[Rheumatology: what's new in 2023]

In rheumatology, this year has been characterized by a broader knowledge of the pathogenesis of rheumatoid arthritis and mechanisms involved in the onset and persistence of low back pain. Studies relevant to the management of of gout, axial spondyloarthritis, autoinflammatory diseases and systemic vasculitides were published. New data on the safety of JAK inhibitors have been published. The ASAS-EULAR recommendations for the treatment of axial spondyloarthritis were updated, and the 2023 EULAR/PReS guidelines for the diagnosis and treatment of systemic juvenile idiopathic arthritis and adult-onset Still's disease are now available. New molecules and different glucocorticoid sparing strategies were introduced for giant cell arteritis.

[Chronic pain : from symptom to disease]

At last, chronic pain, with its consequences and impact for patients and society, is now considered as a disease in its own in the 11th revision of the international classification of diseases (ICD). We present here in the light of two clinical cases, why the diagnosis of chronic primary pain is useful and how to utilize these new codes. We hope to rapidly see the awaited impact on the healthcare system (from the patient care to insurance issues), as on research and teaching.

Measurement properties of 72 movement biomarkers aiming to discriminate non‑specific chronic low back pain patients from an asymptomatic population

The identification of relevant and valid biomarkers to distinguish patients with non-specific chronic low back pain (NSCLBP) from an asymptomatic population in terms of musculoskeletal factors could contribute to patient follow-up and to evaluate therapeutic strategies. Several parameters related to movement impairments have been proposed in the literature in that respect. However, most of them were assessed in only one study, and only 8% were evaluated in terms of reliability, validity and interpretability. The aim of this study was to consolidate the current knowledge about movement biomarkers to discriminate NSCLBP patients from an asymptomatic population. For that, an experimental protocol was established to assess the reliability, validity and interpretability of a set of 72 movement biomarkers on 30 asymptomatic participants and 30 NSCLBP patients. Correlations between the biomarkers and common patient reported outcome measures were also analysed. Four biomarkers reached at least a good level in reliability (ICC ≥ 0.75) and validity (significant difference between asymptomatic participants and NSCLBP patients, p ≤ 0.01) domains and could thus be possibly considered as valuable biomarkers: maximal lumbar sagittal angle, lumbar sagittal angle range of motion, mean lumbar sagittal angular velocity, and maximal upper lumbar sagittal angle during trunk sagittal bending. These four biomarkers demonstrated typically larger values in asymptomatic participants than in NSCLBP patients. They are in general weakly correlated with patient reported outcome measures, arguing for a potential interest in including related musculoskeletal factors in the establishment of a valuable diagnosis and in guiding treatment response.

Sensitivity and specificity of the flexion and extension relaxation ratios to identify altered paraspinal muscles' flexion relaxation phenomenon in nonspecific chronic low back pain patients

BACKGROUND

Among the main methods used to identify an altered flexion relaxation phenomenon (FRP) in nonspecific chronic low back pain (NSCLBP), it has been previously demonstrated that flexion relaxation ratio (FRR) and extension relaxation ratio (ERR) are more objective than the visual reference method.

OBJECTIVE

To determine the sensitivity and specificity of the different methods used to calculate the ratios in terms of their ability to identify an altered FRP in NSCLBP.

METHODS

Forty-four NSCLBP patients performed a standing maximal trunk flexion task. Surface electromyography (sEMG) was recorded along the erector spinae longissimus (ESL) and multifidus (MF) muscles. Altered FRP based on sEMG was visually identified by three experts (current standard). Six FRR methods and five ERR methods were used both for the ESL and MF muscles. ROC curves (with areas under the curve (AUC) and sensitivity/specificity) were generated for each ratio.

RESULTS

All methods used to calculate these ratios had an AUC higher than 0.9, excellent sensitivity (>90 %), and good specificity (80-100 %) for both ESL and MF muscles.

CONCLUSION

Both FRP ratios (FRR and ERR) for MF and ESL muscles, appear to be an objective, sensitive and specific method for identifying altered FRP in NSCLBP patients.

Adding a back care package to the primary healthcare; a community-based cluster-randomized trial

Introduction

The clinical course of LBP is complex and chronicity is more frequent than once thought. Moreover, insufficient evidence was found in support of any specific approach at the level of the general population.

Research question

This study aimed to evaluate the effectiveness of providing a back care package through the primary healthcare system in decreasing the rate of CLBP in the community.

Material and methods

Clusters were primary healthcare units with the covered population as participants. The intervention package comprised both exercise and educational content in the form of booklets. Data regarding LBP were collected at baseline, 3 and 9-month follow-ups. The LBP prevalence and the incidence of CLBP in the intervention group compared to the control group were analyzed using logistic regression through GEE.

Results

Eleven clusters were randomized including 3521 enrolled subjects. At 9 months, the intervention group showed a statistically significant decrease in both the prevalence and the incidence of CLBP, compared to the control group (OR ​= ​0.44; 95% CI ​= ​0.30-0.65; P ​< ​0.001 and OR ​= ​0.48; 95% CI ​= ​0.31-0.74; P ​< ​0.001, respectively).

Discussion and conclusion

The population-based intervention was effective in reducing the LBP prevalence and CLBP incidence. Our results suggest that preventing CLBP through a primary healthcare package including exercise and educational content is achievable.

The pandemic toll and post-acute sequelae of SARS-CoV-2 in healthcare workers at a Swiss University Hospital

Healthcare workers have potentially been among the most exposed to SARS-CoV-2 infection as well as the deleterious toll of the pandemic. This study has the objective to differentiate the pandemic toll from post-acute sequelae of SARS-CoV-2 infection in healthcare workers compared to the general population.

The study was conducted between April and July 2021 at the Geneva University Hospitals, Switzerland. Eligible participants were all tested staff, and outpatient individuals tested for SARS-CoV-2 at the same hospital. The primary outcome was the prevalence of symptoms in healthcare workers compared to the general population, with measures of COVID-related symptoms and functional impairment, using prevalence estimates and multivariable logistic regression models.

Healthcare workers (n = 3083) suffered mostly from fatigue (25.5 %), headache (10.0 %), difficulty concentrating (7.9 %), exhaustion/burnout (7.1 %), insomnia (6.2 %), myalgia (6.7 %) and arthralgia (6.3 %). Regardless of SARS-CoV-2 infection, all symptoms were significantly higher in healthcare workers than the general population (n = 3556). SARS-CoV-2 infection in healthcare workers was associated with loss or change in smell, loss or change in taste, palpitations, dyspnea, difficulty concentrating, fatigue, and headache. Functional impairment was more significant in healthcare workers compared to the general population (aOR 2.28; 1.76–2.96), with a positive association with SARS-CoV-2 infection (aOR 3.81; 2.59–5.60).

Symptoms and functional impairment in healthcare workers were increased compared to the general population, and potentially related to the pandemic toll as well as post-acute sequelae of SARS-CoV-2 infection. These findings are of concern, considering the essential role of healthcare workers in caring for all patients including and beyond COVID-19.

[New guidelines for the management of low back pain in general practice - «Stop pain without drugs»]

The so-called 4P medicine, preventive, predictive, participatory, and personalized, which places the patient at the center has influenced the latest recommendations for the management of common low back pain. The management of low back pain in the acute, subacute, and chronic phase is currently based on the profile of each patient with their risk factors, their prognosis, and the respect of their preferences, promoting an integrative approach. During the first consultation, it is important to identify factors of moderate to poor prognosis, including kinesiophobia and to search for false beliefs, through a detailed medical history. The non-pharmacological approaches are more effective and have less side effects than the medications. Reassurance and therapeutic education are the first steps in good management of common low back pain.

One-year persistent symptoms and functional impairment in SARS-CoV-2 positive and negative individuals

BACKGROUND

Persistent symptoms of SARS-CoV-2 are prevalent weeks to months following the infection. To date, it is difficult to disentangle the direct from the indirect effects of SARS-CoV-2, including lockdown, social, and economic factors.

OBJECTIVE

The study aims to characterize the prevalence of symptoms, functional capacity, and quality of life at 12 months in outpatient symptomatic individuals tested positive for SARS-CoV-2 compared to individuals tested negative.

METHODS

From 23 April to 27 July 2021, outpatient symptomatic individuals tested for SARS-CoV-2 at the Geneva University Hospitals were followed up 12 months after their test date.

RESULTS

At 12 months, out of the 1447 participants (mean age 45.2 years, 61.2% women), 33.4% reported residual mild to moderate symptoms following SARS-CoV-2 infection compared to 6.5% in the control group. Symptoms included fatigue (16% vs. 3.1%), dyspnea (8.9% vs. 1.1%), headache (9.8% vs. 1.7%), insomnia (8.9% vs. 2.7%), and difficulty concentrating (7.4% vs. 2.5%). When compared to the control group, 30.5% of SARS-CoV-2 positive individuals reported functional impairment at 12 months versus 6.6%. SARS-CoV-2 infection was associated with the persistence of symptoms (adjusted odds ratio [aOR] 4.1; 2.60-6.83) and functional impairment (aOR 3.54; 2.16-5.80) overall, and in subgroups of women, men, individuals younger than 40 years, those between 40-59 years, and in individuals with no past medical or psychiatric history.

CONCLUSION

SARS-CoV-2 infection leads to persistent symptoms over several months, including in young healthy individuals, in addition to the pandemic effects, and potentially more than other common respiratory infections. Symptoms impact functional capacity up to 12 months post infection.

[Which imaging in patients with low back pain ?]

Low back pain is a major public health problem, with a significant physical and psychosocial impact. Inappropriate use of diagnostic imaging is one of the main factors contributing to the costs of these conditions. In addition, there is evidence to suggest that imaging and the accompanying report are risk factors for chronicity. This article reviews the main clinical situations that clinicians face and summarizes the good clinical practice recommendations for each of them.

[Rheumatology: 2021 update]

In rheumatology, this year has seen an expansion of knowledge about the effects of COVID and the vaccine response in patients with autoimmune diseases, but also a re-examination of the usual doses of glucocorticoids in vasculitides and new treatments strategies for diseases such as systemic lupus erythematosus, spondylarthritis and rheumatoid arthritis. New criteria for imaging assessment in spondylarthritis and new management guidelines for patients with low back pain have also been proposed.

Normalisation of a biarticular muscle EMG signal using a submaximal voluntary contraction: Choice of the standardised isometric task for the rectus femoris, a pilot study

BACKGROUND

Electromyography (EMG) signal amplitude is often altered by factors related to the participants and the measurement system. To overcome this issue, a normalisation of the EMG signal amplitude can be performed. Recently, it has been demonstrated that a submaximal voluntary contraction (subMVC) normalisation approach, inspired by grade 3 of manual muscle testing, could produce reliable results. However, rectus femoris (RF) normalisation resulted in low reliability. While the normalisation task chosen for this biarticular muscle was to maintain a knee extension against gravity (ISO-K), a hip flexion isometric task (ISO-H) could also be applied.

RESEARCH QUESTION

This pilot study aimed to assess the impact of the normalisation task on the RF EMG signal quality and related intra-rater within-day reliability during ISO-K and ISO-H, and intra-rater between-day reliability of the EMG signal amplitude during gait.

METHODS

Twenty-four asymptomatic participants were asked to perform ISO-K and ISO-H tasks with both legs and then to walk at self-spontaneous speed, in two identical sessions one week apart. A wireless EMG system was used to record the EMG signal of bilateral RF during each task.

RESULTS

Signal-to-noise ratio during ISO-K and ISO-H was ≥ 15 dB in respectively 51% and 98% of all task repetitions. Intra-rater within-day reliability was acceptable using ISO-K (ICC = 0.71 (0.57; 0.83)) with high %SEM of 35%, and excellent using ISO-H (ICC = 0.94 (0.90; 0.96)) with high %SEM of 34%. Intra-rater between-day reliability during gait was acceptable using ISO-K (ICC = 0.74 (0.61; 0.81)) with a high %SEM of 49%, and excellent using ISO-H (ICC = 0.87 (0.76; 0.93)) with a high %SEM of 38%.

SIGNIFICANCE

The reliability (ICC) of RF EMG signal normalisation was higher using ISO-H than using ISO-K. However, even if signal-to-noise ratio was notably improved using ISO-H, %SEM remains high whatever the normalisation task used. Some additional improvements might thus still be needed to obtain a normalisation protocol allowing more reproducible measurements.

Adult-onset Acute Calcific Discitis

Acute calcific discitis is a rare condition of unknown etiology, observed mainly in childhood.¹ Few cases have been described in adults, and most of these involve the thoracic spine.².

[Chronic low back pain and unhelpful beliefs]

Chronic back pain is a very frequent and highly morbid disease. Among the different factors influencing chronicization are the intensity of the initial episode, lack of physical activity and psychological factors. This paper focuses on this last point, and more specifically on the so-called unhelpful beliefs. The aim is to review the degree of evidence for some of these beliefs frequently found in patients and health professionals.

The flexion relaxation phenomenon in nonspecific chronic low back pain: prevalence, reproducibility and flexion-extension ratios. A systematic review and meta-analysis

PURPOSE

The flexion relaxation phenomenon (FRP) is characterized by the reduction of paraspinal muscle activity at maximum trunk flexion. The FRP is reported to be altered (persistence of spinal muscle activity) in nonspecific chronic low back pain (NSCLBP) and is considered a promising biomarker. The aim of this systematic review was to synthetize current knowledge on FRP in the NSCLBP population regarding prevalence, the reliability of FRP measurement using surface electromyography (sEMG), the average value, and variation of the relaxation ratios (RR).

METHODS

Five databases were searched (PubMed, EMBASE, Web of Sciences, Cochrane Library, Pedro). A qualitative analysis was done for all included studies and meta-analysis studying prevalence, mean value of flexion relaxation ratio (FRR) and extension relaxation ratio (ERR), and difference between asymptomatic and NSCLBP FRR.

RESULTS

Twenty-seven studies were included for qualitative analysis and 21 studies for meta-analysis. The prevalence of the altered FRP was 55% (95%CI [32-79%]) in the NSCLBP population. The studies on reliability reported good within-session and between-session reproducibility. In the NSLBP population, the mean FRR was 2.96 (95%CI [2.02; 3.90]) and the mean ERR was 4.07 (95%CI [2.08; 6.07]). The difference between asymptomatic and NSCLBP FRR was - 1.19 (95%CI [- 1.92, - 0.45]). In all meta-analysis, the I² index was > 80%.

CONCLUSION

An altered FRP is frequently found in NSCLBP population using sEMG and the test has a good reproducibility. The difference between asymptomatic and NSCLBP FRR was significant. Nevertheless, considering the high heterogeneity observed, additional research is required to confirm the value of RR.

Greater trochanteric pain syndrome: predicting who will respond to a local glucocorticoid injection

Objectives: This study aimed to explore whether certain clinical tests or a rapid improvement in lateral hip pain following periarticular injection are predictive of subsequent efficacy of local glucocorticoid (GC) injection in greater trochanteric pain syndrome (GTPS).Method: This secondary analysis of a randomized controlled trial of an injection of GC and local anaesthetic (LA) versus placebo included 44 patients with GTPS. Two subgroups of patients were defined: (i) 30 min responders, reporting a decrease of ≥ 50% of the initial pain at 30 min post-injection; and (ii) positive triple test, presenting a combination of three positive clinical tests (30-second single-leg stance, FABER, and Lequesne). Median level of numeric rating scale for pain at 1 month was the primary outcome. Interaction analysis of treatment effect in the subgroups was performed using a linear regression adjusting for pain at baseline.Results: Sixteen patients (36%) were 30 min responders. In this group, GC treatment was associated with a significant improvement in pain at 1 month compared to non-responders (p = 0.03). The 30 min response was not associated with the use of LA. Positive triple test (22% of patients) was associated with higher pain scores at baseline (p = 0.03). In this group, patients who received placebo had significantly more pain at 1 month than those with the cortisone injection (p = 0.04).Conclusion: Patients with GTPS who present a rapid decrease in pain after periarticular injection, and those who display a combination of three specific clinical tests, are more likely to benefit from an injection with GC and anaesthetic.

Psychomotor therapy as a treatment of chronic spinal pain: A qualitative study

OBJECTIVE

Psychomotor therapy is an innovative complementary approach that enhances the mind-body connection. It could have a positive effect on chronic pain syndromes but has not yet been specifically studied for spinal pain. We thus aimed to explore the experiences of chronic spinal pain patients with psychomotor therapy.

DESIGN

We conducted a qualitative study using semi-structured interviews. 17 patients with chronic spinal pain were recruited from a multidisciplinary spinal pain program in a rehabilitation hospital in Switzerland. Participants received psychomotor therapy as part of this care. All interviews were transcribed and thematic analysis was performed.

SETTING

Division of General Medical Rehabilitation, Geneva University Hospitals, Geneva, Switzerland.

RESULTS

Four themes emerged from thematic analysis: 1) Connecting body and mind; 2) Passive individualized care; 3) Effect on mobility and well-being versus pain; and 4) Need for further care. Participants particularly appreciated the person-centered approach, relaxation and link between body and mind in the psychomotor therapy sessions. They shared positive effects of psychomotor therapy on mobility, kinesiophobia and overall well-being, rather than on pain. Finally, they would have liked more follow-up care at the end of the program.

CONCLUSIONS

Experiences reported by patients in this study suggest that psychomotor therapy could be a promising complementary therapy for chronic spinal pain within a biopsychosocial approach. To better understand the benefits of psychomotor therapy for chronic spinal pain, further research is needed and should consider patient-reported outcome measures such as well-being, fear-avoidance belief and disability.

Usual care including home exercise with versus without spa therapy for chronic low back pain: protocol for the LOMBATHERM' study, a multicentric randomised controlled trial

BACKGROUND

Low back pain is highly prevalent and a major source of disability worldwide. Spa therapy is frequently used to treat low back pain, but the associated level of evidence for efficacy is insufficient. To fill this knowledge gap, this protocol proposes an appropriately powered, prospective, evaluator-blinded, multi-centre, two-parallel-arm, randomised (1:1), controlled trial that will compare spa therapy in addition to usual care including home exercise (UCHE) versus UCHE alone for the treatment of chronic low back pain.

METHODS

Eligible patients (anticipated sample size of 358) will have had low back pain for more than 3 months and scores for pain greater than 40 mm on a visual analogue scale (VAS). Following initial consent for UCHE and baseline evaluations, patients are randomised (1:1) to UCHE alone, or UCHE plus spa therapy (18 days of mud packs, underwater massages, showers and water exercises under medical supervision). Patients in the latter arm will be requested to sign an additional consent form as per Zelen randomisation. Follow-up visits will occur at approximately months 1, 6 and 12 and (along with baseline assessments) will cover changes over time in VAS pain scores, the impact of lower back pain on daily life (the Rolland and Morris Disability Questionnaire (RMDQ)), inappropriate fears and beliefs about lower back pain (the fear, avoidance, belief questionnaire (FABQ)), general quality of life (the Euroqol Group 5 dimension, 5 level questionnaire (EQ-5D-5 L)), Patient Acceptable Symptom State (PASS), consumption of analgesic drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), and overall state of health. Health resource use and days of sick leave (and subsequently the associated costs) will also be recorded. The primary outcome is the presence/absence of a clinically relevant change (improvement of at least 30%) in the VAS score for pain at 6 months.

DISCUSSION

Despite the fact that previous, rather dated recommendations encourage spa therapy for the treatment of low back pain, the current literary corpus is methodologically poor. This protocol has been designed to provide results spanning a thorough range of outcomes at the highest evidence level possible.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03910023. Registered on 10 April 2019.

Big Five Personality Traits and Disabling Chronic Low Back Pain: Association with Fear-Avoidance, Anxious and Depressive Moods

Purpose

Physical dysfunction in chronic low back pain patients is influenced by psychological variables rather than by pain severity. Assessing personality traits may help clinicians address the complexity of patients’ experiences and design treatments that target these vulnerabilities. This study aimed to identify the distinguishing personality traits of a cohort of patients with disabling chronic low back pain and to determine associations between those traits and fear-avoidance beliefs, depressive, and anxious moods.

Patients and Methods

This cross-sectional study included 102 chronic low back pain patients (57% male), who failed standard management and were referred to a multidisciplinary rehabilitation program. All patients completed the five domains of the NEO Personality Inventory (NEO PI)–Revised (Neuroticism, Extraversion, Openness to experience, Agreeableness and Conscientiousness), the Tampa Scale for Kinesiophobia (TSK), and the Hospital Anxiety and Depression Scale (HADS). One-sample t-test was used to compare sample personality means with average population norms. Association between the five personality domains with TSK and HADS was assessed using Pearson’s correlation, adjusted for patient demographics and pain-related variables. Linear regression was used to estimate associations adjusted for covariates.

Results

Both men and women had significantly lower scores in the Openness to experience domain and significantly higher scores in the Conscientiousness domain than the general population norms. After adjusting for covariates, Neuroticism was associated with higher fear-avoidance, depression and anxiety scores. Conversely, Extraversion and Openness to experience negatively correlated with depression scores. Extraversion also inversely correlated with fear-avoidance. Conscientiousness negatively correlated with depression and anxiety after adjustment.

Conclusion

Patients with disabling chronic low back pain show personality characteristics that deviate significantly from the normal population norms but do not reach maladaptive forms of personality disorders. Clinicians would benefit from assessing patients’ personality traits to address protective and risk factors for psychological distress, particularly in difficult-to-treat, highly disabled low back pain patients.

Recovering the capability to work among patients with chronic low Back pain after a four-week, multidisciplinary biopsychosocial rehabilitation program: 18-month follow-up study

Background

Chronic low back pain (LBP) is a leading cause of disability worldwide. Biopsychosocial rehabilitation programs have been advocated for its management, especially since the widespread acceptance of the biopsychosocial model of chronic pain. Despite extensive evidence of its short-term benefits, few studies have reported on its long-term effect and more specifically on indirect outcomes such as return to work and quality of life (QoL). The present study evaluated the long-term effect of a multidisciplinary biopsychosocial rehabilitation (MBR) program for patients with chronic LBP, for which short- and intermediate-term efficacy had been established, with an emphasis on recovering work capability.

Methods

This prospective cohort study enrolled 201 patients on a four-week MBR program incorporating physical and occupational therapies and psychological counselling. Assessments occurred at program admission and discharge and at 6 and 18 months. Work capability, Oswestry Disability Index, Tampa Scale for Kinesiophobia, Core Outcome Measures Index (COMI), and Hospital Anxiety and Depression Scale were assessed. Multiple mixed models were used to detect changes in each outcome. Logistic regressions were calculated to identify predictors of recovery of work capability.

Results

Of the 201 patients who fulfilled the eligibility criteria, 160 (79.8%) attended the discharge assessment, 127 (63.2%) attended the 6-month follow-up, and 107 (53.3%) continued to the 18-month follow-up. Initially, 128 patients (71.5%) had been on sick leave. At 6 and 18 months, 72 (56.7%) and 84 (78.5%) participants had recovered their work capability, respectively. There were significant improvements in pain, disability, kinesiophobia, and anxiety and depression scores over time. Patients who recovered work capability showed significantly greater improvements in their total COMI score, general QoL, and disability, which were the best three predictors of recovering work capability.

Conclusions

This study extends previous results confirming the program’s contribution to recovering work capability among chronic LBP patients.

What low back pain is and why we need to pay attention

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria

BACKGROUND CONTEXT

Because imaging findings of lumbar spinal stenosis (LSS) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are needed.

PURPOSE

The objective of this study was to develop clinical classification criteria that identify patients with neurogenic claudication (NC) caused by LSS.

STUDY DESIGN

This study is a two-stage process that includes Phase 1, the Delphi process, and Phase 2, the cross-sectional study.

PATIENT SAMPLE

Outpatients were recruited from spine clinics in five countries.

OUTCOME MEASURE

The outcome measure includes items from the patients' history and physical examination.

METHODS

In Phase 1, a list of potential predictors of NC caused by LSS was based on the available literature and was evaluated through a Delphi process involving 17 spine specialists (surgeons and non-surgeons) from eight countries. In Phase 2, 19 different clinical spine specialists from five countries identified patients they classified as having (1) NC caused by LSS, (2) radicular pain caused by lumbar disc herniation (LDH), or (3) non-specific low back pain (NSLBP) with radiating leg pain. The patients completed survey items and the specialists documented the examination signs. Coefficients from general estimating equation models were used to select predictors, to generate a clinical classification score, and to obtain a receiver operating characteristic curve. Conduction of the Delphi process, data management, and statistical analysis were partially supported by an unrestricted grant of less than 15,000 US dollars from Merck Sharp & Dohme. No fees were allocated to participating spine specialists.

RESULTS

Phase 1 generated a final list of 46 items related to LSS. In Phase 2, 209 patients with leg pain caused by LSS (n=63), LDH (n=89), or NSLBP (n=57) were included. Criteria that independently predicted NC (p<.05) were age over 60 years, positive 30-second extension test, negative straight leg test, pain in both legs, leg pain relieved by sitting, and leg pain decreased by leaning forward or flexing the spine. A classification score using a weighted set of these criteria was developed. The proposed N-CLASS score ranged from 0 to 19 and had an area under the curve of 0.92, and the cutoff (>10/19) to obtain a specificity of >90.0% resulted in a sensitivity of 82.0%.

CONCLUSIONS

Clinical criteria independently associated with neurogenic claudication due to LSS were identified. The use of these symptom and physical variables as a classification score for clinical research could improve homogeneity among enrolled patients.

Identifying Subgroups of Patients With Chronic Nonspecific Low Back Pain Based on a Multifactorial Approach: Protocol For a Prospective Study

Background

Low back pain, especially nonspecific chronic low back pain (LBP), the leading cause of disability worldwide, represents both social and economic problems. Different therapeutic management techniques can be used, but their effects vary. Clinicians and researchers attribute the variation in the efficacy of therapeutic and management techniques to the heterogeneity of the nonspecific chronic low back pain population, and they agree that nonspecific chronic LBP must be subgrouped.

Objective

This study aims to identify nonspecific chronic LBP subgroups based on a multifactorial approach, including biomechanical, physical, and psychosocial data.

Methods

A total of 100 nonspecific chronic LBP patients and 30 healthy participants aged between 18 and 60 years will be recruited for this prospective study. A psychosocial profile will be established using questionnaires on anxiety, depression, functional disability, pain, fear of pain, avoidance belief, and physical activity. A physical capacity evaluation will be conducted. It will evaluate flexibility of the hips, lumbar spine, and lateral thoracolumbar segment, as well as trunk (extensor and flexor) muscle endurance. The subjects will perform functional daily life activities, such as walking, object lifting, forward bending, sit-to-stand, stand-to-sit, balance, and usual postures. Full body kinematics, kinetics, and surface electromyography of the trunk and hip muscles will be assessed during these tasks. The clustering classification methods for the statistical analysis will be determined according to the data and will be used to identify the subgroups of nonspecific chronic LBP patients.

Results

Data collection started in September 2017 and will be completed with the inclusion of all the participants (100 nonspecific chronic LBP and 30 control). The study results will be published in peer-reviewed journals and presented at relevant international conferences.

Conclusions

Numerous studies have showed that the therapeutic management of nonspecific chronic LBP is difficult and has inconstant effects caused by the complexity and heterogeneity of nonspecific chronic LBP. Identifying subgroups with a multifactorial approach is more comprehensive and closer to the pathophysiology of nonspecific chronic LBP. It also represents benefit interests and a challenge both clinically and socially. The perspective of this study is expected to support clinicians for a more adapted therapeutic management for each subgroup.

Clinical classification criteria for radicular pain caused by lumbar disc herniation: the radicular pain caused by disc herniation (RAPIDH) criteria

BACKGROUND CONTEXT

Classification criteria are recommended for diseases that lack specific biomarkers to improve homogeneity in clinical research studies. Because imaging evidence of lumbar disc herniations (LDHs) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are required.

PURPOSE

This study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH.

STUDY DESIGN

The study design was a two-stage process. Phase 1 included a Delphi process and Phase 2 included a cohort study.

PATIENT SAMPLE

The patient sample included outpatients recruited from spine clinics in five countries.

OUTCOME MEASURES

The outcome measures were items from history and physical examination.

MATERIALS AND METHODS

In Phase 1, 17 spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2, 19 different clinical experts identified patients they confidently classified as presenting with (1) radicular pain caused by LDH, (2) neurogenic claudication (NC) caused by lumbar spinal stenosis, or (3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than US$15,000 was received from MSD: It was used to support the conception of the Delphi, data management, and statistical analysis. No fees were allocated to participating spine specialists.

RESULTS

Phase 1 generated a final list of 74 potential symptoms and signs. In Phase 2, 209 patients with pain caused by LDH (89), NC (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p<.05) were monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test <60° (or femoral stretch test), unilateral motor weakness, and asymmetric ankle reflex. The score had an AUC of 0.91. An easy-to-use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%).

CONCLUSIONS

Classification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies.

[Spinal injection : risks and side effects]

The efficacy of spinal injection for chronic spinal pain is dubious for most conditions. They are however frequently prescribed. Side effects are poorly reported in the literature. In addition to benign and transient problems, serious and lethal side effects have been reported due to infection, hematoma or central and spinal cord infarctions which could be related to intravascular injection of corticoids. Although their frequency is excessively low, they should be discussed with every patient before prescription and should be mentioned in the consent form.

Modifying beliefs about back pain: A pilot study among healthcare professionals

OBJECTIVES

This study aimed to explore whether a preventive intervention based on the non-injury model and the biopsychosocial model of back pain succeeded in shifting beliefs toward less negative representations and in decreasing fear-avoidance beliefs related to back pain.

METHODS

One hundred and one healthcare professionals took part in a 10-h educational program held over 2 consecutive days, based on the key messages of the "Back Book." Baseline values were measured 6 weeks before the intervention and when it started. Follow-up was performed at the end of the intervention and six months later.

RESULTS

No significant changes were observed between baseline values and values measured at the beginning of the intervention, but participants' beliefs about LBP changed significantly after the program. The benefit remained at 6 months follow-up.

CONCLUSION

A prevention program based on the non-injury and bio-psychosocial models of LBP, introducing empowerment and problem-solving strategies, significantly reduced fear-avoidance and negative beliefs about LBP. The change was clinically relevant and thus could decrease direct and indirect healthcare costs.

[THE MALADAPTIVE BELIEFS OF PATIENTS WITH LOW BACK PAIN. A NARRATIVE REVIEW]

OBJECTIVE

to summarize the knowledge regarding the maladaptive beliefs of patients with non-specific low back pain.

METHODS

a narrative literature review on these beliefs was conducted by an international and multidisciplinary team of experts in the field.

RESULTS

these beliefs, which can result in negative consequences on functioning and on patient prognosis, have various origins: family and friends, media, previous experience and/or health care professionals' messages. The latter, who have a considerable and enduring influence, have the potential to change and correct the patients' misbeliefs; however, they can also reinforce them in case of inappropriate messages and attitudes. Informing and educating the patient (by means of reassurance, explanations of the non-systematic association pain-injury, encouragement to get and stay physically active) are the basis of treatment. Taking into account the consequences of some words which may be misinterpreted, the results of imaging should be wisely discussed with the patient. Pain neurophysiology education and cognitive behavioral therapy (i.a., in vivo graded exposure techniques) are effective additional treatments.

CONCLUSIONS

Misbeliefs are frequent in patient with low back pain. They do need to be looked for and corrected.

[Greater trochanteric pain syndrome]

Trochanteric bursitis, also known as "greater trochanter pain syndrome", is a frequent and often under-diagnosed cause of pain in the lateral hip region. The diagnosis is essentially based on the clinical examination; however various forms of imaging may be useful to confirm the diagnosis and particularly to ex- clude other aetiologies. The different therapeutic options include non-steroidal anti-inflammatories, physiotherapy, local injections of cortisone and local anaesthetic, and extra-corporeal shock wave therapy. Surgical intervention is only indicated in rare cases.

Validity of the French version of the Core Outcome Measures Index for low back pain patients: a prospective cohort study

PURPOSE

Among the many questionnaires available to evaluate low back pain (LBP) patients, the Core Outcome Measures Index (COMI) has the unique advantage to investigate five dimensions using seven short questions. The aim of this study was to explore additional properties of the questionnaire in a French-speaking non-surgical population.

METHODS

This study was conducted on 168 patients suffering from subacute or chronic LBP and followed up for 6 months in three French-speaking countries. In addition to basic psychometric properties (e.g., construct validity, floor and ceiling effect, reproducibility), internal validity was analyzed by a factor analysis using Cronbach's alpha. Responsiveness and sensitivity to change were assessed through minimal detectable change (MDC), effect size, and Minimal Clinically Important Improvement (MCII). We used an anchor-based method with receiver operating characteristic (ROC) curve analysis to assess MCII and the Patient Acceptable Symptom State.

RESULTS

Construct validity, reliability (Cronbach's alpha = 0.87), reproducibility and the absence of floor and ceiling effects were confirmed. Factor analysis indicated a one-dimensional construct that validates the use of a sum score. The MDC (2.1) was inferior to the MCII (2.3). The limit below which the patient claims to be in a fair condition (Patient Acceptable Symptom State) was set at 3.

CONCLUSIONS

The COMI is a self-report questionnaire with the capacity to easily and quickly explore several dimensions in patients with LBP that can be then summarized in a meaningful sum score. Additional knowledge provided by our study should encourage the widespread use of the COMI among the spine community.

[Inter-hospital CHUV-HUG medical consensus of back pain management. Its application in care pathways within CHUV of Lausanne]

Back pain is a considerable economical burden in industrialised countries. Its management varies widely across countries, including Switzerland. Thus, the University Hospital and University of Lausanne (CHUV) recently improved intern processes of back pain care. In an already existing collaborative context, the two university hospitals in French-speaking Switzerland (CHUV, University Hospital of Geneva), felt the need of a medical consensus, based on a common concept. This inter-hospital consensus produced three decisional algorithms that bear on recent concepts of back pain found in literature. Eventually, a fast track was created at CHUV, to which extern physicians will have an organised and rapid access. This fast track aims to reduce chronic back pain conditions and provides specialised education for general practitioners-in-training.

Added value of an intensive multidisciplinary functional rehabilitation programme for chronic low back pain patients

BACKGROUND

Several treatments exist for chronic low back pain (cLBP) patients although none has shown superiority. Among group treatments, muscle reconditioning programmes (MRPs) are the most commonly used. Multidisciplinary functional rehabilitation programmes (MFRPs) are an alternative.

OBJECTIVE

To compare a MFRP with a MRP as few studies compare these treatments

METHODS

This was a prospective, nonrandomised, controlled study comparing cLBP patients participating in a MRP or MFRP in an outpatient setting. The predetermined primary outcome measure was the daily life activity subscale (DLA) of the Dallas Pain Questionnaire (DPQ) within one year after the end of the treatment.

RESULTS

Twenty-one patients were included in the MRP and 24 in the MFRP. At inclusion, the groups were similar in terms of age (mean 40 years), sex (50%-60% males), sick leave duration (mean 6.0 months, standard deviation (SD) 4.4 months) and follow up (mean 9.0 months, SD 2.0 months). The DLA score decreased from 59.5% (SD 16.9) to 44.8% (SD 25.4), p <0.01, in the MFRP and from 62.3 (SD 20.3) to 58.8 (SD 20.7), p = 0.3, in the MRP. The between-groups difference at follow-up was 13.8, p = 0.05, and the difference in the mean improvement was -11.5 (5.9), p = 0.058. Seventy-eight percent of MFRP patients versus 47 % in the MRP group returned to work (p = 0.08).

DISCUSSION

In a population of highly disabled cLBP patients, MFRP seems more effective in increasing function and return to work. Interpretation is limited by the small population included and by the type of trial.

CONCLUSION

Randomised studies are needed to confirm these results and explore the cost-effectiveness of MFRP.

Effectiveness of preventive back educational interventions for low back pain: a critical review of randomized controlled clinical trials

PURPOSE

A systematic search was conducted to study the efficiency of preventive educational interventions mainly focused on a biomechanical/biomedical model.

METHODS

The PubMed electronic database and the Cochrane Library were searched based on a combination of keywords related to low back pain (LBP) and posture education. Only randomized controlled trial (RCT) studying the efficiency on outcomes directly related to LBP of a preventive intervention programme mainly based on education of proper care of the back for subjects not seeking treatment were included. References of the articles meeting these inclusion criteria were also checked to identify other potential citations. Besides, a methodological study assessment of the included RCTs was performed.

RESULTS

Nine studies, all conducted at the workplace were included in this review. Their mean quality level was low (5.1/12) and among the four studies with a huge sample size (n > 400 subjects), only one had an acceptable methodological quality score (6/12). The education interventions differed widely from one study to another. No significant differences between the control and education groups were found at the follow-up in eight out of the nine studies on the incidence of back pain, disability and sick leave.

CONCLUSIONS

The results of the RCTs included in this review suggest that educational interventions mainly focused on a biomechanical/biomedical model are not effective in preventing LBP. However, taking into account the methodological quality level of the RCTs as well as the very short and heterogeneous interventions often proposed, additional high-quality studies with a longer education period are needed to conclude that such interventions are inefficient.

[Spinal stenosis: diagnosis and treatment]

Spondylotic cervical myelopathy (SCM) is a radiologic entity that can match a clinical syndrome of varying degree of severity, and results from spinal canal narrowing due to physiological degeneration of the cervical spine. Clinically, cervical spinal canal narrowing can produce minimal symptoms such as non-specific neck pain, foraminal entrapment of nerve roots, or more severe, chronic myelopathy. SCM initially manifests by signs of posterior medullary tract dysfunction with subsequent pallesthesia, resulting in gait and balance disturbance. Spasticity due to lower motoneurone impairment and incontinence may appear in later stages. Once the symptoms of myelopathy occur, functional deterioration will take place sooner or later. Surgery can then be recommended and scheduled according to the severity of functional impairment and imaging.

[Postural hygiene and ergonomic advices for low back pain: rethinking our practice]

In recent years, scientific understanding of low back pain has increased considerably, sometimes shoving concepts thought to be unshakable. If we consider postural hygiene,whose techniques were conceptualized in the 70's and are still widely used, not only some axioms were not confirmed but some evidences suggest that it may sometimes have deleterious effects. After reviewing these elements it appears that there is no simple formula applicable to all patients with low back pain. Instead we offer food for thought so that every therapist can adapt his practice on an individual basis.

[Lumbar spinal stenosis: clinical course, pathophysiology and treatment]

The lumbar spinal stenosis is a radiological description of a pathology that can present clinically by a neurogenic intermittent claudication; its diagnosis is mainly clinical. After listing the main criteria allowing the clinician to make a diagnosis, a review of available treatments is proposed. There are few quality studies and an empirical approach is often necessary. In severe cases, very disabling despite correct treatment, a surgical approach may be considered and discussed with the patient to avoid failure, sometimes linked to excessive expectations.

[Interdisciplinary treatment of chronic low back pain: psychological aspects and personality traits]

Evidence on chronic low back pain treatments stresses the need for a multidimensional approach that aims a biopsychosocial rehabilitation. The caregiver team of the rheumatology division of the University Hospitals of Geneva has successfully applied this approach over the last years and this article emphasizes the value of a close collaboration with the division of liaison psychiatry. The use of cognitive-behavioral and psycho-educational techniques guaranties the definition of patient-centred and measurable treatment objectives. The inclusion of a psychotherapy group promotes free expression and sharing of psychological distress. Assessment of personality traits allows for considering the global nature of the patients rather than merely aiming the normalization of their deviant aspects.

[Use of glucocorticoids in low back pain due to disc herniation with radicular involvement]

Although systemic glucocorticoids are frequently used for the treatment of radicular pain due to disc herniation, there are only few studies available. No trial has successfully demonstrated the superiority of systemic glucocorticoids compared to placebo. Therefore their use is not recommended. Spinal injection using radiographic guidance appears to provide some beneficial short-term effect on pain. It might be offered when pain treatments according to the WHO steps have failed. Because rare but serious adverse events have been reported, transforaminal periradicular injections should only be used after thorough analysis of risks and benefits with the patient.

Adalimumab in acute sciatica reduces the long-term need for surgery: a 3-year follow-up of a randomised double-blind placebo-controlled trial

INTRODUCTION

Two subcutaneous injections of adalimumab in severe acute sciatica significantly reduced the number of back operations in a short-term randomised controlled clinical trial.

OBJECTIVE

To determine in a 3-year follow-up study whether the short-term benefit of adalimumab in sciatica is sustained over a longer period of time.

METHODS

The primary outcome of this analysis was incident discectomy. Three years after randomisation, information on surgery could be retrieved in 56/61 patients (92%).A multivariate Cox proportional hazard models, adjusted for potential confounders, was used to determine factors predisposing to surgery.

RESULTS

Twenty-three (41%) patients had back surgery within 3 years, 8/29 (28%) in the adalimumab group and 15/27 (56%) in the placebo group, p=0.04. Adalimumab injections reduced the need for back surgery by 61% (HR)=0.39 (95% CI 0.17 to 0.92). In a multivariate model, treatment with a tumour necrosis factor-α antagonist remained the strongest protective factor (HR=0.17, p=0.002). Other significant predictors of surgery were a good correlation between symptoms and MRI findings (HR=11.6, p=0.04), baseline intensity of leg pain (HR=1.3, p=0.06), intensity of back pain (HR=1.4, p=0.03) and duration of sickness leave (HR=1.01 per day, p=0.03).

CONCLUSION

A short course of adalimumab in patients with severe acute sciatica significantly reduces the need for back surgery.

Reliability and validity of the cross-culturally adapted French version of the Core Outcome Measures Index (COMI) in patients with low back pain

PURPOSE

To conduct a cross-cultural adaptation of the Core Outcome Measures Index (COMI) into French according to established guidelines.

METHODS

Seventy outpatients with chronic low back pain were recruited from six spine centres in Switzerland and France. They completed the newly translated COMI, and the Roland Morris disability (RMQ), Dallas Pain (DPQ), adjectival pain rating scale, WHO Quality of Life, and EuroQoL-5D questionnaires. After ~14 days RMQ and COMI were completed again to assess reproducibility; a transition question (7-point Likert scale; "very much worse" through "no change" to "very much better") indicated any change in status since the first questionnaire.

RESULTS

COMI whole scores displayed no floor effects and just 1.5% ceiling effects. The scores for the individual COMI items correlated with their corresponding full-length reference questionnaire with varying strengths of correlation (0.33-0.84, P < 0.05). COMI whole scores showed a very good correlation with the "multidimensional" DPQ global score (Rho = 0.71). 55 patients (79%) returned a second questionnaire with no/minimal change in their back status. The reproducibility of individual COMI 5-point items was good, with test-retest differences within one grade ranging from 89% for 'social/work disability' to 98% for 'symptom-specific well-being'. The intraclass correlation coefficient for the COMI whole score was 0.85 (95% CI 0.76-0.91).

CONCLUSIONS

In conclusion, the French version of this short, multidimensional questionnaire showed good psychometric properties, comparable to those reported for German and Spanish versions. The French COMI represents a valuable tool for future multicentre clinical studies and surgical registries (e.g. SSE Spine Tango) in French-speaking countries.

Development and validation of a questionnaire assessing volitional competencies to enhance the performance of physical activities in chronic low back pain patients

Background

Motivation has long been emphasized as the most important determinant of action. However, there is a substantial gap between people's goals and their attainment. Patients may be motivated and yet unable to take action if their volitional competencies are insufficient. One of the important tasks of volition is goal-maintenance. Research has stressed the importance of a volitional tool, the implementation intentions. Implementation intentions indicate where, when, and how the action leading to the goal will be performed. Forming implementation intentions favours the execution of goal-directed efforts, and reinforces the relationship between intentions and behaviours. Results from various studies clearly suggest that volitional competencies and implementation intentions could play a role in low back pain (LBP) patients. However, there is at present no questionnaire allowing assessing the capacity of implementation intentions of physical activities in LBP patients.

Methods/Design

This study will develop such a questionnaire, using a 3-step approach. A first qualitative step to build categories and generate items; 30 patients suffering chronic LBP will be invited to participate in semi-structured interviews; verbatim and derived items will then be submitted to a panel of experts, using a Delphi method; a second quantitative step to examine the properties of items, and determine the factorial structure of the questionnaire; 100 patients suffering chronic LBP will be recruited to respond to this phase; and third, preliminary psychometric analyses (item-scale correlations, construct validity, reliability); 180 chronic LBP patients will be recruited for this phase of the study. The relationships between implementation intentions and variables affecting physical activity on chronic LBP patients, i.e. pain, physical capacities, fear-avoidance beliefs, kinesiophobia, work status, and level of physical activity will be considered.

Discussion

Developing a questionnaire to assess implementation intentions would allow investigating the role of these intentions in the transition from acute to chronic LBP. The results of this study should contribute to the understanding of the psychological processes at stake in the development of chronic LBP, and in particular to the identification of factors eventually favouring patients' participation in and adherence to active physical treatments.