesized that pain beliefs would be stronger in drop-out subjects, decrease during treatment, and after treatment correlate strongly with disability measures.

DESIGN

Prospective cohort.

SETTING

Outpatient, functionally oriented rehabilitation program for chronic low back pain.

PATIENTS

72 consecutive chronic low back pain referral patients disabled from working because of pain. INVOLVEMENT: Interdisciplinary rehabilitation with a focus on intensive physical reconditioning was employed.

OUTCOME MEASURES

Program completion versus drop-out groups and pretreatment and posttreatment pain, disability, depression, and PAIRS scores were compared.

RESULTS

Thirty patients dropped out and 42 subjects completed treatment. The PAIRS scores at evaluation were similar for both groups. The PAIRS scores improved significantly during treatment (p < 0.001). Posttreatment PAIRS scores correlated highly with disability measures (r = 0.79, p < 0.001).

CONCLUSION

Pain beliefs are of minimal value for predicting treatment compliance, but may be altered during functionally oriented treatment of chronic low back pain. Posttreatment disability closely mirrored attitudes and belief-associated pain and impairment.

The association of pain with physical activities in chronic low back pain

Most patients with chronic low back pain associate strenuous physical activities with increased pain. This association can cause avoidance of those activities believed to cause intolerable discomfort. This study explored the relationship of performance of physical activities with self-reported pain measures in 40 consecutive patients with disabling low back pain (mean duration 17 months) during a functional restoration rehabilitation program (mean treatment period 7 weeks). Evaluations were performed at initial presentation and at program completion. Measures included quantification of performance on eight physical tests assessing flexibility, lifting capacity and endurance. Before physical testing patients were asked to complete a pain analog scale, a quantified pain drawing, and a rating of the pain anticipated to result from the performance of each physical test. Results showed that pain measures did not generally correlate with measured physical performance. At completion of treatment, significant improvement in performance on all physical tests was found, but these were not associated with consistent changes in pain measures. These results demonstrate that subjects with chronic low back pain can increase their physical performance abilities within their same pain experiences. Medical recommendations for subjects' involvement in physical activities should not be based solely on the reported association of pain with those activities.

Prolactinemia in exercising male athletes

8 male collegial athletes were submitted at random to three (55, 70 and 85% of VO2 max) ergocycle exercises of 20-min duration. Venous blood samples were obtained before, during and after ergocycling sessions by antecubital catheterization. Serum prolactin was measured by RIA using specific antiserum. The exercise treatments induced a blood prolactin response proportional to the intensity of the work loads.