Protopsaltis TS
STUDY DESIGN: Retrospective. OBJECTIVE: This study assessed the feasibility of combining Oswestry and Neck Disability Index (ODI and NDI) into 1 shorter "Total Disability Index" (TDI) from which reconstructed scores could be computed. SUMMARY OF BACKGROUND DATA: ODI and NDI are not pure assessments of disability related to back and neck, respectively. Because of similarities/redundancies of questions, ODI scores may be elevated in neck-pain patients and the converse is true for NDI in back-pain patients. METHODS: Spine patients completed ODI and NDI, and complaints were recorded as back pain (BP), neck pain (NP), or both (BNP). Questionnaire scores were compared across cohorts via descriptives and Spearman (rho) correlations. In exploring the feasibility of merging ODI/NDI, TDI was constructed from 9 ODI and 5 NDI items. Extracting questions from TDI, reconstructed 9-item rODI and 10-item rNDI indices were formed and compared with true ODI/NDI. RESULTS: There were a total of 1207 patients: 741 BP, 134 NP, and 268 BNP. Mean ODI was 37 +/- 21 and mean NDI was 32 +/- 21. Patients with concurrent BP and NP had significantly more disability. Seventy-eight patients of 134 (58%) patients with NP only had at least "moderate disability" by ODI and 297 of 741 (40%) patients with back pain only, had at least "moderate disability" by NDI. ODI versus NDI correlation was rho = 0.755; ODI versus reconstructed rODI correlated at rho = 0.985, and NDI versus reconstructed rNDI correlated at rho = 0.967 (P < 0.01). CONCLUSION: Elevated ODI/NDI scores in patients with isolated complaints show that disability in 1 region affects scores on both surveys. This study constructed a 14-item TDI that represents every domain of ODI/NDI with exception of ODI "Sex Life." From this TDI, reconstructed scores correlated near perfectly with true scores. TDI provides a more global assessment of spinal disability and is a questionnaire that reduces the time burden to patients. The TDI allows for simultaneous assessment of back, neck, and global spinal disability.
Dorius J
RATIONALE, AIMS AND OBJECTIVE: Low back pain (LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs. METHODS: A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting. RESULTS: 747 patients were identified (mean age = 38.2 (+/- 10.7) years, 61.2% female). Entry setting was primary care (n = 409, 54.8%), chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%). Relative to primary care, entry in physiatry increased risk for radiographs (OR = 3.46, P = 0.001), advanced imaging (OR = 3.38, P < 0.001), injections (OR = 4.91, P < 0.001), surgery (OR = 4.76, P = 0.012) and LBP-related costs (standardized Beta = 0.67, P < 0.001). Entry in chiropractic was associated with decreased risk for advanced imaging (OR = 0.21, P = 0.001) or a surgeon visit (OR = 0.13, P = 0.005) and increased episode of care duration (standardized Beta = 0.51, P < 0.001). Entry in physical therapy decreased risk of radiographs (OR = 0.39, P = 0.017) and no patient entering in physical therapy had surgery. CONCLUSIONS: Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs.
George SZ
BACKGROUND: Because of its high global burden, determining biopsychosocial influences of chronic low back pain (CLBP) is a research priority. Psychological factors such as pain catastrophizing are well established. However, cognitive factors such as working memory warrant further investigation to be clinically useful. OBJECTIVE: The purpose of this study was to determine how working memory and pain catastrophizing are associated with CLBP measures of daily pain intensity and movement-evoked pain intensity. DESIGN: This study was a cross-sectional analysis of individuals with >/=3 months of CLBP (n=60) compared with pain-free controls (n=30). METHOD: Participants completed measures of working memory, pain catastrophizing, and daily pain intensity. Movement-evoked pain intensity was assessed using the Back Performance Scale. Outcome measures were compared between individuals with CLBP and those who were pain-free using nonparametric testing. Associations were determined using multivariate regression analyses. RESULTS: Participants with CLBP (mean age=47.7 years, 68% female) had lower working memory performance (P=.008) and higher pain catastrophizing (P<.001) compared with pain-free controls (mean age=47.6 years, 63% female). For individuals with CLBP, only working memory remained associated with daily pain intensity (R(2)=.07, standardized beta=-.308, P=.041) and movement-evoked pain intensity (R(2)=.14, standardized beta=-.502, P=.001) after accounting for age, sex, education, and interactions between pain catastrophizing and working memory. LIMITATIONS: The cross-sectional design prevented prospective analysis. Findings also are not indicative of overall working memory (eg, spatial) or cognitive performance. CONCLUSION: Working memory demonstrated the strongest association with daily pain and movement-evoked pain intensity compared with (and after accounting for) established CLBP factors. Future research will elucidate the prognostic value of working memory on prevention and recovery of CLBP.
Moseley GL
BACKGROUND: Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration. METHODS: Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be >/= 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of >/= 30% disabled (on the study authors' chosen disability outcome measure). RESULTS: We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was 'non-informative' (pooled AUC = 0.59 (0.55-0.63), n = 1153) and 'acceptable' for discriminating disability outcomes (pooled AUC = 0.74 (0.66-0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was 'poor' for discriminating pain outcomes (pooled AUC = 0.69 (0.62-0.76), n = 360), 'acceptable' for disability outcomes (pooled AUC = 0.75 (0.69-0.82), n = 512), and 'excellent' for absenteeism outcomes (pooled AUC = 0.83 (0.75-0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only. CONCLUSIONS: LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict. SYSTEMATIC REVIEW REGISTRATION: PROSPERO international prospective register of systematic reviews registration number CRD42015015778 .
Spira D
OBJECTIVES: To retrospectively assess the interreader reproducibility and reliability of EOS 3D full spine reconstructions in patients with adolescent idiopathic scoliosis (AIS). METHODS: 73 patients with mean age of 17 years and a moderate AIS (median Cobb Angle 18.2 degrees ) obtained low-dose standing biplanar radiographs with EOS. Two independent readers performed "full spine" 3D reconstructions of the spine with the "full-spine" method adjusting the bone contour of every thoracic and lumbar vertebra (Th1-L5). Interreader reproducibility was assessed regarding rotation of every single vertebra in the coronal (i.e. frontal), sagittal (i.e. lateral), and axial plane, T1/T12 kyphosis, T4/T12 kyphosis, L1/L5 lordosis, L1/S1 lordosis and pelvic parameters. Radiation exposure, scan-time and 3D reconstruction time were recorded. RESULTS: Interclass correlation (ICC) ranged between 0.83 and 0.98 for frontal vertebral rotation, between 0.94 and 0.99 for lateral vertebral rotation and between 0.51 and 0.88 for axial vertebral rotation. ICC was 0.92 for T1/T12 kyphosis, 0.95 for T4/T12 kyphosis, 0.90 for L1/L5 lordosis, 0.85 for L1/S1 lordosis, 0.97 for pelvic incidence, 0.96 for sacral slope, 0.98 for sagittal pelvic tilt and 0.94 for lateral pelvic tilt. The mean time for reconstruction was 14.9 minutes (reader 1: 14.6 minutes, reader 2: 15.2 minutes, p<0.0001). The mean total absorbed dose was 593.4muGy +/-212.3 per patient. CONCLUSION: EOS "full spine" 3D angle measurement of vertebral rotation proved to be reliable and was performed in an acceptable reconstruction time. Interreader reproducibility of axial rotation was limited to some degree in the upper and middle thoracic spine due the obtuse angulation of the pedicles and the processi spinosi in the frontal view somewhat complicating their delineation.
Rodriguez-Sanz D
The myofascial pain syndrome (MPS) is considered the most common musculoskeletal condition. The lumbopelvic pain (LPP) is established as one of the most prevalent musculoskeletal disorders. Nevertheless, previous research has not yet studied the contractibility changes by tensiomyography between myofascial trigger point (MTrP) types and normal tissue. Therefore, the aim of this study was to determine the tensiomyography, sonoelastography, and pressure pain threshold (PPT) differences between the palpation area of active and latent MTrPs with regards to control points in the lumbar erector spinae muscles of subjects with LPP. A cross-sectional descriptive study was performed. A convenience sample of 60 points (20 active MTrPs, 20 latent MTrPs, and 20 control points) was registered bilaterally in the lumbar erector spinae muscles from subjects with nonspecific LPP. The palpation order of active MTrPs, latent MTrPs, or control points was randomized for each side. The outcome assessors were blinded to the order or point type. The outcome measurements order for each point was sonoelastography manual strain index, tensiomyography, and PPT, separated by 15 minutes. Five contractile objective parameters were: maximal radial displacement (Dm), contraction time (Tc), sustain time (Ts), delay time (Td), and half-relaxation time (Tr). Tensiomyography parameters did not show any statistically significant difference (P > 0.05) between active MTrPs, latent MTrPs, and control points. Nevertheless, PPT and sonoelastography showed statistically significant differences (P < 0.05) between all point types, except for active and latent MTrPs PPT comparison (P = 0.091). Regarding the active MTrPs, a moderate positive correlation was observed between PPT and Dm (P = 0.047; tauB = 0.450). Considering the control points, a moderate positive correlation was shown between sonoelastography and Td (P = 0.044; tauB = 0.328). The tensiomyography contractile properties did not seem to show differences, while the sonoelastography and mechanosensitivity presented a higher stiffness and a lower PPT, respectively, between the palpation area of active and latent MTrPs with regards to control points in the lumbar erector spinae muscles of subjects with LPP. Considering the correlations, further research is needed regarding the muscle contractile properties modifications under MPS treatments, especially Dm in active MTrPs and Td in normal sites.
Kim KT
OBJECTIVES: Scoliosis is associated with pectus excavatum. However, the change in the degree of scoliosis after pectus excavatum correction has not been clarified. This study examined how the correction of pectus excavatum influences the status of pre-existing scoliosis. METHODS: A total of 779 pectus excavatum patients operated between 2007 and 2011 using the pectus bar were retrospectively analysed. Preoperative severity and postoperative change of scoliosis in accordance with the severity of pectus excavatum were evaluated. Cobb angle, Haller index and sternal tilt degree were measured from pre- and postoperative whole-spine anteroposterior radiographs and chest computed tomography. RESULTS: Sixty-three (8%) patients had scoliosis (Cobb angle >10 degrees ). No significant correlation was noted between postoperative changes in Cobb angle, Haller index or sternal tilt angle. Preoperative severity of scoliosis showed a positive correlation with postoperative changes in Cobb angle ( r = 0.527, P < 0.001). In analyses between groups with mild and moderate scoliosis (Cobb angle <15 degrees and >15 degrees , respectively), the mean postoperative Cobb angle was decreased in mild scoliosis (-2.88 degrees ) but was increased in moderate scoliosis (3.86 degrees ; P < 0.001). Regarding the 'improvement' and 'aggravation' of scoliosis after pectus correction, preoperative severity of scoliosis was the only significant factor in univariable and multivariable analysis. CONCLUSIONS: Pectus excavatum repair using a pectus bar may improve scoliosis, but when the preoperative Cobb angle exceeds 15 degrees , scoliosis may be aggravated. Therefore, pectus excavatum with concomitant moderate scoliosis requires extra caution during repair. This preliminary result suggests further investigation into the effect of chest cage remodelling on spine dynamics.
Negrini S
BACKGROUND: A temperature monitor is used to objectively measure brace wear time in adolescent idiopathic scoliosis. The reliability of this device have been demonstrated, and some specialists introduced the use of a compliance monitor as a standard of care in everyday clinical practice, as we did since 2010 with the Thermobrace (TB). The attitude towards these objective monitors has never been investigated. The present study aims to investigate the attitude of parents and patients towards the use of temperature sensors for measuring brace wear compliance. METHODS: Three hundred one consecutive girls and 63 boys and their parents have been interviewed. The inclusion criteria were as follows: brace wear full-time prescription at first visit and at least one visit with download and discussion of TB data. Usefulness, acceptability, reliability, and feeling related to data download were the investigated domains. Patients were invited by the administrative staff to complete anonymously the questionnaire. The European Commission was informed about the present survey and approved it (ICT-37-2015-1). Descriptive statistic was used to present the results. RESULTS: Among the 364 invited patients and parents, 336 adhered by completing it (rate of responders was 93.2%). The mean age was 14.65 (SD 2.36), the mean Cobb angle was 34.18 (SD 13.57), and the average brace wear prescription was 21.76 h per day (SD 2.53). We did not ask parents about their age, profession, nor other personal data. Globally, the interviewed patients and parents showed a very positive attitude towards the TB monitor: the mean rate of parents stating a completely or at least partially positive attitude towards this electronic device was 94.0% while among patients, it was 85.6%. CONCLUSIONS: This is the first study investigating the attitude of parents and patients towards a brace wear compliance monitor. People who experienced this objective monitoring are aware of the advantages related to it and support its usefulness not only for clinicians but also for patients and parents to respect the hours prescribed without any affection on the children and parents or the patient-physician relationship. The present results should encourage the spread of these tools in daily clinical practice.
Matsumoto M
STUDY DESIGN: A prospective observational study. OBJECTIVE: To evaluate whether scoliosis is a risk factor for gastroesophageal reflux disease (GERD) in elderly patients. SUMMARY OF BACKGROUND DATA: Sagittal spinal deformities are reported to cause GERD, but its association with spinal deformity in the coronal plane is not well studied. METHODS: We examined 190 patients with spinal disorders (mean age 70.6+/-8.6 y) who underwent standing whole-spine x-rays in the coronal and sagittal planes. GERD symptoms were assessed by Quest score, with a cutoff of 6 points. The relationship between GERD symptoms and radiographic parameters was evaluated. Right convex coronal curves were given negative values, and left convex curves positive values. Degenerative scoliosis was defined when the thoracolumbar/lumbar Cobb angle had an absolute value >10 degrees. Risk factors for GERD were evaluated with univariate and multivariate logistic regression analyses. RESULTS: Of the patients, 126 had degenerative scoliosis at the thoracolumbar/lumbar spine (42 with right and 84 with left convex curve), and 59 had GERD. Multivariate logistic regression analysis revealed that the lumbar Cobb angle was significantly associated with GERD (P<0.05, odds ratio=1.021). When patients were categorized by Cobb angle of the lumbar curve (<-30 degrees, large right convex curve; -30 to +30 degrees, small curve; or >+30 degrees, large left convex curve), a large left convex curve was strongly associated with GERD (P<0.05, odds ratio=10.925). CONCLUSIONS: Left thoracolumbar/lumbar curve was a significant risk factor for GERD, and risk increased with a curve >30 degrees. Organ disorders such as GERD should be considered when treating elderly patients with degenerative scoliosis.
Negrini S
BACKGROUND CONTEXT: Spinal deformities are commonly associated with poor health-related quality of life (HRQOL). Several questionnaires (eg, Scoliosis Research Society-24 [SRS-24] and Scoliosis Research Society-22 [SRS-22]) have been developed to evaluate HRQOL in these conditions. In adults as well as during growth, the HRQOL is considered one of the most relevant outcomes of both conservative and surgical treatments. Rasch analysis is a powerful statistical technique for developing high-quality and valid questionnaires. The SRS-24 and SRS-22 have been evaluated using the Rasch analysis but showed poor measurement properties. Thus, a proper measure of HRQOL in people with a spine condition is still missing. PURPOSE: This study aimed to develop a new questionnaire that is totally Rasch consistent for measuring the HRQOL in young people with a spine condition. STUDY DESIGN: This is a cross-sectional study for developing a new HRQOL measure. PATIENT SAMPLE: A total of 402 participants with adolescent idiopathic scoliosis or Scheuermann juvenile kyphosis were included in the study. OUTCOME MEASURE: The outcome measure used was the Italian Spine Youth Quality of Life (ISYQOL) questionnaire. MATERIALS AND METHODS: The study consisted of different stages: a conventional approach content analysis, an opinion poll among clinicians trained in spine deformities, and the Rasch analysis (partial credit model). RESULTS: The Rasch analysis showed that all items of the ISYQOL questionnaire had ordered thresholds and a good fit to the model. Differential item functioning was present for Item 1, with bracing only, and was solved with a conventional items splitting procedure. The ISYQOL item map spans an adequate range of HRQOL. The principal component analysis for Rasch residuals showed, in practical terms, the ISYQOL unidimensionality. The reliability of ISYQOL was high enough so that approximately three significantly different levels of HRQOL could be discerned. Two questionnaire versions were provided for patients with and without the brace, respectively. CONCLUSIONS: ISYQOL is the first HRQOL questionnaire developed according to the Rasch analysis. It was developed in a conservative treatment setting for all types of spinal deformities, including also patients with surgical curves. Validation in many languages is already under way.
Ferrante S
STUDY DESIGN: Single-center, prospective study. OBJECTIVE: Evaluating the responsiveness and minimal important changes (MICs) for the Scoliosis Research Society-22 Patient Questionnaire (SRS-22) in adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AS). SUMMARY OF BACKGROUND DATA: Despite the SRS-22 properties have been investigated in various different languages, there is still a lack of information concerning responsiveness and MIC, limiting the use of SRS-22 for clinical and research purposes. METHODS: At the beginning and end of multidisciplinary rehabilitation programs, 149 subjects with mild AIS (Cobb angle <25 degrees ) and 140 subjects with moderate AS (Cobb angle <35 degrees ) completed the SRS-22. Upon completing the programs, subjects also performed the global perceived effect (GPE) scales test, which was divided to produce a dichotomous outcome (improved vs. stable). Responsiveness was calculated for all SRS-22 domains but satisfaction with management by distribution (effect size; standardized response mean) and anchor-based methods (receiver operating characteristic [ROC] curves; correlations between change scores of the SRS-22 and GPE). ROC curves were also used to compute the MICs. RESULTS: The effect size ranged from 1.23 to 1.50 in AIS and from 1.02 to 1.37 in AS. The standardized response mean ranged from 0.95 to 1.27 in AIS and from 0.66 to 0.90 in AS. The ROC analyses revealed the following MIC values (area under the curve; sensitivity; specificity): function, 0.70 (0.739;66;70) for AIS and 0.60 (0.842;84;76) for AS; pain, 0.70 (0.731;71;70) for AIS and 0.40 (0.817;81;70) for AS; mental health, 0.50 (0.708;83;58) for AIS and 0.55 (0.750;69;78) for AS; self-perceived image, 0.40 (0.609;79;42) for AIS and 0.60 (0.751;61;82) for AS. Correlations between change scores of the SRS-22 domains and GPE were low to moderate, ranging from -0.347 to -0.667. CONCLUSION: The SRS-22 was sensitive in detecting clinical changes in subjects with adolescent and adult scoliosis. We recommend taking the MICs provided into account when assessing patients' improvement or planning studies in these clinical contexts. LEVEL OF EVIDENCE: 3.
Yakut Y
BACKGROUND: Bracing is the most common nonsurgical treatment for adolescent idiopathic scoliosis. Spinal braces affect glenohumeral and scapulothoracic motion because they restrict trunk movements. However, the potential spinal-bracing effects on scapular kinematics are unknown. The present study aimed to investigate the acute effects of spinal bracing on scapular kinematics in adolescent idiopathic scoliosis. METHODS: Scapular kinematics, including scapular internal/external rotation, posterior/anterior tilting, and downward/upward rotation during scapular plane elevation, were evaluated in 27 in-brace and out-of-brace adolescent idiopathic scoliosis patients with a three-dimensional electromagnetic tracking system. Data on the position and orientation of the scapula at 30 degrees , 60 degrees , 90 degrees , and 120 degrees humerothoracic elevation were used for statistical comparisons. The paired t-test was used to assess the differences between the mean values of in-brace and out-of-brace conditions. FINDINGS: The in-brace condition showed significantly increased (P<0.05) scapular anterior tilting and decreased internal rotation in the resting position on the convex and concave sides; increased scapular downward rotation at 120 degrees humerothoracic elevation on the convex side and at 30 degrees , 60 degrees , 90 degrees , and 120 degrees humerothoracic elevation on the concave side; increased scapular anterior tilt at 30 degrees , 60 degrees , 90 degrees , and 120 degrees humerothoracic elevation on the convex and concave sides; and decreased (P<0.05) maximal humerothoracic elevation of the arm. INTERPRETATION: Spinal bracing affects scapular kinematics. Observed changes in scapular kinematics with brace may also affect upper extremity function for adolescents with idiopathic scoliosis. Therefore, clinicians should include assessments of the glenohumeral and scapulothoracic joints when designing rehabilitation protocols for patients with adolescent idiopathic scoliosis.
Zaina F, Pesenti F, Persani L, Capodaglio P, Negrini S, Polli N
PURPOSE: A long debate exists about the connection between anorexia nervosa (AN) and scoliosis due to conflicting evidence. No study so far has evaluated the prevalence of scoliosis in patients with AN. The aim of the study is to evaluate the prevalence of idiopathic scoliosis in patients with AN. METHODS: Design: cross-sectional study. STUDY GROUP: convenience sample of all patients matching the inclusion criteria. CONTROL GROUP: female participants coming from an epidemiological screening for scoliosis. INCLUSION CRITERIA: patients had a diagnosis of AN during adolescence according to the DSM-IV-TR criteria. We applied a two-level screening using a Bunnell scoliometer and a radiograph. We calculated the odds ratio compared with participants coming from a school screening. RESULTS: Seventy-seven females with AN were compared to 816 females screened for scoliosis. The prevalence of scoliosis in the AN group was 16.9% (OR 5.77, 95% CI 3.12-10.67) with respect to the control group. If we consider as positive only those who received a scoliosis diagnosis during adolescence, the OR would be 3.15 (95% CI 1.55-6.42). DISCUSSION: This is the first study performed on patients with AN showing a sixfold greater odds of presenting with scoliosis. A cause-effect relationship cannot be determined due to the design.
Tomaszewski R, Wiktor L, Machala L
PURPOSE: The aim of our study was to evaluate thoracic vertebrae rotation in patients with pectus excavatum. Moreover, we wanted to assess the prevalence, the severity and relationship between pectus excavatum and adolescent idiopathic scoliosis (AIS). METHODS: We performed retrospective analysis of 82 preoperative chest CT in children with pectus excavatum performed between January 2008 and December 2011. For each patient Haller Index and Cobb angle was measured. To evaluate the severity of thoracic scoliosis we measured vertebral rotation for Th8 and for vertebra at the level of highest chest deformation using Aaro-Dahlborn method. RESULTS: From the group of 54 patients with pectus excavatum enrolled in the study AIS was diagnosed in 8 patients (14,81%). In patients with symmetric deformation, Th8 rotation was found in 21 patients; the rotation of the apical vertebra was found in 20 patients. In patients with asymmetric deformation Th8 rotation was found in 10 patients; the rotation of the apical vertebra was found in 8 patients. CONCLUSIONS: 1. We have confirmed the higher prevalence of pectus excavatum in boys; 2. We have found a significant relationship between pectus excavatum and adolescent idiopathic scoliosis; 3. We have shown that deformation of the anterior chest wall enforces rotation of the thoracic spine; 4. We haven't found the relationship between the severity of the chest deformity (HI measured) and severity of AIS (Cobb angle measured); 5. We have shown a significant association between HI measured and rotation of thoracic vertebra at the level of highest chest deformation (apical vertebra) in symmetric pectus excavatum. LEVEL OF EVIDENCE: Level IV, Diagnostic study.
Silva RTE, Fernandes RJR, Ono AHA, Marcon RM, Cristante AF, Barros TEP Filho
OBJECTIVE: To evaluate the hormonal profile of patients with adolescent idiopathic scoliosis (AIS) and its relationship to the severity of the curvature and quality of life . METHOD: Patients with scoliosis (Cobb angle above 10 degrees ), of both genders, diagnosed after 10 years of age were included, excluding those who presented other condition that could lead to scoliosis. Serum levels of 25-hydroxyvitamin D (25-OHD), cortisol and gastrin were correlated with Cobb angle and quality of life, measured by the SRS-30 questionnaire . RESULTS: The levels of 25-OHD decreased in 97% of patients. There was an inverse relationship between gastrin levels and quality of life (p = 0.016). Moreover, there was an inverse correlation between the value of Cobb angle and quality of life (p = 0.036). There were no changes in cortisol levels. There was no correlation between Cobb angle and any of the hormones measured . CONCLUSION: The patients had levels of 25-OHD diminished, strengthening the hypothesis of its involvement in the development of AIS. This study also suggests that increased gastrin levels may be associated with a worse quality of life in patients with AIS. Level of Evidence II, Diagnostic Study.
Place HM, Hayes AM, Huebner SB, Hayden AM, Israel H, Brechbuhler JL
BACKGROUND CONTEXT: There has been renewed interest in the pelvic vertebrae by spinal surgeons recently. Those involved in working with patients with adult spinal deformity focus on the position of the fused spine as it relates to the pelvis, and determine success or failure by specific numbers for given pelvic parameters. The pelvic parameters that are commonly measured for these patients are pelvic tilt, sacral slope, and pelvic incidence (PI). Out of the three, PI has always been considered to be the fixed measurement, whereas pelvic tilt and sacral slope have the capacity to change in relation to external forces. The assumption that the PI does not change has not been proven in a healthy, asymptomatic population. PURPOSE: This study aimed to investigate the differences in PI between three pelvic positions used in common functional activities: resting baseline pelvic posture, maximal anterior pelvic rotation, and maximal posterior pelvic rotation. STUDY DESIGN/SETTING: This was a randomized, prospective study of 50 healthy, asymptomatic, individuals who were recruited from the vicinity of our institution. PATIENT SAMPLE: Fifty patients (16 men with a mean age of 26.5+/-12.1 years; 34 women with a mean age of 27.2+/-10.8 years) were recruited for this study. Initial screening occurred by telephone. The inclusion criteria consisted of participants being between 18 and 79 years of age, no previous history of spine, pelvic, or lower extremity pain which had lasted longer than 48 hours, or history of any disorder in the spine, pelvis, or lower extremity that had required medical care. Female patients could not be pregnant at the time of participation. OUTCOME MEASURES: Changes in PI were assessed by examining the differences between the values of the PI with each change in pelvic position: resting to maximal anterior pelvic rotation and resting to maximal posterior pelvic rotation. Inter-rater reliability was assessed using Cronbach's alpha. METHODS: This study was funded by a Small Exploratory Grant from the Scoliosis Research Society. All subjects had an initial posterior-anterior and lateral radiograph taken in their resting pelvic position. If no spinal deformity was noted, each subject was instructed to maximally rotate their pelvis anteriorly and an immediate lateral radiograph was taken. The subject was then instructed to maximally rotate their pelvis posteriorly and an immediate lateral radiograph was again taken. Radiographic measurements of PI were independently measured by a board-certified, fellowship trained orthopedic spine surgeon and a board-certified musculoskeletal radiologist after defining and agreeing to the specific manner of measurement. RESULTS: Pelvic incidence values changed in 44 of 50 subjects (88%) when they maximally anteriorly rotated their pelvis from the resting pelvic position. The mean change was 2.9 degrees , with 23 of 50 subjects (46%) changing >/=3 degrees . Pelvic incidence values changed in 40 of 50 subjects (80%) when they maximally posteriorly rotated their pelvis from the resting position. The mean change was 2.82 degrees with 27 of 50 subjects (54%) changing by >/=3 degrees . CONCLUSIONS: This study demonstrated that for a high percentage of the healthy subjects who participated, the PI changed when the subjects varied their pelvic position. This questions the assumption that PI is a fixed parameter and suggests a potential functional motion at the sacroiliac joint. It also supports the idea that intentionally changing one's posture could lead to a change in PI, an idea that could have ramifications in surgical cases.
Hayden AM, Hayes AM, Brechbuhler JL, Israel H, Place HM
BACKGROUND CONTEXT: To date, many studies have examined how pelvic position affects the spinal curvature and spinopelvic parameters. However, these studies focus on a static relationship, comparing pelvis and spine in a relaxed or baseline position only. Indeed, the spinopelvic connection is dynamic, as subjects can easily be taught to rotate their pelvis anteriorly or posteriorly on the femoral head, all while maintaining an erect posture. Therefore, for a true understanding of pelvic influence on the spinal column, it is necessary to examine spinopelvic parameters in multiple pelvic positions within the same subject. PURPOSE: The objective of this study was to examine the dynamic effect of pelvic motion on the spine and associated radiographic parameters. STUDY DESIGN: This is a single-center, cross-sectional study of 50 healthy, asymptomatic volunteers. PATIENT SAMPLE: Subjects were recruited and screened based on the following criteria: between 18 and 79 years of age; no known spinal, pelvic, or lower extremity pain lasting for >48 hours; no history of spinal, pelvic, or lower extremity dysfunction requiring medical care; no radiographic evidence of spinal or pelvic abnormality, scoliosis deformity, or other associated spinal pathologies; not currently pregnant and with no possibility of being pregnant; and a body mass index of <30. 64. The subjects were screened and 14 were excluded for a total of 50 subjects. OUTCOME MEASURES: The outcome measures included thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis (SVA), pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI). MATERIALS AND METHODS: This study was funded by a Small Exploratory Research Grant from the Scoliosis Research Society. Each subject was instructed and observed to stand in three different positions: pelvic resting, anterior pelvic rotation, and posterior pelvic rotation. Lateral standing radiographs were taken in each position and each image was examined by an orthopedic spine surgeon who digitally measured the TK, LL, SVA, PT, SS, and PI. The data were then statistically examined to determine the affect of pelvic position on each parameter. RESULTS: Subjects demonstrated a measurable, statistically significant change in each parameter with pelvic rotation. There was a clear pattern of change for LL, PT, and SS with the anterior and posterior pelvic rotations. A change in LL demonstrated a strong correlation with changes in all measured parameters with pelvic rotation. CONCLUSIONS: In asymptomatic subjects, pelvic motion affects the position of the spinal column and resultant spinopelvic parameters. The results of this study demonstrate that one can intentionally change the position of the pelvis and the adjacent spinal column in space. Knowledge of this relationship is important to the understanding of sagittal balance and could influence the treatment of patients with spinal deformity.
Rivett DA
Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. This study investigated the effects of sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) on cervicogenic dizziness compared to a placebo at 12 months post-treatment. Eighty-six participants (mean age 62 years, standard deviation (SD) 12.7) with chronic cervicogenic dizziness were randomised to receive SNAGs with self-SNAGs (n = 29), PJMs with range-of-motion (ROM) exercises (n = 29), or a placebo (n = 28) for 2-6 sessions over 6 weeks. Outcome measures were dizziness intensity, dizziness frequency (rated between 0 [none] and 5 [>once/day]), the Dizziness Handicap Inventory (DHI), pain intensity, head repositioning accuracy (HRA), cervical spine ROM, balance, and global perceived effect (GPE). At 12 months both manual therapy groups had less dizziness frequency (mean difference SNAGs vs placebo -0.7, 95% confidence interval (CI) -1.3, -0.2, p = 0.01; PJMs vs placebo -0.7, -1.2, -0.1, p = 0.02), lower DHI scores (mean difference SNAGs vs placebo -8.9, 95% CI -16.3, -1.6, p = 0.02; PJMs vs placebo -13.6, -20.8, -6.4, p < 0.001) and higher GPE compared to placebo, whereas there were no between-group differences in dizziness intensity, pain intensity or HRA. There was greater ROM in all six directions for the SNAG group and in four directions for the PJM group compared to placebo, and small improvements in balance for the SNAG group compared to placebo. There were no adverse effects. These results provide evidence that both forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.
Santaguida PL
BACKGROUND: Neck pain is common, disabling and costly. Exercise is one treatment approach. OBJECTIVES: To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain. SEARCH METHODS: We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors). SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy. DATA COLLECTION AND ANALYSIS: Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity. MAIN RESULTS: Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises. AUTHORS' CONCLUSIONS: No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.
Taube W
BACKGROUND: Impaired cervical joint position sense is a feature of chronic neck pain and is commonly argued to rely on abnormal cervical input. If true, muscle vibration, altering afferent input, but not mental interventions, should have an effect on head repositioning acuity and neck pain perception. AIM: The aim of the present study was to determine the short-term effects of neck muscle vibration, motor imagery, and action observation on cervical joint position sense and pressure pain threshold in people with chronic neck pain. DESIGN: Forty-five blinded participants with neck pain received concealed allocation and were randomized in three treatment groups. A blinded assessor performed pre- and post-test measurement. SETTING: Patients were recruited from secondary outpatient clinics in the southwest of Germany. POPULATION: Chronic, non specific neck pain patients without arm pain were recruited for this study. METHODS: A single intervention session of 5 minutes was delivered to each blinded participant. Patients were either allocated to one of the following three interventions: (1) neck muscle vibration; (2) motor imagery; (3) action observation. Primary outcomes were cervical joint position sense acuity and pressure pain threshold. Repeated measures ANOVAs were used to evaluate differences between groups and subjects. RESULTS: Repositioning acuity displayed significant time effects for vibration, motor imagery, and action observation (all P<0.05), but revealed no time*group effect. Pressure pain threshold demonstrated a time*group effect (P=0.042) as only vibration significantly increased pressure pain threshold (P=0.01). CONCLUSION: Although motor imagery and action observation did not modulate proprioceptive, afferent input, they nevertheless improved cervical joint position sense acuity. This indicates that, against the common opinion, changes in proprioceptive input are not prerequisite to improve joint repositioning performance. However, the short-term applications of these cognitive treatments had no effect on pressure pain thresholds, whereas vibration reduced pressure pain thresholds. This implies different underlying mechanisms after vibration and mental training. CLINICAL REHABILITATION IMPACT: Mental interventions were effective in improving cervical joint position sense and are easy to integrate in rehabilitation regimes. Neck muscle vibration is effective in improving cervical joint position sense and pressure pain thresholds within 5 minutes of application.
Salvador-Coloma P
BACKGROUND: In patients with neuromuscular disease and a forced vital capacity (FVC) of <30% of the predictive value, scoliosis correction operation was Background. An unstable shoe was developed as a walking device to strengthen the lower extremity muscles and reduce joint loading. A large number of studies have reported increased electromyographic (EMG) activity throughout the gait cycle in most of the lower limb muscles, and significant kinematic changes in the lower extremity. However, no studies have investigated the effects of wearing unstable shoes on spine kinematics and trunk muscle activity during gait. AIM: To compare trunk muscle activity and lumbar spine range of motion (ROM) during gait using an unstable shoe and a conventional stable control shoe. DESIGN: Cross-sectional study. SETTING: A Biomechanics laboratory. POPULATION: Forty-eight healthy voluntary participants (24.5+/-5.6 years and 22.7+/-6.8 kg/m2). METHODS: Subjects underwent gait analysis while simultaneously collecting surface EMG data of erector spinae (ES) and rectus abdominis (RA) and lumbar spine sagittal plane ROM while treadmill walking wearing regular shoes and unstable shoes. RESULTS: The results showed that the unstable shoes resulted in significantly higher ES and RA EMG muscle activity levels in all gait phases compared to control shoes (P<0.001). In addition, the unstable shoe condition showed a significantly higher mean (mean difference: 3.1 masculine; 95% CI 2.2 masculine to 4 masculine) and maximum (mean difference: 4.5 masculine; 95% CI 2.6 masculine to 6.5 masculine) lumbar spine extension values (P<0.001). CONCLUSIONS: Unstable shoes increase trunk muscle activity (ES, RA) and lumbar lordosis during gait compared to control shoes. CLINICAL REHABILITATION IMPACT: Based on these findings, the use of unstable shoes may have potential implications in promoting spine tissue health, particularly in strengthening trunk muscles in healthy population or in low back pain treatment.
Osborne N
BACKGROUND: Chronic low back pain (CLBP) is a multifactorial condition with a variety of symptoms, one of which is abnormal gait. The lumbar spine and its musculature are important in controlling gait, and in CLBP the lumbar extensors are often deconditioned. Because of this specific isolated lumbar extension, exercise often is recommended. It was therefore of interest to examine its effects of upon gait variability. OBJECTIVE: To examine the effects of isolated lumbar extension resistance training on lumbar kinematic variability during gait in participants with CLBP. DESIGN: Randomized controlled trial. SETTING: University Health, Exercise and Sport Science Laboratory. PARTICIPANTS: Twenty-four participants with nonspecific CLBP. INTERVENTIONS: Participants were randomly allocated to a 12-week isolated lumbar extension exercise intervention (1x/week performing a single set to momentary muscular failure using a load equal to 80% max tested torque) or nontraining control period. MAIN OUTCOME MEASUREMENTS: Lumbar kinematics during gait, including angular displacement, kinematic waveform pattern (CVp), and offset (CVo) variability, were examined via 3-dimensional analyses. RESULTS: No significant changes in displacement or CVo were found as a result of the intervention; however, a small but significant reduction in sagittal plane CVp (-20.90 +/- 3.53%, effect size = 0.48, P = .044) occurred, indicating improved motor pattern replication through this movement plane. CONCLUSIONS: Considering the role of the lumbar extensors in gait, and their common deconditioning in CLBP, an isolated lumbar extension resistance exercise intervention may reduce gait variability. These results suggest isolated lumbar extension exercise may specifically reduce sagittal plane variability, indicating improved motor pattern replication through this movement plane, perhaps attributable to the plane of movement used during the exercise.
Lind B
STUDY DESIGN: Prospective randomized controlled trial. OBJECTIVE: To analyze factors that may influence the outcome of anterior cervical decompression and fusion (ACDF) followed by physiotherapy versus physiotherapy alone for treatment of patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: An understanding of patient-related factors affecting the outcome of ACDF is important for preoperative patient selection. No previous prospective, randomized study of treatment effect modifiers relating to outcome of ACDF compared with physiotherapy has been carried out. METHODS: 60 patients with cervical radiculopathy were randomized to ACDF followed by physiotherapy or physiotherapy alone. Data for possible modifiers of treatment outcome at 1 year, such as sex, age, duration of pain, pain intensity, disability (Neck Disability Index, NDI), patient expectations of treatment, anxiety due to neck/arm pain, distress (Distress and Risk Assessment Method), self-efficacy (Self-Efficacy Scale) health status (EQ-5D), and magnetic resonance imaging findings were collected. A multivariate analysis was performed to find treatment effect modifiers affecting the outcome regarding arm/neck pain intensity and NDI. RESULTS: Factors that significantly altered the treatment effect between treatment groups in favor of surgery were: duration of neck pain less than 12 months (P = 0.007), duration of arm pain less than 12 months (P = 0.01) and female sex (P = 0.007) (outcome: arm pain), low EQ-5D index (outcome: neck pain, P = 0.02), high levels of anxiety due to neck/arm pain (outcome: neck pain, P = 0.02 and NDI, P = 0.02), low Self-Efficacy Scale score (P = 0.05), and high Distress and Risk Assessment Method score (P = 0.04) (outcome: NDI). No factors were found to be associated with better outcome with physiotherapy alone. CONCLUSION: In this prospective, randomized study of patients with cervical radiculopathy, short duration of pain, female sex, low health quality, high levels of anxiety due to neck/arm pain, low self-efficacy, and a high level of distress before treatment were associated with better outcome from surgery. No factors were found to be associated with better outcome from physiotherapy alone.
Sabeti-Aschraf M
OBJECTIVE: Comparison of climbing versus no treatment to treat chronic low back pain. DESIGN: Prospective randomized controlled trial. SETTING: Tertiary. PARTICIPANTS: A total of 30 patients with chronic low back pain were recruited and randomly assigned to 2 different groups: climbing and control. The inclusion criteria were defined as chronic low back pain, age between 18 and 45 years, body mass index lower than 25, and no climbing experience. INTERVENTIONS: Patients in the climbing group were instructed to climb 5 different climbing routes. A climbing activity of 10 sessions in 8 weeks, at least once a week with a minimum duration of 1 hour, was mandatory. MAIN OUTCOME MEASURES: The participants were examined before (T0) and after therapy (8 weeks, T8) and after another 6 weeks (T14). The outcome was evaluated using Oswestry Disability Index, Visual Analog Scale (VAS), Likert scale, and magnetic resonance imaging (MRI). Radiologists evaluating MRI were blinded. The study was performed as a single-center study. RESULTS: Evaluating the Oswestry Disability Index, a significant difference in the time course between the 2 groups was detected (P = 0.022). Significant improvements comparing climbing and control group were also found when assessing VAS in a minimal finger-floor-distance position (P = 0.048). Patients in the climbing group showed a reduction in size of disc protrusion. CONCLUSIONS: Climbing may be an effective and low-cost therapy option for people with chronic low back pain. CLINICAL RELEVANCE: Low back pain is a very common disease but still a challenge to treat. Therapy strategies vary from conservative ones, pharmacological treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and weak opioids, to invasive treatment with acupuncture, injections, and operative reconstruction. Some can be costly and not without risks. For instance, many people who use NSAIDs are at risk of common side effects such as gastrointestinal complications (irritation, ulcers, and bleeding) that may lead to hospitalization. Climbing could offer reduction of pain and better performance in daily life, because it offers a closed chain muscle training that has the potential to improve posture, perception of the trunk midline, and muscle control. Climbing may also lead to a better adherence to continuing treatment than traditional physical therapy and exercise due to a more exciting aspect of the sports activity.
Dobos G
OBJECTIVES: With growing evidence for the effectiveness of craniosacral therapy (CST) for pain management, the efficacy of CST remains unclear. This study therefore aimed at investigating CST in comparison with sham treatment in chronic nonspecific neck pain patients. MATERIALS AND METHODS: A total of 54 blinded patients were randomized into either 8 weekly units of CST or light-touch sham treatment. Outcomes were assessed before and after treatment (week 8) and again 3 months later (week 20). The primary outcome was the pain intensity on a visual analog scale at week 8; secondary outcomes included pain on movement, pressure pain sensitivity, functional disability, health-related quality of life, well-being, anxiety, depression, stress perception, pain acceptance, body awareness, patients' global impression of improvement, and safety. RESULTS: In comparison with sham, CST patients reported significant and clinically relevant effects on pain intensity at week 8 (-21 mm group difference; 95% confidence interval, -32.6 to -9.4; P=0.001; d=1.02) and at week 20 (-16.8 mm group difference; 95% confidence interval, -27.5 to -6.1; P=0.003; d=0.88). Minimal clinically important differences in pain intensity at week 20 were reported by 78% within the CST group, whereas 48% even had substantial clinical benefit. Significant between-group differences at week 20 were also found for pain on movement, functional disability, physical quality of life, anxiety and patients' global improvement. Pressure pain sensitivity and body awareness were significantly improved only at week 8. No serious adverse events were reported. DISCUSSION: CST was both specifically effective and safe in reducing neck pain intensity and may improve functional disability and the quality of life up to 3 months after intervention.
Solheim O
STUDY DESIGN: Observational multicenter study. OBJECTIVE: To evaluate if the severity of lumbar spinal stenosis (LSS) on magnetic resonance imaging (MRI) correlates with preoperative disability, pain, or surgical outcomes. SUMMARY OF BACKGROUND DATA: Surgeons use the morphological appearance of LSS on MRI for clinical decision making. However, the associations between radiological severity of LSS and disability, pain, or surgical outcomes remain unclear. METHODS: Evaluation of severity of LSS on preoperative MRI according to the Schizas morphological classification. Patient and treatment data were retrieved from the Norwegian Registry for Spine Surgery. Preopertaive outcome measures were Oswestry disability index (ODI) and numeric rating scale (NRS) scores for back and leg pain. Postopertive outcome measures were ODI and NRS scores for back and leg pain at 1 year, changes in ODI and NRS scores after treatment, duration of surgery, length of hospital stay, and perioperative complications. RESULTS: Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI (P = 0.089), NRS back pain (P = 0.273), or NRS leg pain (P = 0.282) scores. There were no differences in ODI (P = 0.933), NRS back pain (P = 0.652), or NRS leg pain (P = 0.912) scores after 1 year. The radiological severity of stenosis was not associated with change in ODI (P = 0.494), NRS back pain (P = 0.235), NRS leg pain (P = 0.790), duration of surgery (P = 0.661), length of hospital stay (P = 0.739), or perioperative complication rates (P = 0.467). CONCLUSION: Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making. LEVEL OF EVIDENCE: 2.
Aguilar-Ferrandiz ME
BACKGROUND CONTEXT: Chronic low back pain (LBP) is a prevalent condition associated with pain, disability, decreased quality of life, and fear of movement. To date, no studies have compared the effectiveness of spinal manipulation and functional technique for the management of this population. PURPOSE: This study aimed to compare the effectiveness of spinal manipulation and functional technique on pain, disability, kinesiophobia, and quality of life in patients with chronic LBP. STUDY DESIGN/SETTING: A single-blind pragmatic randomized controlled trial conducted in a university research clinic was carried out. PATIENT SAMPLE: Sixty-two patients (62% female, age: 45+/-7) with chronic LBP comprised the patient sample. OUTCOME MEASURES: Data on disability (Roland-Morris Disability Questionnaire [RMQ], Oswestry Low Back Pain Disability Index [ODI]), pain intensity (Numerical Pain Rate Scale [NPRS]), fear of movement (Tampa Scale of Kinesiophobia [TSK]), quality of life (Short Form-36 [SF-36] quality of life questionnaire), isometric resistance of abdominal muscles (McQuade test), and spinal mobility in flexion (finger-to-floor distance) were collected at baseline immediately after the intervention phase and at 1 month postintervention by an assessor blinded to group allocation of the patients. METHODS: Patients were randomly assigned to the spinal manipulative therapy group or the functional technique group and received three once-weekly sessions. RESULTS: In comparison to patients receiving functional technique, those receiving spinal manipulation experienced statistically, although not clinically, significant greater reductions in terms of RMQ (standardized mean difference in score changes between groups at post-treatment: 0.1; at 1 month: 0.1) and ODI (post-treatment: 2.9; at 1 month: 1.4). Linear longitudinal analysis showed a significant improvement in both groups over time for RMQ (manipulative: F=68.51, p<.001; functional: F=28.58, p<.001) and ODI (manipulative: F=104.66, p<.001; functional: F=32.15, p=.001). However, significant treatment-by-time interactions were not detected for pain intensity (p=.488), TSK (p=.552), any domains of the SF-36 quality of life questionnaire (p
Woby SR
OBJECTIVES: To determine whether adding a physiotherapist-led cognitive-behavioural intervention to an exercise programme improved outcome in patients with chronic neck pain (CNP). DESIGN: Multicentre randomised controlled trial. SETTING: Four outpatient physiotherapy departments. PARTICIPANTS: Fifty-seven patients with CNP. Follow-up data were provided by 39 participants [57% of the progressive neck exercise programme (PNEP) group and 79% of the interactive behavioural modification therapy (IBMT) group]. INTERVENTIONS: Twenty-eight subjects were randomised to the PNEP group and 29 subjects were randomised to the IBMT group. IBMT is underpinned by cognitive-behavioural principles, and aims to modify cognitive risk factors through interactive educational sessions, graded exercise and progressive goal setting. MAIN OUTCOME MEASURES: The main outcome measure was disability, measured by the Northwick Park Questionnaire (NPQ). Secondary outcomes were the Numeric Pain Rating Scale (NPRS), Pain Catastrophising Scale, Tampa Scale for Kinesiophobia (TSK), Chronic Pain Self-efficacy Scale (CPSS) and the Pain Vigilance and Awareness Questionnaire. RESULTS: No significant between-group differences in disability were observed (mean NPQ change: PNEP=-7.2, IBMT=-10.2). However, larger increases in functional self-efficacy (mean CPSS change: PNEP=1.0, IBMT=3.2) and greater reductions in pain intensity (mean NPRS change: PNEP=-1.0, IBMT=-2.2; P<0.05) and pain-related fear (mean TSK change: PNEP=0.2, IBMT=-4.7, P<0.05) were observed with IBMT. Additionally, a significantly greater proportion of participants made clinically meaningful reductions in pain (25% vs 55%, P<0.05) and disability (25% vs 59%, P<0.05) with IBMT. CONCLUSIONS: The primary outcome did not support the use of cognitive-behavioural physiotherapy in all patients with CNP. However, superior outcomes were observed for several secondary measures, and IBMT may offer additional benefit in some patients. CLINICAL TRIAL REGISTRATION NUMBER: ISRCTN27611394.
Moseley GL
BACKGROUND: Despite common use of proprioceptive retraining interventions in people with chronic, idiopathic neck pain, evidence that proprioceptive dysfunction exists in this population is lacking. Determining whether proprioceptive dysfunction exists in people with chronic neck pain has clear implications for treatment prescription. PURPOSE: The aim of this study was to synthesize and critically appraise all evidence evaluating proprioceptive dysfunction in people with chronic, idiopathic neck pain by completing a systematic review and meta-analysis. DATA SOURCES: MEDLINE, CINAHL, PubMed, Allied and Complementary Medicine, EMBASE, Academic Search Premier, Scopus, Physiotherapy Evidence Database (PEDro), and Cochrane Collaboration databases were searched. STUDY SELECTION: All published studies that compared neck proprioception (joint position sense) between a chronic, idiopathic neck pain sample and asymptomatic controls were included. DATA EXTRACTION: Two independent reviewers extracted relevant population and proprioception data and assessed methodological quality using a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. DATA SYNTHESIS: Thirteen studies were included in the present review. Meta-analysis on 10 studies demonstrated that people with chronic neck pain perform significantly worse on head-to-neutral repositioning tests, with a moderate standardized mean difference of 0.44 (95% confidence interval=0.25, 0.63). Two studies evaluated head repositioning using trunk movement (no active head movement thus hypothesized to remove vestibular input) and showed conflicting results. Three studies evaluated complex or postural repositioning tests; postural repositioning was no different between groups, and complex movement tests were impaired only in participants with chronic neck pain if error was continuously evaluated throughout the movement. LIMITATIONS: A paucity of studies evaluating complex or postural repositioning tests does not permit any solid conclusions about them. CONCLUSIONS: People with chronic, idiopathic neck pain are worse than asymptomatic controls at head-to-neutral repositioning tests.
Taylor NF
BACKGROUND: Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders. METHODS: This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models. RESULTS: Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone. CONCLUSIONS: 10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of >/=6 weeks and
Goode A
BACKGROUND: Lumbar disc herniation has a prevalence of up to 58% in the athletic population. Lumbar discectomy is a common surgical procedure to alleviate pain and disability in athletes. We systematically reviewed the current clinical evidence regarding athlete return to sport (RTS) following lumbar discectomy compared to conservative treatment. METHODS: A computer-assisted literature search of MEDLINE, CINAHL, Web of Science, PEDro, OVID and PubMed databases (from inception to August 2015) was utilised using keywords related to lumbar disc herniation and surgery. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodological quality of individual studies was assessed using the Downs and Black scale (0-16 points). RESULTS: The search strategy revealed 14 articles. Downs and Black quality scores were generally low with no articles in this review earning a high-quality rating, only 5 articles earning a moderate quality rating and 9 of the 14 articles earning a low-quality rating. The pooled RTS for surgical intervention of all included studies was 81% (95% CI 76% to 86%) with significant heterogeneity (I(2)=63.4%, p<0.001) although pooled estimates report only 59% RTS at same level. Pooled analysis showed no difference in RTS rate between surgical (84% (95% CI 77% to 90%)) and conservative intervention (76% (95% CI 56% to 92%); p=0.33). CONCLUSIONS: Studies comparing surgical versus conservative treatment found no significant difference between groups regarding RTS. Not all athletes that RTS return at the level of participation they performed at prior to surgery. Owing to the heterogeneity and low methodological quality of included studies, rates of RTS cannot be accurately determined.
Li M
STUDY DESIGN: A retrospective study. OBJECTIVE: The aim of this study is to introduce a novel regional predictor for sagittal balance in elderly populations and explore its effectiveness of evaluating sagittal balance. SUMMARY OF BACKGROUND DATA: Sagittal balance is getting increasing recognition of importance due to its significant association of health-related quality of life. However, no regional parameters could well reflect and predict the whole sagittal balance. METHODS: Medical records of elderly patients in our outpatient clinic from January 2012 to January 2014 were reviewed with standing full-spine lateral radiograph. Radiological parameters were evaluated, including max thoracic kyphosis (maxTK), max lumbar lordosis (maxLL), LL minus TK(LL-TK), PI minus LL (PI-LL), sacrum slope (SS), pelvic tilt (PT), pelvic incidence (PI), and SVA (sagittal vertical axis). Correlation analysis between SVA, LL-TK, and other radiological spinopelvic parameters and was pursued. Patients were divided into two groups according to whether patients were well-aligned in sagittal plane: Group A (well-aligned, SVA 50 mm), and demographic and sagittal parameters were compared. LL-TK >/=0 degrees and PI-LL /=0 degrees and PI-LL 13 degrees , 34 patients were poorly aligned (34/39, 87%). CONCLUSION: LL-TK was a good regional predictor for sagittal balance in elderly population, especially combined with PI-LL. LEVEL OF EVIDENCE: 4.
Maher CG
STUDY DESIGN: A cross-sectional survey. OBJECTIVE: The aim of this study was to compare patients' and physiotherapists' views on triggers for low back pain (LBP) and to identify any novel factors not previously reported. SUMMARY OF BACKGROUND DATA: Most research on risk factors for LBP is guided by the views of clinicians and researchers, not patients. Consequently, potentially valuable information about risk factors for LBP is not available from those suffering the condition. This study aimed to compare patients' and physiotherapists' views on triggers for LBP and to identify any novel factors not previously reported. METHODS: One hundred two physiotherapists and 999 patients with a sudden, acute episode of LBP participated in this study. Participating physiotherapists were asked to nominate the most likely short-term risk factors to trigger a LBP episode. Similarly, patients were asked what they thought had triggered their onset of LBP. Responses were coded into risk factor categories and subcategories by 2 independent researchers. Endorsement of each category was compared using the Pearson Chi-square statistic. RESULTS: Both patients and physiotherapists endorsed biomechanical risk factors as the most important risk factor category (87.7% and 89.4%, respectively) and had similar levels of endorsement for 3 of the top 5 subcategories (lifting, bending, and prolonged sitting). There were significant differences in endorsement of awkward postures (13.4% vs 1.2%; P < 0.001) sports injuries (15.9% vs 4.7%; P < 0.001), physical trauma (3.4% vs 9.2%; P < 0.001), and unaccustomed activity (2.3% vs 7.3%; P < 0.001) by patients and physiotherapists, respectively. CONCLUSION: Overall, patients' and physiotherapists' views were remarkably similar. Both patients and physiotherapists endorsed lifting as the most important trigger for LBP and agreed on 3 of the top 5 (lifting, bending, and prolonged sitting). No new risk factors were suggested by patients. LEVEL OF EVIDENCE: 2.
de Kleuver M
STUDY DESIGN: Cohort study. OBJECTIVE: To analyze long-term clinical and radiological outcomes of surgically treated Scheuermann patients. SUMMARY OF BACKGROUND DATA: Long-term clinical and radiological outcomes of surgery for Scheuermann kyphosis are unknown. A single-center cohort of 33 consecutive, surgically treated (between 1991 and 1998) Scheuermann patients was studied. METHODS: Clinical and radiological data of 29 surgically treated Scheuermann patients were collected (posterior approach n = 13; combined anterior-posterior procedure n = 16), after a mean follow-up of 18 years. Oswestry Disability Index (ODI) scores were measured preoperatively (PRE) and twice postoperatively: 2 to 8 years postoperative (FU 1) and 14 to 21 years postoperative (FU 2). Visual Analog Score pain, Short Form-36 (SF-36), and EQ-5d scores were recorded at FU 2 only. Radiographs were analyzed for correction, distal and proximal junctional kyphosis, and implant failures. RESULTS: Mean preoperative kyphosis of the corrected levels was 76 degrees (range 60 degrees -105 degrees ) and decreased to a Cobb of 58 degrees (range 30 degrees -105 degrees ) at FU 2. Median Visual Analog Score was 2.5 points (range 0-8) and median ODI score was 12 (range 0-62) at FU 2. The ODI score at FU 1 was significantly better as compared to PRE (P < 0.001) and FU 2 (P < 0.001). Also, anterior-posterior treated group had a significantly better ODI score as compared to the posterior-only group (P = 0.023). EQ-5d scores on mobility, usual activities, and pain/discomfort were worse compared to an age-matched population control group; however, SF-36 outcome scores were comparable.Proximal junctional kyphosis was present in 53% of patients, distal junctional kyphosis did not occur, and implant failure/removal had occurred in 69% of patients. Radiological complications do not relate with the ODI, EQ-5d, and SF-36 and 72% of the patients were satisfied. CONCLUSION: Radiological results of this cohort were disappointing but did not relate to clinical outcome scores. Even lumbar pain could not prevent a high patient satisfaction and quality of life. Patients treated with a combined anterior-posterior approach tended to perform better. LEVEL OF EVIDENCE: 3.
Costa LO
STUDY DESIGN: Systematic review. OBJECTIVE: To determine the effects of the Pilates method for patients with nonspecific acute, subacute, or chronic low back pain. SUMMARY OF BACKGROUND DATA: The Pilates method is one of the most common forms of intervention based on exercise used for treating patients with low back pain. However, its effectiveness is not well established. METHODS: We conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, and SPORTDiscus up to March 2014. We included randomized controlled trials examining the effectiveness of Pilates in patients with acute, subacute, or chronic nonspecific low back pain. The outcomes evaluated were pain, disability, function, and global impression of recovery. Two independent reviewers screened for potentially eligible studies, assessed risk of bias, and extracted the data. We evaluated the overall quality of evidence using the GRADE approach and treatment effect sizes were described using mean differences and 95% confidence intervals. RESULTS: Searches retrieved 126 trials, of which 10 were included in the review (n = 510 participants). Seven studies were considered to have low risk of bias, and three were considered at high risk of bias. When compared to minimal intervention, Pilates reduces pain at short and intermediate term with low- to moderate-quality evidence and medium effect sizes. For disability, there is also a significant difference in favor to Pilates with low- to moderate-quality evidence and small effect size for short term and medium effect size for intermediate term compared with minimal intervention. It is unclear whether Pilates is better than other exercises for short-term pain, but there is low-quality evidence that Pilates reduces pain at intermediate term. For disability, there is moderate-quality evidence that there is no significant difference between Pilates and other exercises in either the short term or the intermediate term. CONCLUSION: There is low- to moderate-quality evidence that Pilates is more effective than minimal intervention with most of the effect sizes being considered medium. However, there is no conclusive evidence that Pilates is superior to other forms of exercises. LEVEL OF EVIDENCE: 1.
Witt JP
BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC). PURPOSE: The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out. METHODS: This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years. RESULTS: Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline. CONCLUSIONS: The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuide lines.aspx and will remain updated on a timely schedule.
Chaves TC
OBJECTIVE: To evaluate the additional effect provided by physical therapy in migraine treatment. DESIGN: Randomized controlled trial. SETTING: Tertiary university-based hospital. PARTICIPANTS: Among the 300 patients approached, 50 women (age range, 18-55y) diagnosed with migraine were randomized into 2 groups: a control group (n=25) and a physiotherapy plus medication group (n=25) (N=50). INTERVENTIONS: Both groups received medication for migraine treatment. Additionally, physiotherapy plus medication patients received 8 sessions of physical therapy over 4 weeks, comprised mainly of manual therapy and stretching maneuvers lasting 50 minutes. MAIN OUTCOME MEASURES: A blinded examiner assessed the clinical outcomes of headache frequency, intensity, and self-perception of global change and physical outcomes of pressure pain threshold and cervical range of motion. Data were recorded at baseline, posttreatment, and 1-month follow-up. RESULTS: Twenty-three patients experienced side effects from the medication. Both groups reported a significantly reduced frequency of headaches; however, no differences were observed between groups (physiotherapy plus medication patients showed an additional 18% improvement at posttreatment and 12% improvement at follow-up compared with control patients, P>.05). The reduction observed in the physiotherapy plus medication patients was clinically relevant at posttreatment, whereas clinical relevance for control patients was demonstrated only at follow-up. For pain intensity, physiotherapy plus medication patients showed statistical evidence and clinical relevance with reduction posttreatment (P<.05). In addition, they showed better self-perception of global change than control patients (P<.05). The cervical muscle pressure pain threshold increased significantly in the physiotherapy plus medication patients and decreased in the control patients, but statistical differences between groups were observed only in the temporal area (P<.05). No differences were observed between groups regarding cervical range of motion. CONCLUSIONS: We cannot assume that physical therapy promotes additional improvement in migraine treatment; however, it can increase the cervical pressure pain threshold, anticipate clinically relevant changes, and enhance patient satisfaction.
Critchley DJ
STUDY DESIGN: Systematic review. OBJECTIVE: To review the evidence regarding the mechanism of action of mobilizations. SUMMARY OF BACKGROUND DATA: Spinal mobilizations-low velocity passive oscillatory movements-reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations' mechanism(s) of action are unclear. METHODS: Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool. RESULTS: Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness. CONCLUSION: These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms. LEVEL OF EVIDENCE: 3.
Kaya DO
STUDY DESIGN: Randomized clinical trial. BACKGROUND: Little is known about the efficacy of providing manual therapy in addition to cervical and scapulothoracic stabilization exercises in people with mechanical neck pain (MNP). Objectives To compare the effects of stabilization exercises plus manual therapy to those of stabilization exercises alone on disability, pain, range of motion (ROM), and quality of life in patients with MNP. METHODS: One hundred two patients with MNP (18-65 years of age) were recruited and randomly allocated into 2 groups: stabilization exercise without (n = 51) and with (n = 51) manual therapy. The program was carried out 3 days per week for 4 weeks. The Neck Disability Index, visual analog pain scale, digital algometry of pressure pain threshold, goniometric measurements, and Medical Outcomes Study 36-Item Short-Form Health Survey were used to assess participants at baseline and after 4 weeks. RESULTS: Improvements in Neck Disability Index score, night pain, rotation ROM, and the Medical Outcomes Study 36-Item Short-Form Health Survey score were greater in the group that received stabilization exercise with manual therapy compared to the group that only received stabilization exercise. Between-group differences (95% confidence interval) were 2.2 (0.1, 4.3) points for the Neck Disability Index, 1.1 (0.0, 2.3) cm for pain at night measured on the visual analog scale, -4.3 degrees (-8.1 degrees , -0.5 degrees ) and -5.0 degrees (-8.2 degrees , -1.7 degrees ) for right and left rotation ROM, respectively, and -2.9 (-5.4, -0.4) points and -3.1 (-6.2, 0.0) points for the Medical Outcomes Study 36-Item Short-Form Health Survey physical and mental components, respectively. Changes in resting and activity pain, pressure pain threshold, and cervical extension or lateral flexion ROM did not differ significantly between the groups. Pressure pain threshold increased only in those who received stabilization exercise with manual therapy (P<.05). CONCLUSION: The results of this study suggest that stabilization exercises with manual therapy may be superior to stabilization exercises alone for improving disability, pain intensity at night, cervical rotation motion, and quality of life in patients with MNP. LEVEL OF EVIDENCE: Therapy, level 1b.
Gellhorn AC
STUDY DESIGN: Systematic review. BACKGROUND: Current US practice guidelines suggest an initial "wait-and-see" approach following onset of musculoskeletal pain, particularly for spinal pain. Several studies suggest that early, compared with delayed, initiation of physical therapy for musculoskeletal conditions may decrease health costs and improve outcomes. OBJECTIVE: To compare early and delayed initiation of physical therapy for individuals with musculoskeletal conditions and to assess effects on patient-important outcomes and cost. METHODS: MEDLINE (Ovid), CINAHL (EBSCO), Web of Science, and PEDro were the data sources. We included studies that compared early and delayed initiation of physical therapy for patients with musculoskeletal disorders. Studies in which early and delayed interventions differed were excluded. Two independent reviewers extracted study characteristics and outcomes, and determined eligibility and quality through consensus with a third reviewer. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in summary conclusions. Standardized effect sizes (d) and odds ratios were calculated to assess the effect strength of early versus delayed physical therapy for each included study. RESULTS: Of the 3855 articles initially screened, 14 studies were included. The majority of articles studied low back pain (only 2 articles studied cervical pain). For spinal pain, there was low-quality evidence that early versus delayed physical therapy was associated with decreased cost and decreased frequency of opioid prescriptions, advanced imaging, and surgeries without compromising patient-important outcomes. One subgroup analyzed showed improved function/disability with early physical therapy in an occupational health setting. CONCLUSION: Although there were consistent results across studies favoring early physical therapy for decreased cost and medical utilization, quality was limited. Preliminary evidence suggests that early physical therapy may decrease cost without compromising outcomes. The primary limitation of the current research on this topic is in study design. Additional high-quality research involving prospective randomized designs and economic impact analyses is required to further investigate the outcomes associated with early initiation of physical therapy. LEVEL OF EVIDENCE: Therapy, level 1a.
Shipp K
SUMMARY: Biomechanical analyses support the theory that thoracic spine hyperkyphosis may increase risk of new vertebral fractures. While greater kyphosis was associated with an increased rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture. INTRODUCTION: Biomechanical analyses suggest hyperkyphosis may increase risk of incident vertebral fracture by increasing the load on vertebral bodies during daily activities. We propose to assess the association of kyphosis with incident radiographic vertebral fracture. METHODS: We used data from the Fracture Intervention Trial among 3038 women 55-81 years of age with low bone mineral density (BMD). Baseline kyphosis angle was measured using a Debrunner kyphometer. Vertebral fractures were assessed at baseline and follow-up from lateral radiographs of the thoracic and lumbar spine. We used Poisson models to estimate the independent association of kyphosis with incident fracture, controlling for age and femoral neck BMD. RESULTS: Mean baseline kyphosis was 48 degrees (SD = 12) (range 7-83). At baseline, 962 (32%) participants had a prevalent fracture. There were 221 incident fractures over a median of 4 years. At baseline, prevalent fracture was associated with 3.7 degrees greater average kyphosis (95% CI 2.8-4.6, p < 0.0005), adjusting for age and femoral neck BMD. Before adjusting for prevalent fracture, each 10 degrees greater kyphosis was associated with 22% increase (95% CI 8-38%, p = 0.001) in annualized rate of new radiographic vertebral fracture, adjusting for age and femoral neck BMD. After additional adjustment for prevalent fracture, estimated increased annualized rate was attenuated and no longer significant, 8% per 10 degrees kyphosis (95% CI -4 to 22%, p = 0.18). CONCLUSIONS: While greater kyphosis increased the rate of incident vertebral fractures, our analysis does not show an independent association of kyphosis on incident fracture, after adjustment for prevalent vertebral fracture. Excessive kyphosis may still be a clinical marker for prevalent vertebral fracture.
Sandella D
STUDY DESIGN: Delphi. OBJECTIVE: The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. METHODS: Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. RESULTS: A total of 279 clinicians from 29 different countries, with a mean of 19 (+/-SD: 12) years in practice participated. The six top items were "leg or buttock pain while walking," "flex forward to relieve symptoms," "feel relief when using a shopping cart or bicycle," "motor or sensory disturbance while walking," "normal and symmetric foot pulses," "lower extremity weakness," and "low back pain." Significant change in certainty ceased after six questions at 80% (P < .05). CONCLUSION: This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of "seven history items" that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. LEVEL OF EVIDENCE: 2.
Cleland JA
BACKGROUND: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH. METHODS: One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable. RESULTS: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001). CONCLUSIONS: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months. TRIAL REGISTRATION: NCT01580280 April 16, 2012.
Rushton A
BACKGROUND: Whiplash-associated disorder (WAD) research has largely focused on the neck, yet symptoms often include other areas. The prevalence of acute thoracic spine pain is reported ~66 %, which is perhaps unsurprising given the mechanism of injury involves a forceful loading/eccentric contraction of posterior thoracic structures such as the trapezius. Many individuals with WAD experience disability and pain beyond normal tissue healing time, termed chronic WAD. With the thoracic spine contributing to neck mobility, and 23 % of individuals complaining of thoracic pain 1 year post injury, it is time to look beyond the neck to fully understand the anatomical dysfunction in WAD. METHODS/DESIGN: A systematic review protocol has been designed and will be reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned from inception to the current date. Databases, grey literature and registers will be searched using terms and keywords derived from a scoping search. Two reviewers will independently search information sources, assess studies for inclusion and extract data. A third reviewer will check for accuracy. Data to be extracted include summary data: sample size and characteristics, timescales to reflect disorder state, patient-reported or performance-based measure and findings. Risk of bias within studies will be assessed using the Newcastle-Ottawa Scale. Quantitative meta-analysis approach will be used for homogenous data and where appropriate presented using subgroups. All other results will be presented using narrative summaries. Subgroups will, where possible, be based on patient-reported or performance-based measure of dysfunction and/or stage of condition (acute/sub-acute or chronic). Strength of the overall body of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). DISCUSSION: This is the first study to bring together evidence of thoracic dysfunction post whiplash and provide new insights into the scope and nature of thoracic dysfunction in WAD. With current management options being largely focused to a primary neck complaint and many patients going to become chronic in their presentations, this review may stimulate research and clinical interest in a largely under investigated, yet anatomically and kinematically related, spinal region. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015026983.
Padua L
BACKGROUND CONTEXT: Back pain at a young age is considered to be predictive of chronicity. Several studies have investigated the relationship between the use of a schoolbag and back pain, although some aspects are still unclear. PURPOSE: The aim of this study was to evaluate back pain due to schoolbag use in terms of (1) prevalence and intensity, (2) differences between male and female pupils, and (3) predisposing factors. STUDY DESIGN: This is a cross-sectional study. PATIENT SAMPLE: The sample was composed of 5,318 healthy pupils aged 6 to 19 years (classified according to three age groups: children, younger adolescents, and older adolescents). OUTCOME MEASURES: Schoolbag-related pain was assessed by means of an ad hoc questionnaire. The intensity of pain was assessed using the Wong scale. METHODS: Subjects underwent a face-to-face interview using an ad hoc questionnaire. The intensity of pain was assessed using the Wong scale. On the basis of the prevalence and intensity of back pain, we divided our population into two groups: (1) no or mild pain group and (2) moderate or severe pain group. The "schoolbag load" (ratio between schoolbag and pupil weight multiplied by 100) was calculated for each subject. RESULTS: More than 60% of the subjects reported pain. Although the schoolbag load decreased from children to young and older adolescents, schoolbag-related pain significantly increased (p<.001). Girls reported significantly more frequent and more severe pain than boys. The logistic model confirmed that adolescent girls are the group at greatest risk of suffering from intense pain. The schoolbag load had a weak impact on back pain, whereas the schoolbag carrying time was a strong predictor. CONCLUSIONS: Adolescent girls have the highest risk of experiencing severe back pain, regardless of schoolbag load. This suggests that other factors (anatomical, physiological, or environmental) might play an important role in pain perception. These aspects should be investigated to plan appropriate preventive and rehabilitative strategies.
Lee MJ
STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of this study is to evaluate whether the treatment of low back pain with physical therapy results in clinically significant improvements in patient-reported pain and functional outcomes. SUMMARY OF BACKGROUND DATA: Low back pain is a major cause of morbidity and disability in health care. Previous studies have found poor efficacy for surgery in the absence of specific indications. A variety of nonoperative treatments are available; however, there is scant evidence to guide the practitioner as to the efficacy of these treatments. METHODS: Four thousand five hundred ninety-seven patients who underwent physical therapy for the nonoperative treatment of low back pain were included. The primary outcome measures were pre-and post-treatment scores on the Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS) during activity, and NPRS during rest. Previously published thresholds for minimal clinically important difference (MCID) were used to determine the proportion of patients meeting MCID for each of our outcomes. Patients with starting values below the MCID for each variable were excluded from analysis. Logistic regression analysis was used to determine patient risk factors predictive of treatment failure. RESULTS: About 28.5% of patients met the MCID for improvement in ODI. Presence of night symptoms, obesity, and smoking were predictors of treatment failure for ODI. Fifty-nine percent of patients met the MCID for improvement in resting NPRS, with a history of venous thromboembolism, night symptoms, psychiatric disease, workers' compensation status, smoking, and obesity predictive of treatment failure. Sixty percent of patients met the MCID for improvement in activity NPRS, with night symptoms, workers' compensation status, and smoking predictive of treatment failure. CONCLUSION: We observed that a substantial percentage of the population did not meet MCID for pain and function following treatment of low back pain with physical therapy. Common risk factors for treatment failure included smoking and presence of night symptoms. LEVEL OF EVIDENCE: 4.
Uchio Y
Physical activity has multiple health benefits but may also increase the risk of developing musculoskeletal pain (MSP). However, the relationship between physical activity and MSP has not been well characterized. This study examined the dose-response relationship between sports activity and MSP among adolescents. Two school-based serial surveys were conducted 1 year apart in adolescents aged 12 to 18 years in Unnan, Japan. Self-administered questionnaires were completed by 2403 students. Associations between time spent in organized sports activity and MSP were analyzed cross-sectionally (n = 2403) and longitudinally (n = 374, students free of pain and in seventh or 10th grade at baseline) with repeated-measures Poisson regression and restricted cubic splines, with adjustment for potential confounders. The prevalence of overall pain, defined as having pain recently at least several times a week in at least one part of the body, was 27.4%. In the cross-sectional analysis, sports activity was significantly associated with pain prevalence. Each additional 1 h/wk of sports activity was associated with a 3% higher probability of having pain (prevalence ratio = 1.03, 95% confidence interval = 1.02-1.04). Similar trends were found across causes (traumatic and nontraumatic pain) and anatomic locations (upper limbs, lower back, and lower limbs). In longitudinal analysis, the risk ratio for developing pain at 1-year follow-up per 1 h/wk increase in baseline sports activity was 1.03 (95% confidence interval = 1.02-1.05). Spline models indicated a linear association (P < 0.001) but not a nonlinear association (P >/= 0.45). The more the adolescents played sports, the more likely they were to have and develop pain.
Moja L
STUDY DESIGN: Methodological review of randomized controlled trials (RCTs). OBJECTIVE: To assess the quality of reporting of rehabilitation interventions for mechanical low back pain (LBP) in published RCTs. SUMMARY OF BACKGROUND DATA: Reporting of interventions in RCTs often focused on the outcome value and failed to describe interventions adequately. METHODS: We systematically searched for all RCTs in Cochrane systematic reviews on LBP published in the Cochrane Database of Systematic Reviews until December 2013. The description of rehabilitation interventions of each RCT was evaluated independently by 2 of the investigators, using an ad hoc checklist of 7 items. The primary outcome was the number of items reported in sufficient details to be replicable in a new RCT or in everyday practice. RESULTS: We found 11 systematic reviews, including 220 eligible RCTs, on LBP. Of those, 185 RCTs were included. The median publication year was 1998 (I-III quartiles, 1990 to 2004). The most reported items were the characteristics of participants (91.3%; 95% confidence interval [CI], 87.3-95.4), the intervention providers (81.1%; 95% CI, 75.4-86.7), and the intervention schedule (69.7%; 95% CI, 63-76). Based on the description of the intervention, less than one fifth would be replicable clinically. The proportion of trials providing all essential information about the participants and interventions increased from 14% (n = 7) in 1971 to 1980 to 20% (n = 75) in 2001 to 2010. CONCLUSION: Despite the remarkable amount of energy spent producing RCTs in LBP rehabilitation, the majority of RCTs failed to report sufficient information that would allow the intervention to be replicated in clinical practice. Improving the quality of intervention description is urgently needed to better transfer research into rehabilitation practices. LEVEL OF EVIDENCE: 1.
Aryal S
CONTEXT: Little is known about recovery after spinal manipulation in patients with low back pain (LBP). OBJECTIVE: To assess recovery from chronic LBP after a short regimen of osteopathic manipulative treatment (OMT) in a responder analysis of the OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial. METHODS: A randomized double-blind, sham-controlled trial was conducted to determine the efficacy of 6 OMT sessions over 8 weeks. Recovery was assessed at week 12 using a composite measure of pain recovery (10 mm or less on a 100-mm visual analog scale) and functional recovery (2 or less on the Roland-Morris Disability Questionnaire for back-specific functioning). The RRs and numbers-needed-to-treat (NNTs) for recovery with OMT were measured, and corresponding cumulative distribution functions were plotted according to baseline LBP intensity and back-specific functioning. Multiple logistic regression was used to compute the OR for recovery with OMT while simultaneously controlling for potential confounders. Sensitivity analyses were performed to corroborate the primary results. RESULTS: There were 345 patients who met neither of the recovery criteria at baseline in the primary analyses and 433 patients who met neither or only 1 of these criteria in the sensitivity analyses. There was a large treatment effect for recovery with OMT (RR, 2.36; 95% CI, 1.31-4.24; P=.003), which was associated with a clinically relevant NNT (8.9; 95% CI, 5.4-25.5). This significant finding persisted after adjustment for potential confounders (OR, 2.92; 95% CI, 1.43-5.97; P=.003). There was also a significant interaction effect between OMT and comorbid depression (P=.02), indicating that patients without depression were more likely to recover from chronic LBP with OMT (RR, 3.21; 95% CI, 1.59-6.50; P<.001) (NNT, 6.5; 95% CI, 4.2-14.5). The cumulative distribution functions demonstrated optimal RR and NNT responses in patients with moderate to severe levels of LBP intensity and back-specific dysfunction at baseline. Similar results were observed in the sensitivity analyses. CONCLUSIONS: The OMT regimen was associated with significant and clinically relevant measures for recovery from chronic LBP. A trial of OMT may be useful before progressing to other more costly or invasive interventions in the medical management of patients with chronic LBP. (ClinicalTrials.gov number NCT00315120).
Held U
STUDY DESIGN: A prospective multicenter cohort study. OBJECTIVE: The aim of this study was to identify an association between pain and magnetic resonance imaging (MRI) parameters in patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: At present, the relationship between abnormal MRI findings and pain in patients with LSS is still unclear. METHODS: First, we conducted a systematic literature search. We identified relationships of relevant MRI parameters and pain in patients with LSS. Second, we addressed the study question with a thorough descriptive and graphical analysis to establish a relationship between MRI parameters and pain using data of the LSS outcome study (LSOS). RESULTS: In the systematic review including four papers about the associations between radiological findings in the MRI and pain, the authors of two articles reported no association and two of them did. Of the latters, only one study found a moderate correlation between leg pain measured by Visual Analog Scale (VAS) and the degree of stenosis assessed by spine surgeons. In the data of the LSOS study, we could not identify a relevant association between any of the MRI parameters and buttock, leg, and back pain, quantified by the Spinal Stenosis Measure (SSM) and the Numeric Rating Scale (NRS). Even by restricting the analysis to the level of the lumbar spine with the most prominent radiological "stenosis," no relevant association could be shown. CONCLUSION: Despite a thorough analysis of the data, we were not able to prove any correlation between radiological findings (MRI) and the severity of pain. There is a need for innovative "methods/techniques" to learn more about the causal relationship between radiological findings and the patients' pain-related complaints. LEVEL OF EVIDENCE: 2.
Ahn SH
BACKGROUND: Trunk muscle exercises are widely performed, and many studies have been performed to examine their effects on low back pains. However, the effect of trunk muscles activations during walking with pelvic floor muscle contraction (PFMC) and abdominal hollowing (AH) has not been clarified. OBJECT: To investigate whether walking with PFMC and AH is more effective for promoting local trunk muscle activation than walking without PFMC and AH. METHODS: Twenty healthy men (28.9 +/- 3.14 years, 177.2 +/- 4.25 cm, 72.1 +/- 6.39 kg, body mass index 22.78 +/- 2.38 kg/m2) were participated in this study. Surface electrodes were attached over the multifidus (MF), lumbar erector spinae (LES), thoracic erector spinae (TES), transverse abdominus-internal oblique abdominals (TrA-IO), external oblique abdominals (EO), and rectus abdominus (RA). The amplitudes of electromyographic signals were measured during a normal walking with and without PFMC and AH. RESULT: PFMC and AH while walking was found to result in significant bilateral increases in the normalized maximum voluntary contraction (MVC) of MFs and TrA-IOs (p< 0.05). Ratios of local muscle activity to global muscle activities were increased while performing PFMC and AH during normal walking. Bilateral TrA-IO/EO activity ratios were significantly increased by PFMC and AH (p< 0.05). CONCLUSION: Performance of the PFMC and AH during walking resulted in significantly more recruitment of local trunk muscles. This study suggests that PFMC and AH during normal daily walking improves activation of muscles responsible for spinal dynamic stabilization and might be useful if integrated into low back disability and pain physical rehabilitation efforts.
Airaksinen O
BACKGROUND: Clinical guidelines recommend research on sub-groups of patients with low back pain (LBP) but, to date, only few studies have been published. One sub-group of LBP is movement control impairment (MCI) and clinical tests to identify this sub-group have been developed. Also, exercises appear to be beneficial for the management of chronic LBP (CLBP), but very little is known about the management of sub-acute LBP. METHODS: A randomized controlled trial (RCT) was conducted to compare the effects of general exercise versus specific movement control exercise (SMCE) on disability and function in patients with MCI within the recurrent sub-acute LBP group. Participants having a MCI attended five treatment sessions of either specific or general exercises. In both groups a short application of manual therapy was applied. The primary outcome was disability, assessed by the Roland-Morris Disability Questionnaire (RMDQ). The measurements were taken at baseline, immediately after the three months intervention and at twelve-month follow-up. RESULTS: Seventy patients met the inclusion criteria and were eligible for the trial. Measurements of 61 patients (SMCE n = 30 and general exercise n = 31) were completed at twelve months. (Drop-out rate 12.9 %). Patients in both groups reported significantly less disability (RMDQ) at twelve months follow-up. However, the mean change on the RMDQ between baseline and the twelve-month measurement showed statistically significantly superior improvement for the SMCE group -1.9 points (-3.9 to -0.5) 95 % (CI). The result did not reach the clinically significant three point difference. There was no statistical difference between the groups measured with Oswestry Disability Index (ODI). CONCLUSION: For subjects with non-specific recurrent sub-acute LBP and MCI an intervention consisting of SMCE and manual therapy combined may be superior to general exercise combined with manual therapy. TRIAL REGISTRATION: The study protocol registration number is ISRCTN48684087 . It was registered retrospectively 18th Jan 2012.
Davies GJ
STUDY DESIGN: Experimental randomized crossover. OBJECTIVE: The aim of the study was to determine whether sitting on a ball for 90 min/d instead of a chair has an effect on low back pain (LBP), low back disability, and/or core muscle endurance. SUMMARY OF BACKGROUND DATA: LBP may result from prolonged sitting. It has been proposed that replacing chairs with stability balls can diminish LBP in those who sit for prolonged periods. Research on the topic is sparse and inconclusive. METHODS: A total of 90 subjects (university students, staff, and faculty, ages 18-65, who sit >/=4 hr/d) were randomly assigned to the intervention or control group for the first part of the study. Baseline data were collected: Oswestry Disability Index, a numerical pain rating scale for LBP, and four core muscle endurance tests. For 8 weeks, the control group sat on their usual chair. The intervention group sat on stability balls 5 d/wk, increasing up to 90 min/d. Baseline measurements were repeated postintervention. After a washout period, subjects switched groups, and the procedures were repeated-70 completed participation in control group and 76 in intervention group. RESULTS: There were no statistically significant differences for pain or disability in either group (P > 0.05). Changes in isometric trunk flexion (P = 0.001), nondominant side plank (P = 0.008), and Sorensen (P = 0.006) endurance scores were significant within the intervention group but not the control group. Between-group comparisons revealed a significant difference for isometric trunk flexion (P = 0.005) and Sorensen endurance times (P = 0.010). Analysis also showed that ball-sitting did not prevent an increase in LBP over the 8-week period. CONCLUSION: Ball-sitting had no significant effects on LBP or associated disability, but did improve core endurance in the sagittal plane. Although ball-sitting may be useful as an adjunct treatment for LBP when core muscles are involved, clinicians should rely on other, evidence-based treatments for LBP.
Vanti C
BACKGROUND: Global postural re-education (GPR) has shown positive results for patients with musculoskeletal disorders, but no previous randomized controlled trial (RCT) has investigated its effectiveness as the sole procedure for adult patients with chronic nonspecific neck pain (NP). OBJECTIVE: The purpose of this study was to evaluate the effectiveness of applying GPR compared with a manual therapy (MT) intervention to patients with chronic nonspecific NP. DESIGN: An RCT was conducted. PATIENTS: Ninety-four patients with chronic nonspecific NP (72 women and 22 men; average age=47.5 years, SD=11.3) were randomly assigned to receive either a GPR intervention or an MT intervention. OUTCOME MEASURES: Pain intensity (visual analog scale), disability (Neck Disability Index), cervical range of motion, and kinesiophobia (Tampa Scale of Kinesiophobia) were assessed. METHODS: The experimental group received GPR, and the reference group received MT. Both groups received nine 60-minute-long sessions with one-to-one supervision from physical therapists as the care providers. All participants were asked to follow ergonomic advice and to perform home exercises. Measures were assessed before treatment, following treatment, and at a 6-month follow-up. RESULTS: No important baseline differences were found between groups. The experimental group exhibited a statistically significant reduction in pain following treatment and in disability 6 months after the intervention compared with the reference group. LIMITATIONS: Randomization did not lead to completely homogeneous groups. It also was noted that the time spent integrating the movements practiced during the session into daily routines at the end of each session was requested only of participants in the GPR group and may have had an impact on patient adherence that contributed to a better outcome. CONCLUSIONS: The results suggest that GPR was more effective than MT for reducing pain after treatment and for reducing disability at 6-month follow-up in patients with chronic nonspecific NP.
Soer R
STUDY DESIGN: A prospective cohort study within care as usual. OBJECTIVE: (1) To explore the psychometric properties of a baseline disability questionnaire designed to collect patients' expectation. (2) To analyze relations between satisfaction with care and treatment success in patients with chronic low back pain (CLBP). (3) To determine the chances of being satisfied with the received care in absence of treatment success. SUMMARY OF BACKGROUND DATA: There is a lack of evidence on determinants of treatment satisfaction in patients with CLBP, specifically the role of patient's expectation of disability reduction after treatment. METHODS: Treatment expectation was measured with questions inspired by the Pain Disability Index (PDI) at baseline. Treatment success was considered if disability at the end of therapy was lower than, or equal to pretreatment expectation. An exploratory factor analysis was performed on the new questionnaire. Binary logistic regression models were used to analyze how much variance of satisfaction with care was explained by treatment success, pain disability at baseline, sex, age, duration of complaints, and pain intensity. The odds ratio of being satisfied when treatment was successful was calculated. RESULTS: Six hundred nine patients were included. The factor structure of the PDI-expectancy had optimal fit with a one factor structure. There were low correlations between the expected and baseline disability, pain intensity, and duration of pain. Correlation between treatment success and satisfaction with care was low (chi = 0.13; P < 0.01). Treatment success had a low contribution to satisfaction with care. Of all participating patients, 51.4% were satisfied with care even when treatment was not successful. The odds ratio for being satisfied was 2.42 when treatment was successful compared to when treatment was not successful. CONCLUSION: The PDI-expectancy is internally consistent. Pretreatment expectation contributes uniquely but slightly to satisfaction with care; patients whose treatment was considered successful have 1.38 to 4.24 times higher chance of being satisfied at the end of treatment. Even when treatment was not successful, 51.4% of the patients with CLBP are satisfied with care. LEVEL OF EVIDENCE: 2.
Schecter Weiner S
BACKGROUND: The influence on the treatment response in patients with low back pain (LBP) and neck pain (NP) is unknown. The aim of the study was to investigate the influence of body weight in patients with low back pain (LBP) and neck pain (NP) on baseline and end of treatment disability. METHODS: Cross-sectional analysis of baseline factors. Longitudinal analysis of prospectively collected patient information at an outpatient physical therapy registry (data from June 2010 to December 2012). WHO-BMI classification was used: underweight, lean, overweight, obesity class I, obesity class II and III. The influence of body weight and a predefined set of confounders was analyzed by multiple regression models. RESULTS: In LBP, disability increased with increasing BMI [lean = reference, obesity class I Beta 5.41 (95 % CI 0.75; 10.07), obesity class II-III Beta 7.58 (95 % CI 2.13; 13.03)]. Compared to lean patients, disability after treatment improved in overweight subjects [Beta -3.90 (95 % CI -7.4; -0.41)] but not in subjects with obesity class II-III [Beta 3.43 (95 % CI -3.81; 10.68)]. There were insufficient patients in the sample with severe obesity and therefore this trend has to be confirmed. The likelihood for meaningful important change (MID) was similar in all BMI subgroups. For patients with NP, BMI was not associated with baseline disability, and did not predict end of treatment disability or the likelihood of a MID. These findings must be interpreted with caution as BMI subgroups did not meet the required sample size. CONCLUSION: Overweight and obesity are associated with higher levels of disability before treatment in LBP patients, but not in NP. In severely obese patients class II-III with LBP the rate of MID was lowest indicating that these patients experienced the least treatment response compared to the other groups. Further studies should address the impact of severe obesity on the prognosis of LBP. In patients with LBP, severe obesity may be an important factor to consider during the physical therapy treatment. In particular, combined treatment strategies combining weight management, cardiovascular fitness, and low back pain rehabilitation should be investigated.
Urquhart DM
STUDY DESIGN: A cross-sectional, community-based study. OBJECTIVE: The aim of this study was to investigate the relationship between structural features of the thoracolumbar fascia and low back pain and disability. SUMMARY OF BACKGROUND DATA: The thoracolumbar fascia plays a role in stabilization of the spine by transmitting tension from the spinal and abdominal musculature to the vertebrae. It has been hypothesized that the fascia is associated with low back pain through the development of increased pressure in the paraspinal compartment, which leads to muscle ischemia. METHODS: Seventy-two participants from a community-based study of musculoskeletal health underwent Magnetic Resonance Imaging from the T12 vertebral body to the sacrum. The length of the paraspinal fascia and cross-sectional area of the paraspinal compartment were quantitatively measured from axial images at the level of the transverse processes and the Chronic Pain Grade Scale was used to assess low back pain intensity and disability. RESULTS: A shorter length of fascia around the parapsinal compartment was significantly associated with high intensity low back pain and/or disability, after adjusting for age, gender, and body mass index [right odds ratio (OR) 1.9, 95% CI 0.99-3.8, P = 0.05; left OR 2.6, 95% CI 1.2 to 5.6, P = 0.01). Further adjustment for the cross-sectional area of the compartment strengthened the associations between fascial length and low back pain/or disability (right OR 8.9, 95% CI 1.9-40.9, P = 0.005; left OR 9.6, 95% CI 1.2-42.9, P = 0.003). CONCLUSION: This study has demonstrated that a shorter lumbar paraspinal fascia is associated with high intensity low back pain and/or disability among community-based adults. Although cohort studies are needed, these results suggest that structural features of the fascia may play a role in high levels of low back pain and disability. LEVEL OF EVIDENCE: 3.
Zwart JA
BACKGROUND: Physical activity in leisure time is often considered to have favourable effects on the risk of low back pain (LBP), but demonstrating a definite association in epidemiological studies has proven difficult. The purpose of the present study was to explore associations between physical activity and risk of chronic LBP in an adult population and to investigate whether relationships are limited to certain age groups or to females or males. A particular objective was to determine whether support could be found for a U-shaped relationship, with both low and high activity levels carrying greater risk. METHODS: The relationship between physical activity and risk of chronic LBP was examined in a Norwegian prospective study using data from the community-based HUNT2 and HUNT3 surveys. Participants were 9616 women and 8452 men without LBP at baseline, who reported after 11 years whether they suffered from LBP. Associations between baseline physical activity in leisure time and risk of chronic LBP at end of follow-up were evaluated by generalized linear modelling with adjustment for potential confounders. RESULTS: Significant associations between leisure time physical activity and risk were observed in both sexes after age adjustment, mainly suggesting inverse relationships. Women participating in hard physical activity 1-2 h per week had a relative risk (RR) of chronic LBP of 0.81 (95 % CI 0.71-0.93) compared to those with only light physical activity less than 1 h per week. The corresponding RR in men was 0.71 (95 % CI 0.60-0.85). After adjustment for education, employment, occupational activity, body mass index (BMI) and smoking, significant relationships could only be demonstrated in those aged 50 years or more at baseline. The associations differed between female educational groups, with more U-shaped relationships being observed among women with basic education only. CONCLUSION: No strong support was found overall for U-shaped relationships. However, no further general decrease in risk was seen among those with 3 h or more of hard physical activity per week. The contrasts observed between female educational groups may reflect different preferences regarding specific strenuous activities. Men aged 50 years or more seem in particular to benefit from hard physical activities.
Ostelo RW
BACKGROUND: Physical functioning is a core outcome domain to be measured in nonspecific low back pain (NSLBP). A panel of experts recommended the Roland-Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) to measure this domain. The original 24-item RMDQ and ODI 2.1a are recommended by their developers. PURPOSE: The purpose of this study was to evaluate whether the 24-item RMDQ or the ODI 2.1a has better measurement properties than the other to measure physical functioning in adult patients with NSLBP. DATA SOURCES: Bibliographic databases (MEDLINE, Embase, CINAHL, SportDiscus, PsycINFO, and Google Scholar), references of existing reviews, and citation tracking were the data sources. STUDY SELECTION: Two reviewers selected studies performing a head-to-head comparison of measurement properties (reliability, validity, and responsiveness) of the 2 questionnaires. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to assess the methodological quality of these studies. DATA EXTRACTION: The studies' characteristics and results were extracted by 2 reviewers. A meta-analysis was conducted when there was sufficient clinical and methodological homogeneity among studies. DATA SYNTHESIS: Nine articles were included, for a total of 11 studies assessing 5 measurement properties. All studies were classified as having poor or fair methodological quality. The ODI displayed better test-retest reliability and smaller measurement error, whereas the RMDQ presented better construct validity as a measure of physical functioning. There was conflicting evidence for both instruments regarding responsiveness and inconclusive evidence for internal consistency. LIMITATIONS: The results of this review are not generalizable to all available versions of these questionnaires or to patients with specific causes for their LBP. CONCLUSIONS: Based on existing head-to-head comparison studies, there are no strong reasons to prefer 1 of these 2 instruments to measure physical functioning in patients with NSLBP, but studies of higher quality are needed to confirm this conclusion. Foremost, content, structural, and cross-cultural validity of these questionnaires in patients with NSLBP should be assessed and compared.
Skillgate E
BACKGROUND: Manual therapy as spinal manipulation, spinal mobilization, stretching and massage are common treatment methods for neck and back pain. The objective was to compare the treatment effect on pain intensity, pain related disability and perceived recovery from a) naprapathic manual therapy (spinal manipulation, spinal mobilization, stretching and massage) to b) naprapathic manual therapy without spinal manipulation and to c) naprapathic manual therapy without stretching for male and female patients seeking care for back and/or neck pain. METHOD: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathogskolan - the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes. RESULTS: At 12 weeks follow-up, 64% had a minimal clinically important improvement in pain intensity and 42% in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58% and 40% respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately. CONCLUSION: The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92249294.
Macedo LG
STUDY DESIGN: A systematic review. OBJECTIVE: The aim of this review was to evaluate the effectiveness of motor control exercise (MCE) in patients with nonspecific low back pain (LBP). SUMMARY OF BACKGROUND DATA: MCE is a common form of exercise used for managing LBP. MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. METHODS: We conducted electronic searches of CENTRAL, MEDLINE, EMBASE, five other databases, and two trials registers from their inception up to April 2015. Two independent review authors screened the search results, assessed risk of bias, and extracted the data. A third reviewer resolved any disagreement. We included randomized controlled trials comparing MCE with no treatment, another treatment, or as a supplement to other interventions in patients with nonspecific LBP. Primary outcomes were pain intensity and disability. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group 12-item criteria. We combined results in a meta-analysis expressed as mean difference and 95% confidence interval. We assessed the overall quality of the evidence using the GRADE approach. RESULTS: We included 32 trials (n = 2628). Most included trials had a low risk of bias. For acute LBP, low to moderate quality evidence indicates no clinically important differences between MCE and spinal manipulative therapy or other forms of exercise. There is very low-quality evidence that the addition of MCE to medical management does not provide clinically important improvements. For recurrence at one year, there is very low-quality evidence that MCE and medical management decrease the risk of recurrence. For chronic LBP, there is low to moderate quality evidence that MCE is effective for reducing pain compared with minimal intervention. There is low to high-quality evidence that MCE is not clinically more effective than other exercises or manual therapy. There is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPAs) or telerehabilitation for pain and disability. CONCLUSION: MCE is probably more effective than a minimal intervention for reducing pain, but probably does not have an important effect on disability, in patients with chronic LBP. There was no clinically important difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. LEVEL OF EVIDENCE: 1.
Ferreira PH
Study Design Randomized clinical trial. Background Motor control exercises are believed to improve coordination of the trunk muscles. It is unclear whether increases in trunk muscle thickness can be facilitated by approaches such as the McKenzie method. Furthermore, it is unclear which approach may have superior clinical outcomes. Objectives The primary aim was to compare the effects of the McKenzie method and motor control exercises on trunk muscle recruitment in people with chronic low back pain classified with a directional preference. The secondary aim was to conduct a between-group comparison of outcomes for pain, function, and global perceived effect. Methods Seventy people with chronic low back pain who demonstrated a directional preference using the McKenzie assessment were randomized to receive 12 treatments over 8 weeks with the McKenzie method or with motor control approaches. All outcomes were collected at baseline and at 8-week follow-up by blinded assessors. Results No significant between-group difference was found for trunk muscle thickness of the transversus abdominis (-5.8%; 95% confidence interval [CI]: -15.2%, 3.7%), obliquus internus (-0.7%; 95% CI: -6.6%, 5.2%), and obliquus externus (1.2%; 95% CI: -4.3%, 6.8%). Perceived recovery was slightly superior in the McKenzie group (-0.8; 95% CI: -1.5, -0.1) on a -5 to +5 scale. No significant between-group differences were found for pain or function (P = .99 and P = .26, respectively). Conclusion We found no significant effect of treatment group for trunk muscle thickness. Participants reported a slightly greater sense of perceived recovery with the McKenzie method than with the motor control approach. Level of Evidence Therapy, level 1b-. Registered September 7, 2011 at www.anzctr.org.au (ACTRN12611000971932). J Orthop Sports Phys Ther 2016;46(7):514-522. Epub 12 May 2016. doi:10.2519/jospt.2016.6379.
Straker LM
BACKGROUND: There is conflicting evidence on the association between sagittal neck posture and neck pain. OBJECTIVE: The purposes of this study were: (1) to determine the existence of clusters of neck posture in a cohort of 17-year-olds and (2) to establish whether identified subgroups were associated with biopsychosocial factors and neck pain. DESIGN: This was a cross-sectional study. METHODS: The adolescents (N=1,108) underwent 2-dimensional photographic postural assessment in a sitting position. One distance and 4 angular measurements of the head, neck, and thorax were calculated from photo-reflective markers placed on bony landmarks. Subgroups of sagittal sitting neck posture were determined by cluster analysis. Height and weight were measured, and lifestyle and psychological factors, neck pain, and headache were assessed by questionnaire. The associations among posture subgroups, neck pain, and other factors were evaluated using logistic regression. RESULTS: Four distinct clusters of sitting neck posture were identified: upright, intermediate, slumped thorax/forward head, and erect thorax/forward head. Significant associations between cluster and sex, weight, and height were found. Participants classified as having slumped thorax/forward head posture were at higher odds of mild, moderate, or severe depression. Participants classified as having upright posture exercised more frequently. There was no significant difference in the odds of neck pain or headache across the clusters. LIMITATIONS: The results are specific to 17-year-olds and may not be applicable to adults. CONCLUSION: Meaningful sagittal sitting neck posture clusters were identified in 17-year-olds who demonstrated some differences with biopsychosocial profiling. The finding of no association between cluster membership and neck pain and headaches challenges widely held beliefs about the role of posture in adolescent neck pain.
Cicuttini FM
Back pain causes enormous financial and disability burden worldwide, which could potentially be reduced by understanding its determinants to develop effective prevention strategies. Our aim was to identify whether modifiable risk factors, weight and physical activity, are predictive of back pain in young adult women.Women born between 1973 and 1978 were randomly selected from the national health insurance scheme database to participate in The Australian Longitudinal Study of Women's Health. Self-reported data on back pain in the last 12 months, weight, height, age, education status, physical activity, and depression were collected in 2000, 2003, 2006, 2009, and 2012. In 2000, 9688 women completed the questionnaire and 83% completed follow-up 12 years later.At baseline, median age was 24.6 years and 41% had self-reported back pain. For every 5 kg higher weight at baseline, there was a 5% (95% confidence interval [CI] 4%-6%) increased risk of back pain over the next 12 years. Higher weight at each survey also predicted back pain risk 3 years later (P < 0.001). The effects of weight on back pain were most significant in those with BMI >/=25 kg/m and were observed at all levels of physical activity. Inadequate physical activity and depression were independent predictors of back pain over the following 12 years (both P < 0.001), after adjusting for age, weight, height, and education status.Back pain is common in community-based young adult women. Higher weight, inadequate levels of physical activity, and depression were all independent predictors of back pain over the following decade. Furthermore, the adverse effects of weight on back pain were not mitigated by physical activity. Our findings highlight the role of both higher weight and physical inactivity in back pain among young women and suggest potential opportunities for future prevention.
Kahlaee AH
BACKGROUND: Motor control approach towards chronic non-specific low back pain (CNLBP) has gained increasing attention. CNLBP patients have shown to be more visually dependent for the postural control process than control subjects but no study has yet investigated the treatment programs effect on this disorder. METHODS: Forty CNLBP patients volunteered to participate in this experimental study. The subjects were randomly assigned into either stabilization exercise (SE) or control group both receiving 12 sessions of routine physiotherapy for four weeks. The SE group also received intensive stabilization exercise. Balance (in terms of overall (OSI), anteroposterior (APSI) and mediolateral stability indices (MLSI)) and functional disability were assessed by Biodex Balance System((R)) (BBS) and Oswestry Low Back Disability Questionnaire, respectively prior and after the interventions. The balance tests were performed with open and closed eyes. RESULTS: Both interventions significantly decreased all stability indices but the SE group showed a more pronounced improvement in OSI and APSI. In the SE group, vision deprivation had smaller destabilizing effects on OSI and APSI as compared with the control group. The groups were not statistically different prior and after the interventions on all dependent variables. Oswestry index reduction in the SE group was more pronounced but the interaction of time and group variables were not significant on pain intensity. CONCLUSION: Both interventions effectively enhanced stability indices and functional capabilities and reduced pain intensity in CNLBP patients. The SE protocol made the patients less visual dependent perhaps via better stability. Since pain reduction was not different between the groups, more functional improvement in SE group cannot simply be interpreted via the pain interference and might be related to postural control capabilities of the patients.
Terwee CB
BACKGROUND: The Quebec Back Pain Disability Scale (QBPDS) has been translated into different languages, and several studies on its measurement properties have been done. PURPOSE: The purpose of this review was to critically appraise and compare the measurement properties, when possible, of all language versions of the QBPDS by systematically reviewing the methodological quality and results of the available studies. METHOD: Bibliographic databases (PubMed, Embase, CINAHL, and PsycINFO) were searched for articles with the key words "Quebec," "back," "pain," and "disability" in combination with a methodological search filter for finding studies on measurement properties concerning the development or evaluation of the measurement properties of the QBPDS in patients with nonspecific low back pain. Assessment of the methodological quality was carried out by the reviewers using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for both the original language version of the QBPDS in English and French and all translated versions. The results of the measurement properties were rated based on criteria proposed by Terwee et al. RESULTS: The search strategy resulted in identification of 1,436 publications, and 27 articles were included in the systematic review. There was limited-to-moderate evidence of good reliability, validity, and responsiveness of the QBPDS for the different language versions, but for no language version was evidence available for all measurement properties. CONCLUSION: For research and clinical practice, caution is advised when using the QBPDS to measure disability in patients with nonspecific low back pain. Strong evidence is lacking on all measurement properties for each language version of the QBPDS.
Humphreys BK
STUDY DESIGN: A cross-sectional comparative study between chronic low back pain (CLBP) patients and healthy control subjects. OBJECTIVE: The aim of this study was to investigate reorganization in the sensory cortex by comparing cortical activity due to mechanosensory stimulation of the lumbar spine in CLBP patients versus a control group by using functional magnetic resonance imaging (fMRI). SUMMARY OF BACKGROUND DATA: LBP is now the number 1 condition across the world in terms of years living with a disability. There is growing evidence that maladaptive changes in the processing of sensory input by the central nervous system are central to understanding chronic (back) pain. METHODS: Nonpainful, posterior-anterior (PA) movement pressure was applied manually to lumbar vertebrae at L1, L3, and L5 in 13 healthy subjects and 13 CLBP patients. The manual pressure (30 N) was monitored and controlled using sensors. A randomized stimulation protocol was used consisting of 51 pressure stimuli of 5 seconds duration. fMRI data analysis was performed for the group activation within the primary and secondary sensory cortices (S1 and S2, respectively) and the representation of the individual vertebrae was extracted and statistically analyzed. RESULTS: Nonpainful PA pressure revealed no cortical reorganization in S1. In contrast, the extent of S2 activation in the CLBP group was significantly reduced in both hemispheres. In the control group, a somatotopy was identified for the lumbar vertebrae between L1 and L3, respectively, and L5 in S2 of the right hemisphere. Most importantly, a blurring of the somatotopic representation of the lumbar spine in S2 was observed in the patient group. CONCLUSION: Together, these maladaptive changes suggest a reorganization of higher-order processing for sensory information in CLBP patients that might have implications for a decreased sensory acuity, also related to body perception and subsequent altered functioning of the lumbar spine. LEVEL OF EVIDENCE: 2.
Costa Lda C
Study Design Randomized controlled trial. Background Many clinical practice guidelines endorse both manual therapy and exercise as effective treatment options for patients with low back pain. To optimize the effects of the treatments recommended by the guidelines, a new intervention known as Kinesio Taping is being widely used in these patients. Objectives To determine the effectiveness of Kinesio Taping in patients with chronic nonspecific low back pain when added to a physical therapy program consisting of exercise and manual therapy. Methods One hundred forty-eight patients with chronic nonspecific low back pain were randomly allocated to receive 10 (twice weekly) sessions of physical therapy, consisting of exercise and manual therapy, or the same treatment with the addition of Kinesio Taping applied to the lower back. The primary outcomes were pain intensity and disability (5 weeks after randomization) and the secondary outcomes were pain intensity, disability (3 months and 6 months after randomization), global perceived effect, and satisfaction with care (5 weeks after treatment). Data were collected by a blinded assessor. Results No between-group differences were observed in the primary outcomes of pain intensity (mean difference, -0.01 points; 95% confidence interval [CI]: -0.88, 0.85) or disability (mean difference, 1.14 points; 95% CI: -0.85, 3.13) at 5 weeks' follow-up. In addition, no between-group differences were observed for any of the other outcomes evaluated, except for disability 6 months after randomization (mean difference, 2.01 points; 95% CI: 0.03, 4.00) in favor of the control group. Conclusion Patients who received a physical therapy program consisting of exercise and manual therapy did not get additional benefit from the use of Kinesio Taping. Level of Evidence Therapy, level 1b. Prospectively registered May 28, 2013 at www.ClinicalTrials.gov (NCT01866332). J Orthop Sports Phys Ther 2016;46(7):506-513. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6590.
Lamb SE
BACKGROUND: Cognitive behavioural (CB) approaches are effective in the management of non-specific low back pain (LBP). We developed the CB Back Skills Training programme (BeST) and previously provided evidence of clinical and cost effectiveness in a large pragmatic trial. However, practice change is challenged by a lack of treatment guidance and training for clinicians. We aimed to explore the feasibility and acceptability of an online programme (iBeST) for providing training in a CB approach. METHODS: This mixed methods study comprised an individually randomised controlled trial of 35 physiotherapists and an interview study of 8 physiotherapists. Participants were recruited from 8 National Health Service departments in England and allocated by a computer generated randomisation list to receive iBeST (n = 16) or a face-to-face workshop (n = 19). Knowledge (of a CB approach), clinical skills (unblinded assessment of CB skills in practice), self-efficacy (reported confidence in using new skills), attitudes (towards LBP management), and satisfaction were assessed after training. Engagement with iBeST was assessed with user analytics. Interviews explored acceptability and experiences with iBeST. Data sets were analysed independently and jointly interpreted. RESULTS: Fifteen (94 %) participants in the iBeST group and 16 (84 %) participants in the workshop group provided data immediately after training. We observed similar scores on knowledge (MD (95 % CI): 0.97 (-1.33, 3.26)), and self-efficacy to deliver the majority of the programme (MD (95 % CI) 0.25 (-1.7; 0.7)). However, the workshop group showed greater reduction in biomedical attitudes to LBP management (MD (95 % CI): -7.43 (-10.97, -3.89)). Clinical skills were assessed in 5 (33 %) iBeST participants and 7 (38 %) workshop participants within 6 months of training and were similar between groups (MD (95 % CI): 0.17(-0.2; 0.54)). Interviews highlighted that while initially sceptical, participants found iBeST acceptable. A number of strategies were identified to enhance future versions of iBeST such as including more skills practice. CONCLUSIONS: Combined quantitative and qualitative data indicated that online training was an acceptable and promising method for providing training in an evidence based complex intervention. With future enhancement, the potential reach of this training method may facilitate evidence-based practice through large scale upskilling of the workforce. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82203145 (registered prospectively on 03.09.2012).
Bronfort G
BACKGROUND: Neck pain (NP) is disabling and costly. OBJECTIVES: To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP. METHODS: We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence. MAIN RESULTS: The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT). AUTHORS' CONCLUSIONS: Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.
van Dieen J
OBJECTIVE: To systematically review the relationship between lumbar proprioception and low back pain (LBP). DATA SOURCES: Four electronic databases (PubMed, EMBASE, CINAHL, SPORTDiscus) and reference lists of relevant articles were searched from inception to March-April 2014. STUDY SELECTION: Studies compared lumbar proprioception in patients with LBP with controls or prospectively evaluated the relationship between proprioception and LBP. Two reviewers independently screened articles and determined inclusion through consensus. DATA EXTRACTION: Data extraction and methodologic quality assessment were independently performed using standardized checklists. DATA SYNTHESIS: Twenty-two studies (1203 participants) were included. Studies measured lumbar proprioception via active or passive joint repositioning sense (JRS) or threshold to detection of passive motion (TTDPM). Data from 17 studies were pooled for meta-analyses to compare patients with controls. Otherwise, descriptive syntheses were performed. Data were analyzed according to measurement method and LBP subgroup. Active JRS was worse in patients compared with controls when measured in sitting (standard mean difference, .97; 95% confidence interval [CI], .31-1.64). There were no differences between groups measured via active JRS in standing (standard mean difference, .41; 95% CI, -.07 to .89) or passive JRS in sitting (standard mean difference, .38; 95% CI, -.83 to 1.58). Patients in the O'Sullivan flexion impairment subgroup had worse proprioception than the total LBP cohort. The TTDPM was significantly worse in patients than controls. One prospective study found no link between lumbar proprioception and LBP. CONCLUSIONS: Patients with LBP have impaired lumbar proprioception compared with controls when measured actively in sitting positions (particularly those in the O'Sullivan flexion impairment subgroup) or via TTDPM. Clinicians should consider the relationship between sitting and proprioception in LBP and subgroup patients to guide management. Further studies focusing on subgroups, longitudinal assessment, and improving proprioception measurement are needed.
Cicuttini FM
Two systematic reviews concluded that there was limited evidence to support an association between physical activity and sedentary behavior and developing low back pain (LBP). The aim of this study was to examine the associations of physical activity and television viewing time with LBP intensity and disability in community-based adults.Five thousand fifty-eight participants (44% men) of the Australian Diabetes, Obesity and Lifestyle Study had physical activity and television viewing time measured in 1999 to 2000, 2004 to 2005, and 2011 to 2012, and LBP intensity and disability assessed in 2013 to 2014 using the Chronic Pain Grade Questionnaire. Multinomial logistic regressions were used to estimate the odds ratio for LBP intensity and disability associated with physical activity and television viewing time. Analyses were adjusted for age, education, smoking, dietary guideline index score, body mass index, and mental component summary score. To test whether associations of physical activity or television viewing time with LBP intensity and disability were modified by sex, obesity, or age, interactions were tested using the likelihood ratio test.As gender modified the associations between physical activity and television viewing time and LBP disability (P = 0.05), men and women were examined separately. A total of 81.7% men and 82.1% women had LBP. Most men (63.6%) and women (60.2%) had low intensity LBP with fewer having high intensity LBP (18.1% men, 21.5% women). Most participants had no LBP disability (74.5% men, 71.8% women) with the remainder reporting low (15.8% men, 15.3% women) or high (9.7% men, 12.9% women) LBP disability. Insufficient physical activity (<2.5 hours/week) was not associated with LBP intensity or disability. High television viewing time (>/=2 hours/day) was associated with greater prevalence of LBP disability in women (low disability OR 1.35, 95% CI 1.04-1.73; high disability OR 1.29, 95% CI 1.01-1.72).Although it needs to be confirmed in RCTs our findings suggest that targeting time spent watching television and possibly other prolonged sedentary behaviors may have the potential to reduce LBP disability in community-based adults, particularly in women.
Bronfort G
BACKGROUND CONTEXT: Chronic neck pain is a prevalent and disabling condition among older adults. Despite the large burden of neck pain, little is known regarding the cost-effectiveness of commonly used treatments. PURPOSE: This study aimed to estimate the cost-effectiveness of home exercise and advice (HEA), spinal manipulative therapy (SMT) plus HEA, and supervised rehabilitative exercise (SRE) plus HEA. STUDY DESIGN/SETTING: Cost-effectiveness analysis conducted alongside a randomized clinical trial (RCT) was performed. PATIENT SAMPLE: A total of 241 older adults (>/=65 years) with chronic mechanical neck pain comprised the patient sample. OUTCOME MEASURES: The outcome measures were direct and indirect costs, neck pain, neck disability, SF-6D-derived quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) over a 1-year time horizon. METHODS: This work was supported by grants from the National Center for Complementary and Integrative Health (#F32AT007507), National Institute of Arthritis and Musculoskeletal and Skin Diseases (#P60AR062799), and Health Resources and Services Administration (#R18HP01425). The RCT is registered at ClinicalTrials.gov (#NCT00269308). A societal perspective was adopted for the primary analysis. A healthcare perspective was adopted as a sensitivity analysis. Cost-effectivenesswas a secondary aim of the RCT which was not powered for differences in costs or QALYs. Differences in costs and clinical outcomes were estimated using generalized estimating equations and linear mixed models, respectively. Cost-effectiveness acceptability curves were calculated to assess the uncertainty surrounding cost-effectiveness estimates. RESULTS: Total costs for SMT+HEA were 5% lower than HEA (mean difference: -$111; 95% confidence interval [CI] -$1,354 to $899) and 47% lower than SRE+HEA (mean difference: -$1,932; 95% CI -$2,796 to -$1,097). SMT+HEA also resulted in a greater reduction of neck pain over the year relative to HEA (0.57; 95% CI 0.23 to 0.92) and SRE+HEA (0.41; 95% CI 0.05 to 0.76). Differences in disability and QALYs favored SMT+HEA. The probability that adding SMT to HEA is cost-effective at willingness to pay thresholds of $50,000 to $200,000 per QALY gained ranges from 0.75 to 0.81. If adopting a health-care perspective, costs for SMT+HEA were 66% higher than HEA (mean difference: $515; 95% CI $225 to $1,094), resulting in an ICER of $55,975 per QALY gained. CONCLUSION: On average, SMT+HEA resulted in better clinical outcomes and lower total societal costs relative to SRE+HEA and HEA alone, with a 0.75 to 0.81 probability of cost-effectiveness for willingness to pay thresholds of $50,000 to $200,000 per QALY.
Peolsson A
Study Design Secondary analysis of a randomized clinical trial. Background Patient perception of the benefits gained from treatment is important, yet satisfaction with the outcome of treatment for chronic whiplash-associated disorders (WADs) has not been investigated. Objectives To investigate whether satisfaction with the outcome of treatment for chronic WAD changed over time, and whether there were group differences. Methods Two hundred sixteen people with chronic WAD (66% women; mean age, 40.4 years) participated in a 3-month program of physical therapist-led neck-specific exercises with or without a behavioral approach, or received a prescription of general physical activity. The main outcome was satisfaction with the outcome of treatment, assessed at baseline and 3, 6, and 12 months later. Additional outcomes were enablement and expectation fulfillment. Results Satisfaction improved over time in the 3 groups (odds ratio = 1.15; 95% confidence interval: 1.10, 1.20; P<.001). There was a significant group-by-time interaction (P<.001), with increased odds of being satisfied in the groups receiving neck-specific exercises compared to general physical activity. Enablement increased after completion of the intervention in all groups (P<.001). People who received neck-specific exercises reported greater enablement and expectation fulfillment than people prescribed general physical activity (P<.01). Conclusion Exercise interventions for chronic WAD led to increased satisfaction for 12 months following treatment that was unrelated to the type of exercise intervention received. Level of Evidence Therapy, level 1b. Registered January 22, 2012 at www.ClinicalTrials.gov (NCT01528579). J Orthop Sports Phys Ther 2016;46(8):640-649. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6136.
Ibrahim AH
STUDY DESIGN: A randomized controlled trial with 2-week Kinesio taping intervention. OBJECTIVE: The aim of the study was to investigate the effectiveness of Kinesio taping application on pain, functional disability, and trunk flexion range of motion (ROM) in patients with chronic nonspecific low back pain (chronic NSLBP). SUMMARY OF BACKGROUND DATA: Kinesio taping is a therapeutic tool used for treatment of chronic NSLBP. However, there is little scientific evidence that describes its clinical efficacy. METHODS: Forty-four patients with chronic NSLBP were randomized into experimental group (n = 21) and placebo group (n = 23). The experimental group was treated with Erector Spinae Taping, whereas the placebo group was treated with placebo taping. The primary endpoint was pain intensity on visual analog scale. Secondary endpoints were functional disability on Arabic version of Oswestry disability index (ODI) and trunk flexion ROM on Modified Schober's test. All measurements were recorded at baseline (W0), after 2-week intervention (W2), and at 4-week (W4) follow-up. RESULTS: Both group were comparable at baseline (P > 0.05). The experimental group had a greater decrease in pain than the placebo group after W2 of intervention (mean between-group difference 2.05 cm, 95% confidence interval [CI] = 1.38-2.71 points). This was maintained to W4 follow-up (2.25 cm, 95% CI = 1.67-2.82 points). At W2, the experimental group had significantly greater improvement in disability, by 3.90 points (95% CI = 1.68-8.54 points). This effect was significant at W4 follow-up (5.6, 95% CI = 2.65-8.54 points). Similarly trunk flexion ROM was significantly better at W2 (-0.71 cm, 95% CI = -0.85 to -0.56) and W4 follow-up (-0.73 cm, 95% CI = -0.88 to -0.58). CONCLUSION: Kinesio taping reduces pain and disability and improves trunk flexion ROM after 2 weeks of application. However, thesis effects were very small to be considered clinically relevant and meaningful when compared with placebo taping. LEVEL OF EVIDENCE: 2.
Mork PJ
OBJECTIVES: To prospectively investigate if the risk of chronic neck/shoulder pain is associated with work stress and job control, and to assess if physical exercise modifies these associations. MATERIAL AND METHODS: The study population comprised 29 496 vocationally active women and men in the Norwegian Nord-Trondelag Health Study (HUNT Study) without chronic pain at baseline in 1984-1986. Chronic neck/shoulder pain was assessed during a follow-up in 1995-1997. A generalized linear model (Poisson regression) was used to calculate adjusted relative risks (RRs). RESULTS: Work stress was dosedependently associated with the risk of neck/shoulder pain (ptrend < 0.001 in both sexes). The women and men who perceived their work as stressful "almost all the time" had multi-adjusted RRs = 1.27 (95% confidence interval (CI): 1.1-1.47) and 1.71 (95% CI: 1.46-2), respectively, referencing those with no stressful work. Work stress interacted with sex (p < 0.001). Poor job control was not associated with the risk of neck/shoulder pain among the women (RR = 1.04, 95% CI: 0.92-1.19) nor the men (RR = 1.09, 95% CI: 0.95-1.26). Combined analyses showed an inverse dose-dependent association between hours of physical exercise/week and the risk of neck/shoulder pain in the men with no stressful work (ptrend = 0.05) and among the men who perceived their work as "rarely stressful" (ptrend < 0.02). This effect was not statistically significant among the women or among men with more frequent exposure to work stress. CONCLUSIONS: Work stress is an independent predictor of chronic neck/shoulder pain and the effect is stronger in men than in women. Physical exercise does not substantially reduce the risk among the persons with frequent exposure to work stress.
Yoshida M
OBJECTIVE: The purpose of this study was to evaluate the relations between the degree of encroachment, measured as the cross-sectional area of the dural sac, and low back pain in a large population. METHODS: In this cross-sectional study, data from 802 participants (247 men, 555 women; mean age, 63.5 years) were analyzed. The measurement of the cross-sectional area of the dural sac from the level of L1/2 to L4/5 was taken using axial T2-weighted images. The minimum cross-sectional area was defined as the cross-sectional area of the dural sac at the most constricted level in the examined spine. Participants were divided into three groups according to minimum cross-sectional area measurement quartiles (less than the first quartile, between the first and third quartiles, and greater than the third quartile). A multivariate logistic regression analysis was used to estimate the association between the minimum cross-sectional area and the prevalence of low back pain. RESULTS: The mean minimum cross-sectional area was 117.3 mm2 (men: 114.4 mm2; women: 118.6 mm2). A logistic regression analysis adjusted for age, sex, body mass index, and other confounding factors, including disc degeneration, showed that a narrow minimum cross-sectional area (smaller than the first quartile) was significantly associated with low back pain (odds ratio, 1.78; 95% confidence interval, 1.13-2.80 compared to the wide minimum cross-sectional area group: minimum cross-sectional area greater than the third quartile measured). CONCLUSION: This study showed that a narrow dural sac cross-sectional area was significantly associated with the presence of low back pain after adjustment for age, sex, and body mass index. Further investigations that include additional radiographic findings and psychological factors will continue to elucidate the causes of low back pain.
Jull G
BACKGROUND CONTEXT: A previous study demonstrated that in seniors, the presence of cervical musculoskeletal impairment was not specific to cervicogenic headache but was present in various recurrent headache types. Physiotherapy treatment is indicated in those seniors diagnosed with cervicogenic headache but could also be adjunct treatment for those with cervical musculoskeletal signs who are suspected of having transitional headaches. PURPOSE: This study aimed to determine the effectiveness of a physiotherapy program for seniors with recurrent headaches associated with neck pain and cervical musculoskeletal dysfunction, irrespective of the headache classification. STUDY DESIGN: This is a prospective, stratified, randomized controlled trial with blinded outcome assessment. PATIENT SAMPLE: Sixty-five participants with recurrent headache, aged 50-75 years, were randomly assigned to either a physiotherapy (n=33) or a usual care group (n=32). OUTCOME MEASURES: The primary outcome was headache frequency. Secondary outcomes were headache intensity and duration, neck pain and disability, cervical range of motion, quality of life, participant satisfaction, and medication intake. METHODS: Participants in the physiotherapy group received 14 treatment sessions. Participants in the usual care group continued with their usual care. Outcome measures were recorded at baseline, 11 weeks, 6 months, and 9 months. This study was funded by a government research fund of $6,850. No conflict of interest is declared. RESULTS: There was no loss to follow-up for the primary outcome measure. Compared with usual care, participants receiving physiotherapy reported significant reductions in headache frequency immediately after treatment (mean difference -1.6 days, 95% confidence interval [CI] -2.5 to -0.6), at 6-month follow-up (-1.7 days, 95% CI -2.6 to -0.8), and at 9-month follow-up (-2.4 days, 95% CI -3.2 to -1.5), and significant improvements in all secondary outcomes immediately posttreatment and at 6- and 9-month follow-ups, (p<.05 for all). No adverse events were reported. CONCLUSIONS: Physiotherapy treatment provided benefits over usual care for seniors with recurrent headache associated with neck pain and dysfunction.
Ferreira ML
BACKGROUND CONTEXT: A previous study has shown that transient physical and psychosocial activities increased the risk of developing low back pain. However, the link between these factors in triggering nonpersistent or persistent episodes remains unclear. PURPOSE: We aimed to investigate the association of transient exposures to physical and psychosocial activities with the development of nonpersistent or persistent low back pain. STUDY DESIGN: This was a case-crossover study with 12 months follow-up. PATIENT SAMPLE: We included 999 consecutive participants seeking care for a sudden onset of low back pain. OUTCOME MEASURES: Development of low back pain was the outcome measure. MATERIALS AND METHODS: At baseline, participants reported transient exposures to 12 predefined activities over the 4 days preceding pain onset. After 12 months, participants were asked whether they had recovered and the date of recovery. Exposures in the 2-hour period preceding pain onset (case window) were compared with the 2-hour period, 24 hours before pain onset (control window) in a case-crossover design for all participants. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CI), and interaction analyses were used to compare estimates of nonpersistent (i.e., <6 weeks duration) and persistent cases. This study received funding from Australia's National Health and Medical Research Council (APP1003608). RESULTS: There were 832 participants (83%) who completed the 12 months follow-up successfully. Of these, 430 participants had nonpersistent low back pain (<6 weeks duration), whereas 352 reported persistent symptoms (>/=6 weeks duration). Exposure to several transient activities, such as manual tasks involving heavy loads, awkward postures, live people or animals, moderate or vigorous physical activity, and being fatigued or tired during a task or activity, significantly increased the risk of both nonpersistent and persistent low back pain, with ORs ranging from 2.9 to 11.7. Overall, the risk of developing a persistent or a nonpersistent episode of low back pain associated with the included physical factors did not differ significantly. CONCLUSIONS: Our results revealed that previously identified triggers contribute equally to the development of both nonpersistent and persistent low back pain. Future prevention strategies should focus on controlling exposure to these triggers as they have the potential to decrease the burden associated with both acute and chronic low back pain.
Costa LO
BACKGROUND: Non-specific low back pain is a major health problem worldwide. Interventions based on exercises have been the most commonly used treatments for patients with this condition. Over the past few years, the Pilates method has been one of the most popular exercise programmes used in clinical practice. OBJECTIVES: To determine the effects of the Pilates method for patients with non-specific acute, subacute or chronic low back pain. METHODS: SEARCH METHODS: We conducted the searches in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro and SPORTDiscus from the date of their inception to March 2014. We updated the search in June 2015 but these results have not yet been incorporated. We also searched the reference lists of eligible papers as well as six trial registry websites. We placed no limitations on language or date of publication. SELECTION CRITERIA: We only included randomized controlled trials that examined the effectiveness of Pilates intervention in adults with acute, subacute or chronic non-specific low back pain. The primary outcomes considered were pain, disability, global impression of recovery and quality of life. DATA COLLECTION AND ANALYSIS: Two independent raters performed the assessment of risk of bias in the included studies using the 'Risk of bias' assessment tool recommended by The Cochrane Collaboration. We also assessed clinical relevance by scoring five questions related to this domain as 'yes', 'no' or 'unclear'. We evaluated the overall quality of evidence using the GRADE approach and for effect sizes we used three levels: small (mean difference (MD) < 10% of the scale), medium (MD 10% to 20% of the scale) or large (MD > 20% of the scale). We converted outcome measures to a common 0 to 100 scale when different scales were used. MAIN RESULTS: The search retrieved 126 trials; 10 fulfilled the inclusion criteria and we included them in the review (a total sample of 510 participants). Seven studies were considered to have low risk of bias, and three were considered as high risk of bias.A total of six trials compared Pilates to minimal intervention. There is low quality evidence that Pilates reduces pain compared with minimal intervention, with a medium effect size at short-term follow-up (less than three months after randomization) (MD -14.05, 95% confidence interval (CI) -18.91 to -9.19). For intermediate-term follow-up (at least three months but less than 12 months after randomization), two trials provided moderate quality evidence that Pilates reduces pain compared to minimal intervention, with a medium effect size (MD -10.54, 95% CI -18.46 to -2.62). Based on five trials, there is low quality evidence that Pilates improves disability compared with minimal intervention, with a small effect size at short-term follow-up (MD -7.95, 95% CI -13.23 to -2.67), and moderate quality evidence for an intermediate-term effect with a medium effect size (MD -11.17, 95% CI -18.41 to -3.92). Based on one trial and low quality evidence, a significant short-term effect with a small effect size was reported for function (MD 1.10, 95% CI 0.23 to 1.97) and global impression of recovery (MD 1.50, 95% CI 0.70 to 2.30), but not at intermediate-term follow-up for either outcome.Four trials compared Pilates to other exercises. For the outcome pain, we presented the results as a narrative synthesis due to the high level of heterogeneity. At short-term follow-up, based on low quality evidence, two trials demonstrated a significant effect in favour of Pilates and one trial did not find a significant difference. At intermediate-term follow-up, based on low quality evidence, one trial reported a significant effect in favour of Pilates, and one trial reported a non-significant difference for this comparison. For disability, there is moderate quality evidence that there is no significant difference between Pilates and other exercise either in the short term (MD -3.29, 95% CI -6.82 to 0.24) or in the intermediate term (MD -0.91, 95% CI -5.02 to 3.20) based on two studies for each comparison. Based on low quality evidence and one trial, there was no significant difference in function between Pilates and other exercises at short-term follow-up (MD 0.10, 95% CI -2.44 to 2.64), but there was a significant effect in favour of other exercises for intermediate-term function, with a small effect size (MD -3.60, 95% CI -7.00 to -0.20). Global impression of recovery was not assessed in this comparison and none of the trials included quality of life outcomes. Two trials assessed adverse events in this review, one did not find any adverse events, and another reported minor events. AUTHORS CONCLUSIONS: We did not find any high quality evidence for any of the treatment comparisons, outcomes or follow-up periods investigated. However, there is low to moderate quality evidence that Pilates is more effective than minimal intervention for pain and disability. When Pilates was compared with other exercises we found a small effect for function at intermediate-term follow-up. Thus, while there is some evidence for the effectiveness of Pilates for low back pain, there is no conclusive evidence that it is superior to other forms of exercises. The decision to use Pilates for low back pain may be based on the patient's or care provider's preferences, and costs.
Peolsson A
BACKGROUND: To investigate the effect of neck-specific exercise with (NSEB) or without (NSE) a behavioural approach and prescribed physical activity (PPA) on general pain disability and psychological factors in chronic whiplash-associated disorders (WAD), grade 2 and 3, with a 2-year follow-up. METHODS: A randomized controlled multi-centre study of 3 exercise interventions (NSE, NSEB or PPA) including a 2-year follow-up. A total of 216 volunteers with chronic WAD were recruited and 194 were analyzed, mean age 40.4 (Standard Deviation [SD] 11.4). Measures of general pain disability, pain catastrophizing, anxiety and depression, and kinesiophobia were evaluated at baseline, and 3, 6, 12 and 24 months with linear mixed models. RESULTS: General pain disability decreased by 28% in the NSEB group from baseline to 3 months (P < 0.001) and the improvements in disability were maintained over time (6, 12 and 24 months P < 0.01) compared to the NSE (P > 0.42) and PPA groups (P > 0.43). Pain catastrophizing decreased in the NSE group from baseline to 6 and 12 months (P < 0.01) and in the NSEB group from baseline to 3 and 24 months (P < 0.01) compared to the PPA group (P > 0.82) that showed no change over time. The NSE group improved in kinesiophobia over time from baseline to12 months (P < 0.01) compared to the NSEB (P = 0.052) and the PPA groups (P > 0.74). Anxiety decreased over time from baseline to 12 and 24 months in the NSE group (P > 0.02), but not in the NSEB (P > 0.25) or the PPA (P > 0.50) groups. The PPA had no effect on general disability or any of the measured psychological factors. CONCLUSION: This randomised controlled trial with a 2-year follow-up shows that physiotherapist-led neck-specific exercise with or without the addition of a behavioural approach had superior outcome on general disability and most psychological factors compared to the mere prescription of physical activity.
Poenaru DV
PURPOSE: Spinopelvic parameters can be useful in identifying risk factors for lumbar degenerative disc disease, but few studies assess patients with single-level disc herniation and most do not evaluate symptoms. This comparative retrospective study was aimed to analyse spinopelvic parameters, symptoms and MRI changes in patients with single-level lumbar disc herniation undergoing conservative or surgical treatment. METHODS: Patients with clinical and radiological assessment (Japanese Orthopaedic Association Score) and an MRI evaluation of the lumbar spine were identified and divided into two groups: surgically treated (group A) and not requiring surgery (group B). Spinopelvic parameters were determined on standing profile radiographs of the lumbar spine and pelvis, and mean values were compared to those reported in the literature for normal subjects. MRI findings were graded according to the system described by Pfirrmann et al. RESULTS: The study included 71 patients with single-level lumbar disc herniation: 26 in group A (39.4 +/- 12.1 years) and 45 in group B (51.4 +/- 17.2 years). The notable differences in spinopelvic parameter means between the two groups did not reach statistical significance. A positive correlations of age with pelvic tilt and Pfirrmann changes with pelvic incidence was only found in group A, while both groups showed highly significant positive correlations of pelvic incidence with the spine's conformational type (p = 0.001). CONCLUSIONS: Characteristic changes in spinopelvic parameters identified in patients with lumbar degenerative disc disease were a reduction in pelvic incidence, sacral slope and lumbar lordosis, with an increased pelvic tilt. These were found to correlate with MRI changes in surgically treated patients.
Lind B
OBJECTIVE The aim of this study was to evaluate the 5- to 8-year outcome of anterior cervical decompression and fusion (ACDF) combined with a structured physiotherapy program as compared with that following the same physiotherapy program alone in patients with cervical radiculopathy. No previous prospective randomized studies with a follow-up of more than 2 years have compared outcomes of surgical versus nonsurgical intervention for cervical radiculopathy. METHODS Fifty-nine patients were randomized to ACDF surgery with postoperative physiotherapy (30 patients) or to structured physiotherapy alone (29 patients). The physiotherapy program included general and specific exercises as well as pain coping strategies. Outcome measures included neck disability (Neck Disability Index [NDI]), neck and arm pain intensity (visual analog scale [VAS]), health state (EQ-5D questionnaire), and a patient global assessment. Patients were followed up for 5-8 years. RESULTS After 5-8 years, the NDI was reduced by a mean score% of 21 (95% CI 14-28) in the surgical group and 11% (95% CI 4%-18%) in the nonsurgical group (p = 0.03). Neck pain was reduced by a mean score of 39 mm (95% CI 26-53 mm) compared with 19 mm (95% CI 7-30 mm; p = 0.01), and arm pain was reduced by a mean score of 33 mm (95% CI 18-49 mm) compared with 19 mm (95% CI 7-32 mm; p = 0.1), respectively. The EQ-5D had a mean respective increase of 0.29 (95% CI 0.13-0.45) compared with 0.14 (95% CI 0.01-0.27; p = 0.12). Ninety-three percent of patients in the surgical group rated their symptoms as "better" or "much better" compared with 62% in the nonsurgical group (p = 0.005). Both treatment groups experienced significant improvement over baseline for all outcome measures. CONCLUSIONS In this prospective randomized study of 5- to 8-year outcomes of surgical versus nonsurgical treatment in patients with cervical radiculopathy, ACDF combined with physiotherapy reduced neck disability and neck pain more effectively than physiotherapy alone. Self-rating by patients as regards treatment outcome was also superior in the surgery group. No significant differences were seen between the 2 patient groups as regards arm pain and health outcome.
Van Daele U
OBJECTIVES: To provide a comprehensive overview of clinical tests associated with functional lumbar segmental instability and motor control impairment in patients with low back pain (LBP), and to investigate their intrarater reliability, interrater reliability, or both. DATA SOURCES: A systematic computerized search was conducted on December 1, 2015, in 4 different databases (starting search year is indicated in parentheses, with articles included from that year until December 1, 2015): PubMed (1972-), Web of Science (1955-), Embase (1947-), and MEDLINE (1946-). STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during design, search, and reporting stages of this review. The included population comprised patients with primary LBP. DATA EXTRACTION: Data were extracted as follows: (1) description and scoring of the clinical tests; (2) population characteristics; (3) inclusion and exclusion criteria; (4) description of the used procedures; (5) results for both intra- and interrater reliability; and eventually (6) notification on used statistical method. The risk of bias of the included articles was assessed with the use of the COnsensus-based Standards for the selection of health Measurement INstruments checklist. DATA SYNTHESIS: A total of 16 records were eligible, and 30 clinical tests were identified. All included studies investigated interrater reliability, and 3 studies investigated intrarater reliability. The identified interrater reliability scores ranged from poor to very good (kappa=-.09 to .89; intraclass correlation coefficient, .72-.96), and the intrarater reliability scores ranged from fair to very good (kappa=.51-.86). CONCLUSIONS: Three clinical tests (aberrant movement pattern, prone instability test, Beighton Scale) could be identified as having an adequate interrater reliability. No conclusions could be made for intrarater reliability. However, further research should focus on better study designs, provide an overall agreement for uniformity and interpretation of clinical tests, and should implement research regarding validity.
Oh T
BACKGROUND: Although both pregabalin and gabapentin are known to be useful for treating lumbar radiating pain and reducing the incidence of surgery, the oral corticosteroids sometimes offer a dramatic effect on severe radiating pain despite the lack of scientific evidence. METHODS: A total of 54 patients were enrolled among 703 patients who complained of lumbar radiating pain. Twenty patients who received an oral corticosteroid was classified as group A and 20 patients who received the control drugs (pregabalin or gabapentin) as group B. Oswestry Disability Index (ODI), Revised Roland Morris disability questionnaire (RMDQ), Short Form 36 (SF-36) questionnaire, lumbar radiating pain, objective patient satisfaction, and objective improvement of patients or physicians were assessed at 2, 6, and 12 weeks after medication. RESULTS: No difference in the sex ratio and age was observed between the groups (p = 0.70 and p = 0.13, respectively). Group A showed greater improvement in radiating pain after 2, 6, and 12 weeks than group B (p < 0.001, p = 0.001, and p < 0.001, respectively). No differences were observed between the groups in satisfaction at the beginning and 12 weeks after taking the medication (p = 0.062 and p = 0.061, respectively) and in objective improvement of patients and physicians (p = 0.657 and p = 0.748, respectively). Group A was less disabled and had greater physical health scores than group B (p = 0.014 and p = 0.017, respectively). CONCLUSIONS: Oral corticosteroids for the treatment of lumbar radiating pain can be more effective in pain relief than gabapentin or pregabalin. The satisfaction of patients and physicians with the drug and objective improvement status were not inferior to that with gabapentin or pregabalin.
Williams KD
BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adult Isthmic Spondylolisthesis features evidence-based recommendations for diagnosing and treating adult patients with isthmic spondylolisthesis. The guideline is intended to reflect contemporary treatment concepts for symptomatic isthmic spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of June 2013. NASS' guideline on this topic is the only guideline on adult isthmic spondylolisthesis accepted in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse. PURPOSE: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with isthmic spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: This is a guideline summary review. METHODS: This guideline is the product of the Adult Isthmic Spondylolisthesis Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questionsto address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Adult Isthmic Spondylolisthesis guideline was accepted into the National Guideline Clearinghouse and will be updated approximately every 5 years. RESULTS: Thirty-one clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with isthmic spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines. aspx and will remain updated on a timely schedule.
Curatolo M
Synopsis Whiplash-associated disorder (WAD) is a group of symptoms and clinical manifestations resulting from rear-end or side impact. Despite the wide use of medications in WAD, the published research does not allow recommendations based on high evidence level. It may be meaningful to use nonsteroidal anti-inflammatory drugs in the acute posttraumatic phase. In chronic WAD, the use of nonsteroidal anti-inflammatory drugs is more concerning due to potential gastrointestinal and renal complications with prolonged use and lack of evidence for long-term benefits. Antidepressants can be used in patients with clinically relevant hyperalgesia, sleep disorder associated with pain, or depression. Anticonvulsants are unlikely first-choice medications, but can be considered if other treatments fail. The use of opioids in patients with chronic pain has become the object of severe concern, due to the lack of evidence for long-term benefits and the associated risks. Extreme caution in prescribing and monitoring opioid treatment is mandatory. Nerve blocks of the zygapophyseal (facet) joints have validity for the diagnosis of facet joint pain, which is one of the possible manifestations of WAD. One randomized sham-controlled trial and several high-quality prospective studies support the efficacy of radiofrequency neurotomy for the treatment of facet joint pain. The efficacy of trigger point treatments is uncertain. They can be offered due to possible efficacy and limited risks. Any medication or procedure has to be considered in the frame of a comprehensive patient evaluation. As for any chronic pain condition, concomitant consideration of rehabilitation and psychosocial interventions is mandatory. J Orthop Sports Phys Ther 2016;46(10):845-850. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6906.
Hancock MJ
Study Design Secondary analysis of a prospective cohort study with cross-sectional and longitudinal analyses. Background The clinical importance of a history of whiplash-associated disorder (WAD) in people with neck pain remains uncertain. Objective To compare people with WAD to people with nonspecific neck pain, in terms of their baseline characteristics and pain and disability outcomes over 1 year. Methods Consecutive patients with neck pain who presented to a secondary-care spine center answered a comprehensive self-report questionnaire and underwent a physical examination. Patients were classified into a group of either those with WAD or those with nonspecific neck pain. We compared the outcomes of baseline characteristics of the 2 groups, as well as pain intensity and activity limitation at follow-ups of 6 and 12 months. Results A total of 2578 participants were included in the study. Of these, 488 (19%) were classified as having WAD. At presentation, patients with WAD were statistically different from patients without WAD for almost all characteristics investigated. While most differences were small (1.1 points on an 11-point pain-rating scale and 11 percentage points on the Neck Disability Index), others, including the presence of dizziness and memory difficulties, were substantial. The between-group differences in pain and disability increased significantly (P<.001) over 12 months. At 12-month follow-up, the patients with WAD had on average approximately 2 points more pain and 17 percentage points more disability than those with nonspecific neck pain. Conclusion People referred to secondary care with WAD typically had more self-reported pain and disability and experienced worse outcomes than those with nonspecific neck pain. Caution is required when interpreting the longitudinal outcomes due to lower-than-optimal follow-up rates. Level of Evidence Prognosis, level 2. J Orthop Sports Phys Ther 2016;46(10):894-901. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6588.
O'Sullivan K
QUESTION: What are physiotherapists' perspectives on managing the cognitive, psychological and social dimensions of chronic low back pain after intensive biopsychosocial training? DESIGN: Qualitative study design using semi-structured interviews to explore physiotherapists' perceptions of their identification and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive Functional Therapy (CFT) training. PARTICIPANTS: Thirteen qualified physiotherapists from four countries who had received specific CFT training. The training involved supervised implementation of CFT in clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive descriptive analysis was performed using a qualitative software package. RESULTS: Four main themes emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in professional practice; altered scope of practice; and increased confidence and satisfaction. Participants described increased understanding of the nature of pain, the role of patient beliefs, and a new appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in communication, and adoption of a functional approach. Since undertaking CFT training, participants described a greater awareness of their role and scope of practice as clinicians in identifying and addressing these factors. CONCLUSION: Physiotherapists expressed confidence in their capacity and skill set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials are needed to justify the time and cost of training, so that intensive CFT training may be made more readily accessible to clinicians, which to date has not been the case. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, Robinson K, O'Sullivan K (2016) Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study.Journal of Physiotherapy62: 215-221].
Maher CG
Background: Tai chi is recommended for musculoskeletal conditions; however, the evidence for its clinical effectiveness is uncertain. Purpose: The aim of this study was to determine whether tai chi is beneficial for clinical outcomes in people with musculoskeletal pain. Data Sources: Seven databases were searched: Embase, PEDro, AMED, MEDLINE, CINAHL, SPORTDiscus, and the Cochrane Central Register of Controlled Trials. Study Selection: Randomized controlled trials of tai chi for people with a chronic musculoskeletal condition were included. Data Extraction: Two reviewers extracted data and rated risk of bias. Standardized mean differences (SMDs) and 95% confidence intervals (CI) were calculated for individual trials and pooled effect sizes were calculated using a random-effects model. Data Synthesis: Fifteen studies were identified; these studies included people with osteoarthritis (80%), back pain (13%), and headache (7%). Using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, moderate-quality evidence was found that tai chi was more effective than no treatment or usual care at short term on pain (SMD=-0.66 [95% CI=-0.85, -0.48]) and disability (SMD=-0.66 [95% CI=-0.85, -0.46]). The evidence for other outcomes was of low or very low quality and there was little information regarding long-term effects. Thus, although the number of publications in this area has increased, the rigor has not, hindering physical therapists' ability to provide reliable recommendations for clinical practice. Limitations: The evidence provided in this review is limited by trials with small sample sizes, low methodological quality, and lack of long-term assessment. Conclusions: In order for tai chi to be recommended as an effective intervention, more high-quality trials with large sample sizes assessing tai chi versus other evidence-based treatments at short term and at long term are needed.
Yan ZH
BACKGROUND CONTEXT: Accurately evaluating the extent of trunk imbalance in the coronal plane is significant for patients before and after treatment. We preliminarily practiced a new method, axis-line-angle technique (ALAT), for evaluating coronal trunk imbalance with excellent intra-observer and interobserver reliability. Radiologists and surgeons were encouraged to use this method in clinical practice. However, the optimal cutoff value of the ALAT for determination of the extent of coronal trunk imbalance has not been calculated up to now. PURPOSE: The purpose of this study was to identify the cutoff value of the ALAT that best predicts a positive measurement point to assess coronal balance or imbalance. STUDY DESIGN/SETTING: A retrospective study at a university affiliated hospital was carried out. PATIENT SAMPLE: A total of 130 patients with C7-central sacral vertical line (CSVL) >0 mm and aged 10-18 years were recruited in this study from September 2013 to December 2014. OUTCOME MEASURES: Data were analyzed to determine the optimal cutoff value of the ALAT measurement. METHODS: The C7-CSVL and ALAT measurements were conducted respectively twice on plain film within a 2-week interval by two radiologists. The optimal cutoff value of the ALAT was analyzed via receiver operating characteristic (ROC) curve. Comparison variables were performed with chi-square test between the C7-CSVL and ALAT measurements for evaluating trunk imbalance. Kappa agreement coefficient method was used to test the intra-observer and interobserver agreement of C7-CSVL and ALAT. RESULTS: The ROC curve area for the ALAT was 0.82 (95% confidence interval: 0.753-0.894, p<.001). The maximum Youden index was 0.51, and the corresponding cutoff point was 2.59 degrees . No statistical difference was found between the C7-CSVL and ALAT measurements for evaluating trunk imbalance (p>.05). Intra-observer agreement values for the C7-CSVL measurements by observers 1 and 2 were 0.79 and 0.91 (p<.001), respectively, whereas intra-observer agreement values for the ALAT measurements were both 0.89 by observers 1 and 2 (p<.001). The interobserver agreement values for the first and second measurements with the C7-CSVL were 0.78 and 0.85 (p<.001), respectively, whereas the interobserver agreement values for the first and second measurements with the ALAT were 0.91 and 0.88 (p<.001), respectively. CONCLUSIONS: The newly developed ALAT provided an acceptable optimal cutoff value for evaluating trunk imbalance in the coronal plane with a high level of intra-observer and interobserver agreement, which suggests that the ALAT is suitable for clinical use.
Yoon B
OBJECTIVE: To explore the feasibility of a newly developed smartphone-based exercise program with an embedded self-classification algorithm for office workers with neck pain, by examining its effect on the pain intensity, functional disability, quality of life, fear avoidance, and cervical range of motion (ROM). DESIGN: Single-group, repeated-measures design. SETTING: The laboratory and participants' home and work environments. PARTICIPANTS: Offices workers with neck pain (N=23; mean age +/- SD, 28.13+/-2.97y; 13 men). INTERVENTION: Participants were classified as having 1 of 4 types of neck pain through a self-classification algorithm implemented as a smartphone application, and conducted corresponding exercise programs for 10 to 12min/d, 3d/wk, for 8 weeks. MAIN OUTCOME MEASURES: The visual analog scale (VAS), Neck Disability Index (NDI), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Fear-Avoidance Beliefs Questionnaire (FABQ), and cervical ROM were measured at baseline and postintervention. RESULTS: The VAS (P<.001) and NDI score (P<.001) indicated significant improvements in pain intensity and functional disability. Quality of life showed significant improvements in the physical functioning (P=.007), bodily pain (P=.018), general health (P=.022), vitality (P=.046), and physical component scores (P=.002) of the SF-36. The FABQ, cervical ROM, and mental component score of the SF-36 showed no significant improvements. CONCLUSIONS: The smartphone-based exercise program with an embedded self-classification algorithm improves the pain intensity and perceived physical health of office workers with neck pain, although not enough to affect their mental and emotional states.
Hung M
BACKGROUND: One-fourth of the adult US population has or will experience back pain and has undergone one of a myriad of treatments. Understanding the outcomes of these many treatments from pharmacologic to surgical, from manipulation to modality, allows for a better understanding and value-driven decision making. Patient-reported outcome measures are the current standard and include general and disease-specific measures. The Oswestry Disability Index (ODI) is the most commonly used disease-specific patient-reported outcome tool to measure functional disability related to back pain. Few studies have evaluated its psychometric properties in a large patient sample using a modern tool such as the Rasch analysis model. This study aims to identify the benefits and deficiencies of the ODI as an outcome tool for assessing patients with back pain. PURPOSE: This study aimed to investigate the psychometric properties, performance, and applicability of the ODI in patients with back pain who visited a university-based outpatient clinic. STUDY DESIGN: This study used a secondary analysis-assessment of diagnostic tool on consecutive patients. PATIENT SAMPLE: The sample comprised 1,610 patients visiting an academic spine center. OUTCOME MEASURES: The ODI was the outcome measure. METHODS: Detailed Rasch analysis of the ODI was performed. Standard descriptive statistics were also assessed. RESULTS: The ODI performed well overall. It demonstrated suboptimal unidimensionality (ie, unexplained variance after accounting for the first dimension) of 8.3%. Person reliability was good, at 0.85, and item reliability was excellent, at 1.00. The overall item fit for the ODI was good with an outfit mean square of 1.02. The ODI had a floor effect of 29.9% and ceiling effect of 3.9%. The raw score to measure correlation of the ODI was excellent, at 0.944. CONCLUSIONS: The ODI performed relatively well overall, with some problematic findings. It had good person and item reliability, although it did not demonstrate strong evidence of unidimensionality. The ODI has moderately poor coverage, with a very large floor effect and small ceiling effect, which could present a challenge in interpreting results of scores at the end of the spectrum.
Pinto RZ
OBJECTIVES: To assess the association of physical activity measures, derived with an accelerometer and a self-reported questionnaire, with fear of movement in patients with chronic nonspecific low back pain (LBP) and to investigate the association between disability and fear of movement in this population. DESIGN: Cross-sectional study. SETTING: Outpatient physical therapy university clinics. PARTICIPANTS: Patients (N=119) presenting with nonspecific LBP of >3 months' duration. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical activity levels measured objectively with an accelerometer (ie, counts per minute, time spent in moderate-to-vigorous and light physical activity per day, number of steps per day, and number of 10-minute bouts of moderate-to-vigorous physical activity per day) and subjectively with a self-reported questionnaire (Baecke Physical Activity Questionnaire); fear of movement (Tampa Scale of Kinesiophobia); pain (11-point numerical rating scale); disability (Roland Morris Disability Questionnaire); and depression (Beck Depression Inventory). The associations were examined with correlational, univariate, and multivariable linear regression analyses. RESULTS: None of the objective physical activity measures were associated with fear of movement. The apparent association of self-reported physical activity levels with fear of movement (correlational analyses: r=-.18; P<.05; univariate regression analyses: beta=-.04; 95% confidence interval [CI], -.07 to -.01; P=.04) was not confirmed in multivariable analyses. Fear of movement was consistently associated with disability in both correlational (r=.42; P<.01) and multivariable (beta=.21; 95% CI, .11-.31; P<.001) analyses. CONCLUSIONS: Our data support one aspect of the fear-avoidance model-that higher fear of movement is associated with more disability-but not the aspect of the model linking fear of movement with inactivity.
Ferreira PH
BACKGROUND CONTEXT: Obesity is commonly investigated as a potential risk factor for low back pain (LBP); however, current evidence remains unclear. Limitations in previous studies may explain the inconsistent results in the field, such as the use of a cross sectional design, limitations in the measures used to assess obesity (eg, body mass index-BMI), and poor adjustment for confounders (eg, genetics and physical activity). PURPOSE AND DESIGN: To better understand the effects of obesity on LBP, our aim was to investigate in a prospective cohort whether obesity-related measures increase the risk of chronic LBP outcomes using a longitudinal design. We assessed obesity through measures that consider the magnitude as well as the distribution of body fat mass. A within-pair twin case-control analysis was used to control for the possible effects of genetic and early shared environmental factors on the obesity-LBP relationship. PATIENT SAMPLE AND OUTCOME MEASURES: Data were obtained from the Murcia Twin Registry in Spain. Participants were 1,098 twins, aged 43 to 71 years, who did not report chronic LBP at baseline. Follow-up data on chronic LBP (>6 months), activity-limiting LBP, and care-seeking for LBP were collected after 2 to 4 years. RISK FACTORS: The risk factors were BMI, percentage of fat mass, waist circumference, and waist-to-hip ratio. METHODS: Sequential analyses were performed using logistic regression controlling for familial confounding: (1) total sample analysis (twins analyzed as independent individuals); (2) within-pair twin case-control analyses (all complete twin pairs discordant for LBP at follow-up); and within-pair twin case-control analyses separated for (3) dizygotic and (4) monozygotic twins. RESULTS: No increase in the risk of chronic LBP was found for any of the obesity-related measures: BMI (men/women, odds ratio [OR]: 0.99; 95 % confidence interval [CI]: 0.86-1.14), % fat mass (women, OR: 0.87; 95% CI: 0.66-1.14), waist circumference (women, OR: 0.98; 95% CI: 0.74-1.30), and waist-to-hip ratio (women, OR: 1.05; 95% CI: 0.81-1.36). Similar results were found for activity-limiting LBP and care-seeking due to LBP. After the adjustment for genetics and early environmental factors shared by twins, the non-significant results remained unchanged. CONCLUSIONS: After 2 to 4 years, obesity-related measures did not increase the risk of developing chronic LBP or care-seeking for LBP with or without adjustment for familial factors such as genetics in Spanish adults.
Judge A
STUDY DESIGN: A prospective observational study. OBJECTIVE: The aim of this study was to identify the relationship between obesity, quantified by body mass index (BMI), and both back and leg pain in spinal patients. SUMMARY OF BACKGROUND DATA: Obesity and back pain are massive public health problems. Given the poor correlation between pain and a pathological change in the spine, further investigation is required into other, nonpathological predictors such as obesity. METHODS: The Genodisc Study was one of the largest cross-sectional studies of patients presenting to tertiary spinal units and recruited from six centers in four European countries. In total, 2636 patients were recruited over a 5-year period between 2008 and 2013. Both back and leg pain were scored by patients in the range of 0 to 10. Linear regression was used to model the relationship between BMI and pain. Potential confounders included in the model were age, Zung Depression score, episodes of sport, gender, disability benefit, family history, previous surgery, smoking status, work type, clinical diagnosis, and relevant comorbidities. Back and leg pain outcomes were modeled separately. RESULTS: The study included 1160 men and 1349 women with a mean age of 50.9 years and mean BMI of 27.2 kg/m. In our fully adjusted model, a 5-point increase in BMI was associated with greater leg [0.19 units (95% confidence interval 0.08-0.31)] but not back [0.10 units (95% CI -0.02 to 0.22)] pain scores. Although this relationship was statically significant, given the small magnitude of the relationship, the clinical significance is limited. Similarly, female gender, heavy workload, rheumatoid arthritis, previous spine surgery, and depression were associated with higher back and leg pain. CONCLUSION: In this large observational study of spine patients presenting to tertiary European centers, obesity, as measured by increased BMI, was associated with greater leg pain. LEVEL OF EVIDENCE: 2.
Jarvik JG
BACKGROUND: The association between early physical therapy (PT) and subsequent health-care utilization following a new visit for low back pain is not clear, particularly in the setting of acute low back pain. PURPOSE: This study aimed to estimate the association between initiating early PT following a new visit for an episode of low back pain and subsequent back pain-specific health-care utilization in older adults. DESIGN/SETTING: This is a prospective cohort study. Data were collected at three integrated health-care systems in the United States through the Back Pain Outcomes using Longitudinal Data (BOLD) registry. PATIENT SAMPLE: We recruited 4,723 adults, aged 65 and older, presenting to a primary care setting with a new episode of low back pain. OUTCOME MEASURES: Primary outcome was total back pain-specific relative value units (RVUs), from days 29 to 365. Secondary outcomes included overall RVUs for all health care and use of specific health-care services including imaging (x-ray and magnetic resonance imaging [MRI] or computed tomography [CT]), emergency department visits, physician visits, PT, spinal injections, spinal surgeries, and opioid use. METHODS: We compared patients who had early PT (initiated within 28 days of the index visit) with those not initiating early PT using appropriate, generalized linear models to adjust for potential confounding variables. RESULTS: Adjusted analysis found no statistically significant difference in total spine RVUs between the two groups (ratio of means 1.19, 95% CI of 0.72-1.96, p=.49). For secondary outcomes, only the difference between total spine imaging RVUs and total PT RVUs was statistically significant. The early PT group had greater PT RVUs; the ratio of means was 2.56 (95% CI of 2.17-3.03, p<.001). The early PT group had greater imaging RVUs; the ratio of means was 1.37 (95% CI of 1.09-1.71, p=.01.) CONCLUSIONS: We found that in a group of older adults presenting for a new episode of low back pain, the use of early PT is not associated with any statistically significant difference in subsequent back pain-specific health-care utilization compared with patients not receiving early PT.
Asazuma T
BACKGROUND CONTEXT: Gait patterns and their relationship to demographic and radiographic data in patients with adult spinal deformity (ASD) have not been fully documented. PURPOSE: This study aimed to assess gait pattern in patients with ASD and the effect of corrective spinal surgery on gait. DESIGN/SETTING: This is a prospective case series. PATIENT SAMPLE: The gait patterns of 33 consecutive women with ASD (age 67.1 years; body mass index [BMI] 22.5+/-2.5 kg/m(2), Cobb angle 46.8+/-18.2 degrees , coronal vertical axis [CVA] 1.5+/-3.7 cm, C7 sagittal vertical axis [SVA] 9.1+/-6.4 cm, pelvic incidence minus lumbar lordosis [PI-LL] 38.2+/-22.1 degrees , and lean volume of the lower leg, 5.5+/-0.6 kg) before and after corrective surgery were compared with those of 33 age- and gender-matched healthy volunteers. OUTCOME MEASURES: Scoliosis Research Society Patient Questionnaire (SRS22r), Oswestry Disability Index (ODI), and forceplate analysis. METHODS: All subjects underwent gait analysis on a custom-built forceplate using optical markers placed on all joints and spinal processes. Dual X-ray absorptiometry scores were used to calculate the lean composition of the lower legs. Subjects with ASD were followed for at least 2 years post operation. RESULTS: Preop mean values showed that patients with ASD had a significantly worse gait velocity (54+/-10 m/min vs. 70.7+/-12.9 m/min, p<.01) and stride (97.8+/-13.4 cm vs. 115.3+/-15.1 cm, p<.01), but no difference was observed in the stance-to-swing ratio. The right and left ground reaction force vectors were also discordant in the ASD group (vertical direction; r=0.84 vs. r=.97, p=.01). The hip range of motion (ROM) was also significantly decreased in ASD. Correlation coefficient showed moderate correlations between the preoperative gait velocity and the gravity line (GL), PI, ROM of the lower extremity joints, and lean volume, and between the stride and the lean volume, GL, and PI-LL. Gait pattern, stride, and velocity all improved significantly in the patients with ASD after surgery, but were still not as good as in healthy volunteers. The SRS22r satisfaction domain correlated moderately with postoperative gait velocity (r=0.34). CONCLUSIONS: The patients with ASD had an asymmetric gait pattern and impaired gait ability compared with healthy volunteers. Gait ability correlated significantly with the GL, spinopelvic alignment, lower extremity joint ROM, and lean volume. The surgical correction of spinopelvic alignment and exercises to build muscle strength may improve the gait pattern and ability in patients with ASD.
Taylor NF
BACKGROUND CONTEXT: Physical therapy is commonly sought by people with lumbar disc herniation and associated radiculopathy. It is unclear whether physical therapy is effective for this population. PURPOSE: To determine the effectiveness of physical therapist-delivered individualized functional restoration as an adjunct to guideline-based advice in people with lumbar disc herniation and associated radiculopathy. STUDY DESIGN: This is a preplanned subgroup analysis of a multicenter parallel group randomized controlled trial. PATIENT SAMPLE: The study included 54 participants with clinical features of radiculopathy (6-week to 6-month duration) and imaging showing a lumbar disc herniation. OUTCOME MEASURES: Primary outcomes were activity limitation (Oswestry Disability Index) and separate 0-10 numerical pain rating scales for leg pain and back pain. Measures were taken at baseline and at 5, 10, 26, and 52 weeks. METHODS: The participants were randomly allocated to receive either individualized functional restoration incorporating advice (10 sessions) or guideline-based advice alone (2 sessions) over a 10-week period. Treatment was administered by 11 physical therapists at private clinics in Melbourne, Australia. RESULTS: Between-group differences for activity limitation favored the addition of individualized functional restoration to advice alone at 10 weeks (7.7, 95% confidence interval [CI] 0.3-15.1) and 52 weeks (8.2, 95% CI 0.7-15.6), as well as back pain at 10 weeks (1.4, 95% CI 0.2-2.7). There were no significant differences between groups for leg pain at any follow-up. Several secondary outcomes also favored individualized functional restoration over advice. CONCLUSIONS: In participants with lumbar disc herniation and associated radiculopathy, an individualized functional restoration program incorporating advice led to greater reduction in activity limitation at 10- and 52-week follow-ups compared with guideline-based advice alone. Although back pain was significantly reduced at 10 weeks with individualized functional restoration, this effect was not maintained at later timepoints, and there were no significant effects on leg pain, relative to guideline-based advice.
Hedge A
BACKGROUND: Laptop computers have surpassed desktop computers in popularity, especially among college student users. The portability of these devices raises concerns regarding healthy usage patterns in different settings and there is a need to investigate the postures with which these devices are being used and associated reports of musculoskeletal discomfort. OBJECTIVE: This study investigated the configurations in which laptops are used and the prevalence of musculoskeletal discomfort associated with laptop use in a survey of college students. The purpose of this was to identify differences in discomfort and/or postural choice between males and females. METHODS: A sample of 90 male and 96 female college students completed an online questionnaire consisting of demographic questions, musculoskeletal discomfort indicators and questions regarding configurations of laptop use. RESULTS: Over 53% of participants reported experiencing musculoskeletal discomfort while using a laptop computer, with females reporting a higher prevalence of neck discomfort (p = 0.05) and shoulder discomfort (p = 0.006) than males. Participants reported using a laptop most commonly in positions at a desk and on a bed. Females were more likely than males to use a laptop on a bed with the computer positioned on their lap or with their legs crossed (p < 0.05). Males were more likely than females to work in positions necessitating a large trunk deviation to operate the laptop (p < 0.05), such as "sitting on a sofa with your feet on the floor (knees at 90 degrees ), bending over to use laptop that is resting on a coffee table or ottoman in front of you". CONCLUSIONS: A significant proportion of college students report experiencing musculoskeletal discomfort associated with laptop computer use. Sex differences exist in both choice of configurations and musculoskeletal discomfort associated with laptop use. Due to the portability of laptop computers, they are used in a variety of configurations and environments. This study identifies a number of different ways that laptop computers are used that have not been considered in previous research. These patterns of laptop use can be used to inform future work on the impact of technology use on discomfort.
Pourret S
BACKGROUND: The conservative orthopaedic treatment of adult scoliosis is very disappointing. In a series of 144 patients; only 25 % (33 cases) were monitored at 2 years of treatment. (Papadopoulos 2013). Thereby the literature typically focuses on a small number of patients, which limits the usefulness and relevance of its results. The brace effect on pain has been systematically described, but there is no publication on the effect of treatment on the Cobb angle and main clinical parameters. METHODS: From a prospective database started in 1998, we selected all 158 consecutive patients effectively treated conservatively with the Lyon management treatment and controlled five years after brace fitting. Lyon management includes a lordosing bivalve polyethylene overlapping brace in association with specific physiotherapy. The brace can either be short with anterior support under the chest or long with sterno-clavicular support when there is a high thoracic kyphosis. RESULTS: 1. For the rate of scoliosis controlled after 5 years, the follow-up was 24 % of the 661 patients accepting the treatment. Pain is almost the main reason for the medical consultation, generally correlating with an increase of the scoliotic angulation. 2. The descriptive data can be superimposed on general group with age (m=56 years, SD=13) but initial Cobb angulation is significantly higher (m=40 degrees , SD=17). Ratio Female/Male=0.91. Generally, the scoliosis is stabilized at (m=39.74 degrees , SD=19.40), 8 years after the beginning of the treatment. 38 improvements of more than 5 degrees = 24 %; 88 stable = 56 %; 32 worsening of more than 5 degrees = 20 % The rib hump is improved of by 3 mm, (modelling effect of the brace). The occipital axis is improved by more than 6 mm. But the T1 plumb line distance is worsening by 7 mm (most braces are short without sterno-clavicular support). CONCLUSIONS: For the first time, the number of records and follow up after 8 years allows to study the radiological progression of adult scoliosis rigid bracing. Stability or improvement of more than 5 degrees in 80 % of cases justify rigid bracing in adults. The accentuation of the thoracic kyphosis is the only negative element and a modified ARTbrace will soon be used.
Guzzanti V
BACKGROUND: Conservative treatment in the Scheuermann's kyphosis obtain, during skeletal growth, remodelling of the deformed vertebras. In a previous paper on Scheuermann's kyphosis, we have studied the geometry variations of all vertebrae included in the curve, before and after the treatment. The purpose of this study was to confirm the effectiveness of conservative treatment in Scheuermann's kyphosis and was to evaluate and compare the variation of the vertebral geometry with the curve trend in Cobb degrees, before and after conservative treatment. METHODS: From a consecutive series of patients, we selected 90 patients with thoracic Scheuermann's kyphosis, treated using anti-gravity brace: 59 male, 31 female. The mean age at the beginning of the treatment was 14 years. Radiographical measurements were performed on radiographs from a lateral projection, at the beginning (t1) and at the end of the treatment (t5). Vertebral geometry modifications at t1 and t5 were analysed according to the following parameters and evaluated by three independent observers: Anterior wedging angle (ALFA) of the apex vertebra and Posterior wall inclination (APOS) of the limiting lower vertebra. The curve was measured in Cobb degrees. RESULTS: The results from our study showed that of the 90 patients with a thoracic curve mean value of Cobb degrees was 57.8 +/- 6.0 SD at t1 and 41.3 +/- 5.6 SD at t5. The differences between t1(angle at baseline) and t5 (end of treatment) were calculated for Cobb, ALFA and APOS angle and were respectively -16.4 +/- 4.5, -6.4 +/- 1.4 and -2.7 +/- 1.2; tested with paired t-test were significative (p < 0.01). The results of the regression analysis to test the relationship between the three measures for the kyphosis (Cobb degree, ALFA and APOS) showed that the best association was between Cobb t5 and ALFA t5 (p < 0.01) and Cobb t1 and APOS t1 (p < 0.01). No significative association was found between the difference between ALFA and APOS. CONCLUSION: We sustain that using new parameters to study vertebral remodelling allows us to reach a better comprehension of Scheuermann spine response to anti-gravity brace treatment. Furthermore, the evaluation of the ALFA angle of the apex vertebra confirms to be more reliable than Cobb's angle because it cannot be affected by the radiological position.
Goldberg J
BACKGROUND: Inconsistent associations between modifiable risk factors and chronic back pain (CBP) may be due to the inability of traditional epidemiologic study designs to properly account for an array of potential genetic and environmental confounding factors. The co-twin control research design, comparing modifiable risk factors in twins discordant for CBP, offers a unique way to remove numerous confounding factors. PURPOSE: The study aimed to examine the association of modifiable lifestyle and psychological factors with lifetime CBP. STUDY DESIGN/SETTING: This is a cross-sectional co-twin control study in a nationwide sample of male twin members of the Vietnam Era Twin Registry. PATIENT SAMPLE: The sample is composed of 7,108 participants, including 1,308 monozygotic (MZ) pairs and 793 dizygotic pairs. OUTCOME MEASURE: The outcome measure is the self-reported lifetime history of CBP. METHODS: Lifestyle factors included body mass index (BMI), smoking history, alcohol consumption, habitual physical activity, and typical sleep duration. Psychological factors included depression (Patient Health Questionnaire-9) and posttraumatic stress disorder (PTSD) symptoms (PTSD Checklist). Covariates included age, race, education, and income. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated for the association of risk factors with lifetime CBP when considering twins as individuals, and a within-pair co-twin control analysis that accounted for familial and genetic factors. Funding was through VA Grant 5IK2RX001515; there were no study-specific conflicts of interest. RESULTS: The mean age of respondents was 62 years and the prevalence of lifetime CBP was 28%. All lifestyle factors were associated with CBP in the individual level analysis. However, none of these persisted in the within-pair analyses, except for severe obesity (BMI >/=35.0), which was associated with lifetime CBP in both individual-level (OR=1.6, 95% CI: 1.3-1.9) and within-pair analyses (MZ analysis: OR=3.7, 95% CI: 1.2-11.4). Symptoms of PTSD and depression were strongly associated with lifetime CBP in both the individual-level (moderate or severe depression: OR=4.2, 95% CI: 3.6-4.9, and severe PTSD: OR=4.8, 95% CI: 4.0-5.7) and within-pair (MZ) analyses (moderate or severe depression: OR=4.6, 95% CI: 2.4-8.7, and severe PTSD: OR=3.2, 95% CI: 1.6-6.5). CONCLUSIONS: Many associations between modifiable lifestyle risk factors and CBP are due to confounding by familial and genetic factors. Severe obesity, depression, and PTSD should be considered in the development of intervention strategies to reduce the prevalence of CBP.
Ferreira ML
BACKGROUND: Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear. OBJECTIVES: To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates. SEARCH METHODS: Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews. SELECTION CRITERIA: This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence. MAIN RESULTS: We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'. AUTHORS' CONCLUSIONS: The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.
Huygen FJ
AIMS: The aim of this study was to compare the effect of a percutaneous radiofrequency heat lesion at the medial branch of the primary dorsal ramus with a sham procedure, for the treatment of lumbar facet joint pain. PATIENTS AND METHODS: A randomised sham-controlled double blind multicentre trial was carried out at the multidisciplinary pain centres of two hospitals. A total of 60 patients aged > 18 years with a history and physical examination suggestive of facet joint pain and a decrease of >/= 2 on a numerical rating scale (NRS 0 to 10) after a diagnostic facet joint test block were included. In the treatment group, a percutaneous radiofrequency heat lesion (80(o)C during 60 seconds per level) was applied to the medial branch of the primary dorsal ramus. In the sham group, the same procedure was undertaken without for the radiofrequency lesion. Both groups also received a graded activity physiotherapy programme. The primary outcome measure was decrease in pain. A secondary outcome measure was the Global Perceived Effect scale (GPE). RESULTS: There was a statistically significant effect on the level of pain in the factor Period (T0-T1). However, there was no statistically significant difference with the passage of time between the groups (Group x Period) or in the factor Group. In the crossover group, 11 of 19 patients had a decrease in NRS of >/= 2 at one month crossover (p = 0.65). There was no statistically significant difference in satisfaction with the passage of time between the groups (Group x Period). The independent factors Group and Period also showed no statistically significant difference. There was no statistically significant Group x Period effect for recovery, neither an effect of Group or of Period. CONCLUSION: The hypothesis of no difference in the decrease in pain and in GPE between the treatment and sham groups cannot be rejected. Post hoc analysis revealed that the age of the patients and the severity of the initial pain significantly predicted a positive outcome. Cite this article: Bone Joint J 2016;98-B:1526-33.
Adeeb S
STUDY DESIGN: A validation study. OBJECTIVE: The aim of this study was to independently validate the diagnostic accuracy of surface topography (ST) classification trees to identify curve severity and progression using a new sample of data in participants with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Radiographs for diagnosing and monitoring AIS involve harmful radiation exposure repeated at successive clinical visits. Classification trees using a novel ST technique have been proposed to determine curve severity and progression noninvasively that could be used to monitor scoliosis. METHODS: Forty-five adolescents with AIS treated nonoperatively, with ST scans and radiographs at baseline and follow-up (1 year later), were recruited from a scoliosis clinic. The Cobb angle (CA) from radiographs determined curve severity as mild (10 degrees < CA < 25 degrees ) or moderate/severe (CA >/= 25 degrees ) and progression as an increase >5 degrees .ST scans were analyzed to calculate the best plane of symmetry and associated deviation color map. Root mean squares and maximum deviation were calculated for each area of asymmetry. ST measurements were analyzed using two published decision trees developed to maximize sensitivity and negative predictive value. Curves were classified as mild or moderate/severe and curve progression was predicted. Accuracy statistics were calculated to evaluate performance. RESULTS: For curve severity, sensitivity and specificity were 95% and 35%, respectively. Negative and positive predictive values were 90% and 53%, respectively, with an accuracy of 61%. For curve progression, sensitivity and specificity were 73% and 44%, respectively. Negative and positive predictive values were 83% and 30%, respectively, with an accuracy of 51%. Assuming that mild and nonprogressive curves would not require an x-ray, the use of ST decision trees could eliminate 31% of x-rays. CONCLUSION: Decision trees showed strong negative predictive values and sensitivity suggesting it may be possible to safely use ST asymmetry analysis with validated decision trees to reduce x-rays in patients with mild and nonprogressive curves. LEVEL OF EVIDENCE: 2.
Obeid I
BACKGROUND CONTEXT: Many radiological parameters have been reported to correlate with patient's disability including sagittal vertical axis (SVA), pelvic tilt (PT), and pelvic incidence minus lumbar lordosis (PI-LL). European literature reports other parameters such as lumbar lordosis index (LLI) and the global tilt (GT). If most parameters correlate with health-related quality of life scores (HRQLs), their impact on disability remains unclear. PURPOSE: This study aimed to validate these parameters by investigating their correlation with HRQLs. It also aimed to evaluate the relationship between each of these sagittal parameters and HRQLs to fully understand the impact in adult spinal deformity management. STUDY DESIGN: A retrospective review of a multicenter, prospective database was carried out. PATIENT SAMPLE: The database inclusion criteria were adults (>18 years old) presenting any of the following radiographic parameters: scoliosis (Cobb >/=20 degrees ), SVA >/=5 cm, thoracic kyphosis >/=60 degrees or PT >/=25 degrees . All patients with complete data at baseline were included. OUTCOME MEASURES: Health-related quality of life scores, demographic variables (DVs), and radiographic parameters were collected at baseline. METHODS: Differences in HRQLs among groups of each DV were assessed with analyses of variance. Correlations between radiographic variables and HRQLs were assessed using the Spearman rank correlation. Multivariate linear regression models were fitted for each of the HRQLs (Oswestry Disability Index [ODI], Scoliosis Research Society-22 subtotal score, or physical component summaries) with sagittal parameters and covariants as independent variables. A p<.05 value was considered statistically significant. RESULTS: Among a total of 755 included patients (mean age, 52.1 years), 431 were non-surgical candidates and 324 were surgical candidates. Global tilt and LLI significantly correlated with HRQLs (r=0.4 and -0.3, respectively) for univariate analysis. Demographic variables such as age, gender, body mass index, past surgery, and surgical or non-surgical candidate were significant predictors of ODI score. The likelihood ratio tests for the addition of the sagittal parameters showed that SVA, GT, T1 sagittal tilt, PI-LL, and LLI were statistically significant predictors for ODI score even adjusted for covariates. The differences of R(2) values from Model 1 were 1.5% at maximum, indicating that the addition of sagittal parameters to the reference model increased only 1.5% of the variance of ODI explained by the models. CONCLUSION: GT and LLI appear to be independent radiographic parameters impacting ODI variance. If most of the parameters described in the literature are correlated with ODI, the impact of these radiographic parameters is less than 2% of ODI variance, whereas 40% are explained by DVs. The importance of radiographic parameters lies more on their purpose to describe and understand the malalignment mechanisms than their univariate correlation with HRQLs.
Cagnie B
OBJECTIVES: The function of the scapula is important in normal neck function and might be disturbed in patients with neck pain. The surrounding muscular system is important for the function of the scapula. To date, it is not clear if patients with idiopathic neck pain show altered activity of these scapulothoracic muscles. Therefore, the objective of this study was to investigate differences in deeper and superficial lying scapulothoracic muscle activity between patients with idiopathic neck pain and healthy controls during arm elevation, and to identify the influence of scapular dyskinesis on muscle activity. METHODS: Scapular dyskinesis was rated with the yes/no method. The deeper lying (Levator Scapulae, Pectoralis Minor (Pm) and Rhomboid major) and superficial lying (Trapezius and Serratus Anterior) scapulothoracic muscles' activity was investigated with fine-wire and surface EMG, respectively, in 19 female subjects with idiopathic neck pain (age 28.3+/-10.1years, average duration of neck pain 45.6+/-36.3months) and 19 female healthy control subjects (age 29.3+/-11.7years) while performing scaption and towel wall slide. Possible interactions or differences between subject groups, scapular dyskinesis groups or phases of the task were studied with a linear mixed model. RESULTS: Higher Pm activity during the towel wallslide (p=0.024, mean difference 8.8+/-3.3% MVIC) was shown in patients with idiopathic neck pain in comparison with healthy controls. For the MT, a significant group *dyskinesis interaction effect was found during scaption which revealed that patients with neck pain and scapular dyskinesis showed lower Middle Trapezius (MT) activity in comparison with healthy controls with scapular dyskinesis (p=0.029, mean difference 5.1+/-2.2% MVIC). CONCLUSIONS: In the presence of idiopathic neck pain, higher Pm activity during the towel wallslide was found. Patients with neck pain and scapular dyskinesis showed lower MT activity in comparison with healthy controls with scapular dyskinesis during scaption. Scapular dyskinesis did not have a significant influence on scapulothoracic muscle activity.
Skalli W
PURPOSE: In addition to the sagittal alignment, impact of transverse plane parameters (TPP) and rotatory subluxation on patients reported outcomes were highlighted. One of the hypotheses for genesis of degenerative scoliosis is disc degeneration with increased axial vertebral (AVR) and intervertebral rotation (AIR). Therefore, TPP analysis at early stage of the scoliosis seems of particular interest. This study aims at assessing reliability of tridimensional (3D) reconstructions of adult spinal deformity (ASD) patients. METHODS: Thirty ASD patients underwent biplanar radiographs and were divided into two groups (Cobb angle >30 degrees or <30 degrees ). Spinal parameters and TPP (apical AVR, AIR of upper and lower level of main curve) were measured. Four operators performed 3D reconstructions twice. Intra and inter-observer reliabilities were analyzed using ISO standard 5725-2, to quantify the global standard deviation of reproducibility (S R). RESULTS: Mean Cobb angle was 31 degrees , mean age 55 years (70% of female). Mean values of apical AVR, upper and lower level AIR were, respectively, 16 degrees +/- 15 degrees , 6 degrees +/- 6 degrees and 5 degrees +/- 5 degrees . Spinopelvic parameters S R were below 4.5 degrees . For Cobb angle <30 degrees , S R was 7.8 degrees , 9.6 degrees , 4.5 degrees and 4.9 degrees , respectively, for AVR apex, torsion index, upper and lower AIR. Reliability was worse in the group of patients with Cobb angle above 30 degrees . CONCLUSIONS: 3D analysis was reliable for Cobb and sagittal parameters. 3D analysis for TPP was reproducible when Cobb is below 30 degrees . However, uncertainty is larger for Cobb above 30 degrees . Nevertheless, 3D reconstructions could help surgeons to anticipate onset of rotatory subluxation while assessing axial rotation evolution for small deformity and choose best delay for surgical treatment.
Robinson Y
BACKGROUND CONTEXT: Proper patient selection is of utmost importance in the surgical treatment of degenerative disc disease (DDD) with chronic low back pain (CLBP). Among other factors, gender was previously found to influence lumbar fusion surgery outcome. PURPOSE: This study investigates whether gender affects clinical outcome after lumbar fusion. STUDY DESIGN: This is a national registry cohort study. PATIENT SAMPLE: Between 2001 and 2011, 2,251 men and 2,521 women were followed prospectively within the Swedish National Spine Register (SWESPINE) after lumbar fusion surgery for DDD and CLBP. OUTCOME MEASURES: Patient-reported outcome measures (PROMs), visual analog scale (VAS) for leg and back pain, Oswestry Disability Index (ODI), quality of life (QoL) parameter EQ5D, and labor status and pain medication were collected preoperatively, 1 and 2 years after surgery. METHODS: Gender differences of baseline data and PROM improvement from baseline were analyzed. The effect of gender on clinically important improvement of PROM was determined in a multivariate logistic regression model. Furthermore, gender-related differences in return-to-work were investigated. RESULTS: Preoperatively, women had worse leg pain (p<.001), back pain (p=.002), lower QoL (p<.001), and greater disability than men (p=.001). Postoperatively, women presented greater improvement 2 years from baseline for pain, function, and QoL (all p<.01). Women had better chances of a clinically important improvement than men for leg pain (odds ratio [OR]=1.39, 95% confidence interval [CI]: 1.19-1.61, p<.01) and back pain (OR=1.20,95% CI:1.03-1.40, p=.02) as well as ODI (OR=1.24, 95% CI:1.05-1.47, p=.01), but improved at a slower pace in leg pain (p<.001), back pain (p=.009), and disability (p=.008). No gender differences were found in QoL and return to work at 2 years postoperatively. CONCLUSIONS: Swedish women do not have worse results than men after spinal fusion surgery. Female patients present with worse pain and function preoperatively, but improve more than men do after surgery.
Eberman LE
Reference: Wang XQ, Zheng JJ, Yu ZW, et al. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One. 2012;7(12):e52082. Clinical Questions: Is core stability exercise more effective than general exercise in the treatment of patients with nonspecific low back pain (LBP)? DATA SOURCES: The authors searched the following databases: China Biological Medicine disc, Cochrane Library, Embase, and PubMed from 1970 through 2011. The key medical subject headings searched were chronic pain, exercise, LBP, lumbosacral region, and sciatica. STUDY SELECTION: Randomized controlled trials comparing core stability exercise with general exercise in the treatment of chronic LBP were investigated. Participants were male and female adults with LBP for at least 3 months that was not caused by a specific known condition. A control group receiving general exercise and an experimental group receiving core stability exercise were required for inclusion in the meta-analysis. Core stability was defined as the ability to ensure a stable neutral spine position, but the type of exercise was not specified. Outcome measures of pain intensity, back-specific functional status, quality of life, and work absenteeism were recorded at 3-, 6-, and 12-month intervals. DATA EXTRACTION: The study design, participant information, description of interventions in the control and experimental groups, outcome measures, and follow-up period were extracted. The mean difference (MD) and 95% confidence interval (CI) were calculated to evaluate statistical significance. Risk of bias was assessed using the Cochrane Collaboration Recommendations, and all articles were rated as high risk for other bias with no further explanation given. MAIN RESULTS: Five studies involving 414 patients were included. Four studies assessed pain intensity using the visual analog scale or numeric rating scale. In the core stability exercise group, the reduction in pain was significant at 3 months (MD = -1.29, 95% CI = -2.47, -0.11; P = .003) but not at 6 months (MD = -0.50, 95% CI = -1.36, 0.35; P = .26). Functional status was improved at 3 months (MD = -7.14, 95% CI = -11.64, -2.65; P = .002) but not at 6 months (MD = -0.50, 95% CI = 0.36, 0.35; P = .26) or 12 months (MD = -0.32, 95% CI = -0.87, 0.23; P = .25). All of the included studies assessed back-specific functional status: 4 used the Oswestry Disability Index and 1 used the Roland-Morris Disability Questionnaire. Patients in the core stability exercise groups experienced improved functional status versus the general exercise group at 3 months (MD = -7.14, 95% CI = -11.64, -2.65; P = .002); no results were recorded at 6 or 12 months. CONCLUSIONS: In the short term, core stability exercise was more effective than general exercise for decreasing pain and increasing back-specific functional status in patients with LBP.
Forget M
BACKGROUND: Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are perceptions of benefit. Acupuncture has been used as an alternative to more conventional treatment for musculoskeletal pain. This review summarises the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain. This update replaces our 2006 Cochrane review update on this topic. OBJECTIVES: To determine the effects of acupuncture for adults with neck pain, with focus on pain relief, disability or functional measures, patient satisfaction and global perceived effect. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Manual, Alternative and Natural Therapy Index System (MANTIS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Index to Chiropractic Literature (ICL) from their beginning to August 2015. We searched reference lists, two trial registers and the acupuncture database Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) in China to 2005. SELECTION CRITERIA: We included published trials that used random assignment to intervention groups, in full text or abstract form. We excluded quasi-randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: Two review authors made independent decisions for each step of the review: article inclusion, data abstraction and assessment of quality of trial methods. We assessed study quality by using the Cochrane Back Review Group 'Risk of bias' tool. We used consensus to resolve disagreements, and when clinical heterogeneity was absent, we combined studies by using random-effects meta-analysis models. MAIN RESULTS: Of the 27 included studies, three represented individuals with whiplash-associated disorders (WADs) ranging from acute to chronic (205 participants), five explored chronic myofascial neck pain (186 participants), five chronic pain due to arthritic changes (542 participants), six chronic non-specific neck pain (4011 participants), two neck pain with radicular signs (43 participants) and six subacute or chronic mechanical neck pain (5111 participants).For mechanical neck pain, we found that acupuncture is beneficial at immediate-term follow-up compared with sham acupuncture for pain intensity; at short-term follow-up compared with sham or inactive treatment for pain intensity; at short-term follow-up compared with sham treatment for disability; and at short-term follow-up compared with wait-list control for pain intensity and neck disability improvement. Statistical pooling was appropriate for acupuncture compared with sham for short-term outcomes due to statistical homogeneity (P value = 0.83; I(2) = 20%). Results of the meta-analysis favoured acupuncture (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.20 to -0.07; P value = 0.0006). This effect does not seem sustainable over the long term. Whether subsequent repeated sessions would be successful was not examined by investigators in our primary studies.Acupuncture appears to be a safe treatment modality, as adverse effects are minor. Reported adverse effects include increased pain, bruising, fainting, worsening of symptoms, local swelling and dizziness. These studies reported no life-threatening adverse effects and found that acupuncture treatments were cost-effective.Since the time of our previous review, the quality of RCTs has improved, and we have assessed many of them as having low risk of bias. However, few large trials have provided high-quality evidence. AUTHORS' CONCLUSIONS: Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up, and that those who received acupuncture report less pain and disability at short-term follow-up than those on a wait-list. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up.
Karavelioglu E
BACKGROUND: Symptomatic lumbar intervertebral disc herniation (LDH) is rare in children and adolescents. To date, the treatments available for child and adolescent LDH, and the effect of each treatment, have not been fully reviewed. OBJECTIVE: The purpose of this retrospective study is to report the etiology, familial history, presenting symptoms, level of herniation, duration of symptoms, radiological findings, as well as treatment methods and outcome. METHODS: We retrospectively reviewed medical records of all patients with inclusion criteria of being younger than 20 years. (10-19 years); we used magnetic resonance imaging (MRI) to confirm lumbar disc herniations between 2013 and 2016. All patients were followed up for a minimum of 12 months and discharged if they remained almost asymptomatic for 6 months. All patients were treated conservatively and 6 patients they have progressive neurological deficit and persistent back pain, were treated with surgical procedures. The Visual Analogue Scale (VAS), as well as the Oswestry Disability Scale (ODS) and the modified Ashworth Scale (AS) were used to analyze physical examination findings both before and after treatment. To detect lumbar disc degeneration, we used the modified Pfirrmann grading system with MRI. All statistical analyses were performed with commercially available SPSS 15.0 software, while p
Labelle H
STUDY DESIGN: A cross-sectional study. OBJECTIVES: The aim of this study was to investigate spinal pain prevalence in adolescents with idiopathic scoliosis (AIS) and to explore associations between pain intensity and pain-related disability with scoliosis site, severity, and spinal bracing. SUMMARY OF BACKGROUND DATA: The causal link between spinal pain and AIS remains unclear. Spinal asymmetry has been recognized as a back pain risk factor, which is a known cause of care-seeking in adolescents. METHODS: Participants were recruited from an outpatient tertiary-care scoliosis clinic. Pain intensity and pain-related disability were measured by the Brief Pain Inventory questionnaire and the Roland-Morris Disability Questionnaire. Scoliosis severity estimation was performed using Cobb angles. Associations were explored using multiple linear regressions and reported with unstandardized beta coefficients (beta) adjusted for age and sex. RESULTS: We recruited 500 patients (85% female) with mean (SD) age of 14.2 (1.8) years. Means (SD) of thoracic and lumbar Cobb angle were 24.54(9.77) and 24.13 (12.40), respectively. Spinal pain prevalence was 68% [95% confidence interval (95% CI): 64.5-72.4] with a mean intensity of 1.63 (SD, 1.89). Spinal pain intensity was positively associated with scoliosis severity in the main thoracic (P = 0.003) and lumbar (P = 0.001) regions. The mean (SD) disability score was 1.73 (2.98). Disability was positively associated with scoliosis severity in the proximal thoracic (P = 0.035), main thoracic (P = 0.000), and lumbar (P = 0.000) regions.Spinal bracing was associated with lower spinal pain intensity in the thoracic (P = 0.000) and lumbar regions (P = 0.009). Bracing was also related with lower disability for all spinal areas (P < 0.045). CONCLUSION: Spinal pain is common among patients with AIS, and greater spinal deformity was associated with higher pain intensity. These findings should inform clinical decision-making when caring for patients with AIS. LEVEL OF EVIDENCE: 3.
Tanaka S
BACKGROUND CONTEXT: Previous studies have indicated that the T1 slope correlates with cervical lordosis. In contrast, the specific impact of the C7 sagittal vertical axis (C7SVA) on cervical lordosis remains unknown. PURPOSE: This study aimed to investigate the specific role of C7SVA in cervical lordosis. STUDY DESIGN/SETTING: This was a retrospective radiographic study. PATIENT SAMPLE: Forty-eight consecutive patients who underwent lateral standing radiography of the entire spine were retrospectively reviewed. OUTCOME MEASURES: Radiographic parameters included occipito (Oc)-C7, Oc-C2, C2-C7, C2-C4, and C5-C7 angles; T1 slope; C7SVA; T1 pelvic angle (TPA); pelvic incidence; pelvic tilt; and sacral slope. METHODS: The radiographs of 96 consecutive patients who underwent lateral standing radiography of the entire spine in June 2015 in our hospital were retrospectively reviewed. Patients having cervical deformities, having undergone cervical fusion, and under 18 years of age were excluded. A total of 48 Asian patients (14 men and 34 women; mean age, 54.6 years) were eligible. Pathologies included scoliosis, myelopathy, thoracolumbar deformity, and spondylosis. Spearman rank correlation coefficients were used to examine correlations between the parameters. The relationship between C5-C7 lordosis and the radiographic parameters was calculated using the forward stepwise multivariate regression analysis. The authors do not have financial associations relevant to this article. RESULTS: C7SVA correlated with the Oc-C7 (r=0.42) and C2-C7 (r=0.50) angles. However, the correlation coefficient was smaller than that between the T1 slope and Oc-C7 (r=0.83) or C2-C7 (r=0.76) angles. When the C2-C7 angle was divided into C2-C4 and C5-C7 angles, C7SVA correlated with the C5-C7 (r=0.63) angle but not with the C2-C4 angle. The correlation coefficient between the C5-C7 angle and C7SVA was higher than that between the C5-C7 angle and T1 slope (r=0.53) or the C5-C7 angle and TPA (r=0.60). Using radiographic parameters and age, multiple regression analysis revealed that only C7SVA affected the C5-C7 angle. CONCLUSIONS: C7SVA was the only radiographic parameter that affected the C5-C7 angle. Both T1 slope and C7SVA are key to the shape of the cervical sagittal alignment. The results of this study can be a starting point to improve our understanding of cervical sagittal alignment.
Saraph V
BACKGROUND: It is important to monitor how patients with juvenile and adolescent idiopathic scoliosis comply with their physiotherapeutic scoliosis-specific exercises (PSSE). Physiogame, a newly developed video game using the Game-Trak 3D interactive game controller, combines correct PSSE performance with gaming. It tracks the position of the working limb in 3D space during the exercises as participants aim to hit certain targets and avoid others, and gives direct feedback by stopping the game if the working limb leaves the target 3D space, which is chosen to secure the corrective position according to the Schroth method. Physiogame records the quality and frequency of the exercises performed. We aimed to investigate the influence of this tool on motivation to perform regularly and, correctly, and with self-assessment of performance quality. METHODS: This case series included 8 consecutive patients with idiopathic scoliosis (thoracolumbar 7, lumbar 1), ages 7-13 years, all female and treated according to SOSORT guidelines; the COBB angle of primary curve at the start of brace therapy was 22-34 degrees . In addition to Full Time Rigid Bracing (FTRB, Cheneau) and PSSE (Schroth), the participants were to perform two standardized Schroth exercises (muscle cylinder in standing position, mainly addressing the thoracic curve, and in side-lying position, mainly addressing the lumbar curve) with video game assistance every day for 6 months. The development (first to last month) of the following parameters was analyzed with descriptive methods: the actual training time to assess motivation, the ratio of the actual playing time versus total playing time to assess exercise improvement, and self-assessment of quality of performance. RESULTS: The average number of sessions with Physiogame was 217 per study participant (range 24 to 572, the study protocol targeted at least 180); actual training time decreased from 79 to 52 min (first to last month). Actual playing time increased from 73% of the total playing time to 83% (first to last month), and positive hits per second from 0.33 to 0.56. Self-assessment increased from "good" to "very good". The curve angles ( degrees Cobb) were maintained over the study period (upper thoracic mean -1.3 degrees , median -1 degrees ; lower thoracic mean 3 degrees , median 2 degrees ; lumbar mean 0.5, median 0). CONCLUSIONS: The improvement we saw in exercise performance, is thought to result primarily from the direct given feedback during the game, as the exercises themselves were already familiar to the patients. The synchronous recording of actual training time allows evaluation of Schroth therapy for idiopathic scoliosis, since both prescribed training time and actual training time are captured. No comparable tool was found in literature.
Roach JW
STUDY DESIGN: Case control comparative series OBJECTIVE.: Describe surgical range adolescent idiopathic scoliosis (AIS) patients electing to forgo surgery and compare health related quality of life outcomes to a similar cohort of operated AIS patients by the same single surgeon. SUMMARY OF BACKGROUND DATA: No data have been published either documenting SRS-22r scores of non-operated patients with curves >/= 40 degrees or comparing these scores to a demographically similar operated cohort. METHODS: Individuals with curves >/= 40 degrees , age >/= 18 years, and electing to forgo surgery were identified. All patients completed an SRS-22r questionnaire. This non-operated cohort's SRS-22r scores were compared to those of a large demographically similar cohort operated by the same surgeon. Group differences between the SRS-22r scores were evaluated by comparing these to published Minimal Clinically Important Differences (MCID) for the SRS- 22r. RESULTS: One hundred ninety subjects with non-operated curves were compared to 166 individuals who surgery. The non-operated cohort averaged 23.5 years of age, averaged 7.7 years since curve reached 40 degrees , and had an average 50 degrees Cobb angle at last follow-up. No statistical differences were found between the groups on the Pain, Function, or Mental Health domains of the SRS-22r. Statistically significant differences in favor of the operative cohort were found for Self-image, Satisfaction and Total score. The observed group differences did not meet the established thresholds for minimal clinically important differences in any of the domain scores, the average total score, or raw scores. CONCLUSION: There are no meaningful clinically significant differences in SRS-22r scores at average 8 year follow-up between AIS patients with curves >/= 40 degrees treated with or without surgery. These data in conjunction with an absence of long-term evidence of serious medical consequences with non-surgical management of curves >/= 40 degrees should encourage surgeons to reevaluate the benefits of routine surgical care. LEVEL OF EVIDENCE: 3.
Verska JM
INTRODUCTION: Members of the Scoliosis Research Society are required to annually submit complication data regarding deaths, visual acuity loss, neurological deficit and infection (2012-1st year for this measure) for all deformity operations performed. The purpose of this study is to report the 2012 results and the differences in these complications from the years 2009-2012. METHODS: The SRS M&M database is a self-reported complications registry of deformity operations performed by the members. The data from 2009-2012, inclusive, was tabulated and analyzed. Differences in frequency distribution between years were analyzed with Fisher's exact test. Significance was set at alpha = 0.05. RESULTS: The total number of cases reported increased from 34,332 in 2009 to 47,755 in 2012. Overall mortality ranged from 0.07% in 2011 to 0.12% in 2009. The neuromuscular scoliosis group had the highest mortality rate (0.44%) in 2010. The combined groups' neurological deficit rate increased from 0.44% in 2009 to 0.79% in 2012. Neurological deficits were significantly lower in 2009 compared to 2012 for idiopathic scoliosis >18 years, other scoliosis, degenerative and isthmic spondylolisthesis and other groups. The groups with the highest neurological deficit rates were dysplastic spondylolisthesis and congenital kyphosis. There were no differences in vision loss rates between years. The overall 2012 infection rate was 1.14% with neuromuscular scoliosis having the highest group rate at 2.97%. CONCLUSION: Neuromuscular scoliosis has the highest complication rates of mortality and infection. The neurological deficit rates of all groups combined have slightly increased from 2009 to 2012 with the highest rates consistently being in the dysplastic spondylolisthesis and congenital kyphosis groups. This could be due to a number of factors, including more rigorous reporting.
Acaroglu ER
STUDY DESIGN: Retrospective two-cohort comparative analysis of data collected prospectively. OBJECTIVES: To analyze a cohort of patients with untreated thoracic curves of an adult multicenter deformity database [European spine study group (ESSG)], describe patient characteristics and concerns, and establish the rate and motivations for surgical intervention. SUMMARY OF BACKGROUND DATA: Idiopathic thoracic curves have a significant clinical and socioeconomic impact during adolescence. However, little attention has been given to adult thoracic scoliosis. The complaints of patients that have reached adulthood with an untreated thoracic curve are still not well studied. METHODS: The database of 1,142 prospective consecutive adult patients with deformity was searched to identify patients with untreated thoracic idiopathic curves: Schwab Type T curves, and Schwab Type D with thoracolumbar/lumbar (TL/L) curves <40 degrees and a difference between main thoracic (MT) and the TL/L >/=15 degrees . Demographic data, different radiologic preoperative parameters, and health-related quality of life questionnaires were assessed. RESULTS: Forty-two patients met inclusion criteria, showing the following characteristics: age, 30.9 +/- 12.5 years; thoracic Cobb, 55.6 +/- 10.8 degrees ; lumbar Cobb, 28.1 +/- 7.3 degrees ; sagittal vertical axis, 2.9 +/- 19.3 cm; Core Outcome Measures Index (COMI), 4 +/- 2.5; Oswestry Disability Index (ODI), 20.4 +/- 17.4; Scoliosis Research Society-22 questionnaire (SRS-22) subtotal, 3.6 +/- 0.7; 36-Item Short Form Health Survey (SF-36) mental health, 46.1 +/- 10.1; SF-36 physical health, 47.3 +/- 11.1. Only 13 of these patients underwent surgery. Compared with nonoperated patients, they were younger (24.3 +/- 7.3 vs. 33.8 +/- 13.4 years; p = .009), had larger MT curves (58.7 degrees +/- 9.6 vs. 50.6 degrees +/- 8.3; p = .012), and had worse SRS-22 self-image scores (2.9 +/- 0.8 vs. 3.5 +/- 0.8; p = .042). No patients older than 50 years underwent surgery, despite having worse SRS-22 function (3.0 +/- 0.9 vs. 4.1 +/- 0.9, p = .032) and worse ODI scores (42.4 +/- 19.9 vs. 18.7 +/- 18.0, p = .026). CONCLUSIONS: Very few adult deformity patients sought treatment because of untreated thoracic scoliotic curve. The probability of undergoing surgery was low (13/42), and it was associated with youth, curve magnitude, and poor self-image. The rate of surgical treatment of the thoracic curve appears to diminish with age, despite its being associated with poorer function and greater disability in the older patient.
Southon SC
BACKGROUND: The North American non-surgical standard of care for adolescent idiopathic scoliosis (AIS) includes observation and bracing, but not exercises. Schroth physiotherapeutic scoliosis-specific exercises (PSSE) showed promise in several studies of suboptimal methodology. The Scoliosis Research Society calls for rigorous studies supporting the role of exercises before including it as a treatment recommendation for scoliosis. OBJECTIVES: To determine the effect of a six-month Schroth PSSE intervention added to standard of care (Experimental group) on the Cobb angle compared to standard of care alone (Control group) in patients with AIS. METHODS: Fifty patients with AIS aged 10-18 years, with curves of 10 degrees -45 degrees and Risser grade 0-5 were recruited from a single pediatric scoliosis clinic and randomized to the Experimental or Control group. Outcomes included the change in the Cobb angles of the Largest Curve and Sum of Curves from baseline to six months. The intervention consisted of a 30-45 minute daily home program and weekly supervised sessions. Intention-to-treat and per protocol linear mixed effects model analyses are reported. RESULTS: In the intention-to-treat analysis, after six months, the Schroth group had significantly smaller Largest Curve than controls (-3.5 degrees , 95% CI -1.1 degrees to -5.9 degrees , p = 0.006). Likewise, the between-group difference in the square root of the Sum of Curves was -0.40 degrees , (95% CI -0.03 degrees to -0.8 degrees , p = 0.046), suggesting that an average patient with 51.2 degrees at baseline, will have a 49.3 degrees Sum of Curves at six months in the Schroth group, and 55.1 degrees in the control group with the difference between groups increasing with severity. Per protocol analyses produced similar, but larger differences: Largest Curve = -4.1 degrees (95% CI -1.7 degrees to -6.5 degrees , p = 0.002) and [Formula: see text] (95% CI -0.8 to 0.2, p = 0.006). CONCLUSION: Schroth PSSE added to the standard of care were superior compared to standard of care alone for reducing the curve severity in patients with AIS. TRIAL REGISTRATION: NCT01610908.
Chu WC
BACKGROUND: Patients with adolescent idiopathic scoliosis (AIS) frequently receive x-ray imaging at diagnosis and subsequent follow monitoring. The ionizing radiation exposure has accumulated through their development stage and the effect of radiation to this young vulnerable group of patients is uncertain. To achieve the ALARA (as low as reasonably achievable) concept of radiation dose in medical imaging, a slot-scanning x-ray technique by the EOS system has been adopted and the radiation dose using micro-dose protocol was compared with the standard digital radiography on patients with AIS. METHODS: Ninety-nine participants with AIS underwent micro-dose EOS and 33 underwent standard digital radiography (DR) for imaging of the whole spine. Entrance-skin dose was measured using thermoluminescent dosimeters (TLD) at three regions (i.e. dorsal sites at the level of sternal notch, nipple line, symphysis pubis). Effective dose and organ dose were calculated by simulation using PCXMC 2.0. Data from two x-ray systems were compared using independent-samples t-test and significance level at 0.05. All TLD measurements were conducted on PA projection only. Image quality was also assessed by two raters using Cobb angle measurement and a set of imaging parameters for optimization purposes. RESULTS: Entrance-skin dose from micro-dose EOS system was 5.9-27.0 times lower at various regions compared with standard DR. The calculated effective dose was 2.6 +/- 0.5 (muSv) and 67.5 +/- 23.3 (muSv) from micro-dose and standard DR, respectively. The reduction in the micro-dose was approximately 26 times. Organ doses at thyroid, lung and gonad regions were significantly lower in micro-dose (p < 0.001). Data were further compared within the different gender groups. Females received significantly higher (p < 0.001) organ dose at ovaries compared to the testes in males. Patients with AIS received approximately 16-34 times lesser organ dose from micro-dose x-ray as compared with the standard DR. There was no significant difference in overall rating of imaging quality between EOS and DR. Micro-dose protocol provided enough quality to perform consistent measurement on Cobb angle. CONCLUSIONS: Entrance-skin dose, effective dose and organ dose were significantly reduced in micro-dose x-ray. The effective dose of a single micro-dose x-ray (2.6 muSv) was less than a day of background radiation. As AIS patients require periodic x-ray follow up for surveillance of curve progression, clinical use of micro-dose x-ray system is beneficial for these young patients to reduce the intake of ionizing radiation.
Armstrong DG
STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine motivations for compliance with bracing among female patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Bracing prevents the need for surgery for the majority of girls with AIS with curves of 20 degrees to 40 degrees and 2 or more years of growth remaining. The main obstacle to success is compliance. The factors that either promote or impede compliance previously have not been fully clarified. METHODS: Participants were females 10 to 16 years of age who were prescribed a brace to be worn 16 hours per day for AIS. Each completed a "Scoliosis Compliance Questionnaire" composed of the SRS-22r and five original sections focused on patients' attitudes to scoliosis, situations in which they found wearing the brace to be most and least difficult, factors that motivate brace wear, and interventions that could potentially improve compliance. RESULTS: Thirty-nine subjects completed the study, mean age 13 years (range 11-15 years), at a mean of 15.4 months (range 4-39 months) of brace wear at the time of recruitment. More than 90% of patients stated that their main motivations for compliance were the desire to avoid surgery and to prevent curve progression. Compliance was most challenging during the summer and while at school. Many patients reported pain and skin irritation in the brace. The majority reported they would likely improve their hours of wear if they were able to communicate with a peer in the same situation. SRS-22r scores were similar to those of healthy adolescents. CONCLUSIONS: The most important influences promoting brace wear are the patient's desire to avoid surgery and to prevent curve progression. Peer support potentially may improve compliance. LEVEL OF EVIDENCE: Level III.
Berman BM
BACKGROUND: Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines state that exercise therapy may be beneficial. Yoga is a mind-body exercise sometimes used for non-specific low back pain. OBJECTIVES: To assess the effects of yoga for treating chronic non-specific low back pain, compared to no specific treatment, a minimal intervention (e.g. education), or another active treatment, with a focus on pain, function, and adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, five other databases and four trials registers to 11 March 2016 without restriction of language or publication status. We screened reference lists and contacted experts in the field to identify additional studies. SELECTION CRITERIA: We included randomized controlled trials of yoga treatment in people with chronic non-specific low back pain. We included studies comparing yoga to any other intervention or to no intervention. We also included studies comparing yoga as an adjunct to other therapies, versus those other therapies alone. DATA COLLECTION AND ANALYSIS: Two authors independently screened and selected studies, extracted outcome data, and assessed risk of bias. We contacted study authors to obtain missing or unclear information. We evaluated the overall certainty of evidence using the GRADE approach. MAIN RESULTS: We included 12 trials (1080 participants) carried out in the USA (seven trials), India (three trials), and the UK (two trials). Studies were unfunded (one trial), funded by a yoga institution (one trial), funded by non-profit or government sources (seven trials), or did not report on funding (three trials). Most trials used Iyengar, Hatha, or Viniyoga forms of yoga. The trials compared yoga to no intervention or a non-exercise intervention such as education (seven trials), an exercise intervention (three trials), or both exercise and non-exercise interventions (two trials). All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment assignment, and outcomes were self-assessed. Therefore, we downgraded all outcomes to 'moderate' certainty evidence because of risk of bias, and when there was additional serious risk of bias, unexplained heterogeneity between studies, or the analyses were imprecise, we downgraded the certainty of the evidence further.For yoga compared to non-exercise controls (9 trials; 810 participants), there was low-certainty evidence that yoga produced small to moderate improvements in back-related function at three to four months (standardized mean difference (SMD) -0.40, 95% confidence interval (CI) -0.66 to -0.14; corresponding to a change in the Roland-Morris Disability Questionnaire of mean difference (MD) -2.18, 95% -3.60 to -0.76), moderate-certainty evidence for small to moderate improvements at six months (SMD -0.44, 95% CI -0.66 to -0.22; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -2.15, 95% -3.23 to -1.08), and low-certainty evidence for small improvements at 12 months (SMD -0.26, 95% CI -0.46 to -0.05; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -1.36, 95% -2.41 to -0.26). On a 0-100 scale there was very low- to moderate-certainty evidence that yoga was slightly better for pain at three to four months (MD -4.55, 95% CI -7.04 to -2.06), six months (MD -7.81, 95% CI -13.37 to -2.25), and 12 months (MD -5.40, 95% CI -14.50 to -3.70), however we pre-defined clinically significant changes in pain as 15 points or greater and this threshold was not met. Based on information from six trials, there was moderate-certainty evidence that the risk of adverse events, primarily increased back pain, was higher in yoga than in non-exercise controls (risk difference (RD) 5%, 95% CI 2% to 8%).For yoga compared to non-yoga exercise controls (4 trials; 394 participants), there was very-low-certainty evidence for little or no difference in back-related function at three months (SMD -0.22, 95% CI -0.65 to 0.20; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.99, 95% -2.87 to 0.90) and six months (SMD -0.20, 95% CI -0.59 to 0.19; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.90, 95% -2.61 to 0.81), and no information on back-related function after six months. There was very low-certainty evidence for lower pain on a 0-100 scale at seven months (MD -20.40, 95% CI -25.48 to -15.32), and no information on pain at three months or after seven months. Based on information from three trials, there was low-certainty evidence for no difference in the risk of adverse events between yoga and non-yoga exercise controls (RD 1%, 95% CI -4% to 6%).For yoga added to exercise compared to exercise alone (1 trial; 24 participants), there was very-low-certainty evidence for little or no difference at 10 weeks in back-related function (SMD -0.60, 95% CI -1.42 to 0.22; corresponding to a change in the Oswestry Disability Index of MD -17.05, 95% -22.96 to 11.14) or pain on a 0-100 scale (MD -3.20, 95% CI -13.76 to 7.36). There was no information on outcomes at other time points. There was no information on adverse events.Studies provided limited evidence on risk of clinical improvement, measures of quality of life, and depression. There was no evidence on work-related disability. AUTHORS' CONCLUSIONS: There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance. It is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone. Yoga is associated with more adverse events than non-exercise controls, but may have the same risk of adverse events as other back-focused exercise. Yoga is not associated with serious adverse events. There is a need for additional high-quality research to improve confidence in estimates of effect, to evaluate long-term outcomes, and to provide additional information on comparisons between yoga and other exercise for chronic non-specific low back pain.
Hinman RS
OBJECTIVE: To evaluate whether interventions aimed at increasing adherence to therapeutic exercise increase adherence greater than a contextually equivalent control among older adults with chronic low back pain and/or hip/knee osteoarthritis. DESIGN: A systematic review and meta-analysis. DATA SOURCES: Five databases (MEDLINE (PubMed), CINAHL, SportDISCUS (EBSCO), Embase (Ovid) and Cochrane Library) were searched until 1 August 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials that isolated the effects of interventions aiming to improve adherence to therapeutic exercise among adults >/=45 years of age with chronic low back pain and/or hip/knee osteoarthritis were included. RESULTS: Of 3899 studies identified, nine studies (1045 participants) were eligible. Four studies, evaluating strategies that aimed to increase motivation or using behavioural graded exercise, reported significantly better exercise adherence (d=0.26-1.23). In contrast, behavioural counselling, action coping plans and/or audio/video exercise cues did not improve adherence significantly. Meta-analysis using a random effects model with the two studies evaluating booster sessions with a physiotherapist for people with osteoarthritis revealed a small to medium significant pooled effect in favour of booster sessions (standardised mean difference (SMD) 0.39, 95% CI 0.05 to 0.72, z=2.26, p=0.02, I(2)=35%). CONCLUSIONS: Meta-analysis provides moderate-quality evidence that booster sessions with a physiotherapist assisted people with hip/knee osteoarthritis to better adhere to therapeutic exercise. Individual high-quality trials supported the use of motivational strategies in people with chronic low back pain and behavioural graded exercise in people with osteoarthritis to improve adherence to exercise.
Bailey CS
OBJECTIVE The object of this study was to determine the association between postoperative sagittal spinopelvic alignment and patient-rated outcome measures following decompression and fusion for lumbar degenerative spondylolisthesis. METHODS The authors identified a consecutive series of patients who had undergone surgery for lumbar degenerative spondylolisthesis between 2008 and 2012, with an average follow-up of 3 years (range 1-6 years). Surgery was performed to address the clinical symptoms of spinal stenosis, not global sagittal alignment. Sagittal alignment was only assessed postoperatively. Patients were divided into 2 groups based on a postoperative sagittal vertical axis (SVA) < 50 mm (well aligned) or >/= 50 mm (poorly aligned). Baseline demographic, procedure, and outcome measures were compared between the groups. Postoperative outcome measures and postoperative spinopelvic parameters were compared between groups using analysis of covariance. RESULTS Of the 84 patients included in this study, 46.4% had an SVA < 50 mm. Multiple levels of spondylolisthesis (p = 0.044), spondylolisthesis at the L3-4 level (p = 0.046), and multiple levels treated with fusion (p = 0.028) were more common among patients in the group with an SVA >/= 50 mm. Patients with an SVA >/= 50 mm had a worse SF-36 physical component summary (PCS) score (p = 0.018), a worse Oswestry Disability Index (ODI; p = 0.043), and more back pain (p = 0.039) than those with an SVA < 50 mm after controlling for multiple levels of spondylolisthesis and multilevel fusion. The spinopelvic parameters differing between the < 50-mm and >/= 50-mm groups included lumbar lordosis (LL; 56.4 degrees +/- 4.7 degrees vs 49.8 degrees +/- 4.3 degrees , respectively, p = 0.040) and LL < pelvic incidence +/- 9 degrees (51% vs 23.1%, respectively, p = 0.013) after controlling for type of surgical procedure. CONCLUSIONS Data in this study revealed that patient-rated outcome is influenced by the overall postoperative sagittal balance as defined by the SVA.
Shapiro Y
Study Design Prospective, pragmatic, nonrandomized controlled clinical trial. Background Clinical guidelines recommend physical activity for the treatment of chronic low back pain. But engaging patients in physical activity has proven difficult. Known obstacles to physical activity include low self-efficacy and fear avoidance. Objectives This study tested the effectiveness of an enhanced transtheoretical model intervention (ETMI) aimed at increasing recreational physical activity in patients with chronic low back pain, in comparison to usual physical therapy. Methods Patients (n = 220) referred to physical therapy for chronic low back pain were allocated to ETMI or to a control group. The ETMI was delivered by physical therapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland-Morris Disability Questionnaire). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity. Results Intention-to-treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physical therapy. The difference in mean change from baseline between the interventions was 2.7 points (95% confidence interval: 0.9, 4.5) on the Roland-Morris Disability Questionnaire. At 12 months, worst pain, physical activity, and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for controls. Conclusion Targeting obstacles to physical activity with an intervention that includes components to address self-efficacy and fear avoidance appears to be more effective than usual physical therapy care in reducing long-term disability. Further research is needed to explore the mechanisms that impact outcomes in this intervention package. Level of Evidence Therapy, level 2b. Registered June 7, 2012 at ClinicalTrials.gov (NCT01631344). J Orthop Sports Phys Ther 2017;47(2):57-66. doi:10.2519/jospt.2017.7057.
Poenaru DV
INTRODUCTION: Osteoporotic vertebral fractures (OVF) can lead to late collapse which often causes kyphotic spinal deformity, persistent back pain, decreased lung capacity, increased fracture risk and increased mortality. The purpose of our study is to compare the efficacy and safety of vertebroplasty against conservative management of osteoporotic vertebral fractures without neurologic symptoms. MATERIAL AND METHODS: A total of 66 patients with recent OVF on MRI examination were included in the study. All patients were admitted from September 2009 to September 2012. The cohort was divided into two groups. The first study group consisted of 33 prospectively followed consecutive patients who suffered 40 vertebral osteoporotic fractures treated by percutaneous vertebroplasty (group 1), and the control group consisted of 33 patients who suffered 41 vertebral osteoporotic fractures treated conservatively because they refused vertebroplasty (group 2). The data collection has been conducted in a prospective registration manner. The inclusion criteria consisted of painful OVF matched with imagistic findings. We assessed the results of pain relief and minimal sagittal area of the vertebral body on the axial CT scan at presentation, after the intervention, at six and 12 months after initial presentation. RESULTS: Vertebroplasty with poly(methyl methacrylate) (PMMA) was performed in 30 patients on 39 VBs, including four thoracic vertebras, 27 vertebras of the thoracolumbar jonction and eight lumbar vertebras. Group 2 included 30 patients with 39 OVFs (four thoracic vertebras, 23 vertebras of the thoracolumbar junction and 11 lumbar vertebras). There was no significant difference in VAS scores before treatment (p = 0.229). The mean VAS was 5.90 in Group 1 and 6.28 in Group 2 before the treatment. Mean VAS after vertebroplasty was 0.85 in Group 1. The mean VAS at six months was 0.92 in Group 1 and 3.00 in Group 2 (p < 0.05). The mean VAS at 12 months was 0.92 in Group 1 and 2.36 in Group 2. The mean improvement rate in VAS scores was 84.40% and 62.42%, respectively (p < 0.05). For Group 1, mean area of the VBs measured on sagital CT images was 8.288 at the initial presentation, 8.554 postoperatively, 8.541 at five months and 8.508 at 12 months, respectively, and 8.388 at the initial presentation, 7.976 at six months and 7.585 at 12 months for Group 2 (Fig. 4). DISCUSSIONS: Although conservative treatment is fundamental and achieves good symptom control, in patients who suffer osteoporotic compression fractures (OCF), the incidence of late collapse is high and the prognosis is poor. In order to relieve the pain and avoid VB collapse, vertebroplasty is the recommended treatment in OCFs. Considering the above findings, the dilemma is whether vertebroplasty can change the natural history (pain and deformity) of OCFs. CONCLUSION: In our study on OVF, vertebroplasty delivered superior clinical and radiological outcomes over the first year from intervention when compared to conservative treatment of patients with osteoporotic compression fractures without neurological deficit. We believe that the possibility of evolution towards progressive kyphosis is sufficient to justify prophylactic and therapeutic intervention such as vertebroplasty, a minor gesture compared with extensive correction surgery and stabilization.
Matsumoto M
BACKGROUND: In addition to genetic factors, environmental and lifestyle factors are thought to play an important role in the onset of adolescent idiopathic scoliosis (AIS). This cross-sectional study was conducted to explore lifestyle factors related to AIS. METHODS: This study included 2,759 Japanese female junior high school students who planned a secondary screening after an initial moire topography screening indicated possible scoliosis. The students and their mothers, or guardians, were asked to fill out a questionnaire consisting of 38 questions about demographic factors, lifestyle-related factors, social factors, household environment, participation in sports, health status, and factors related to the mother's pregnancy and delivery. The questionnaire was completed by 2,747 students (a 99.6% response rate). After excluding students with heart disease, neurological disease, or a congenital vertebral anomaly, 2,600 students were eligible for assessment. After undergoing a secondary screening with standing radiographs of the spine, students were assigned to the normal (control) group if radiographs showed a curve of <15 degrees or to the scoliosis group if they had a curve of >/=15 degrees . The odds ratios (ORs) for AIS in relation to the possible risk or preventive factors were estimated by logistic regression analyses. RESULTS: No lifestyle-related factor was significantly associated with AIS. However, AIS was associated with classical ballet training (OR, 1.38; 95% confidence interval [CI], 1.09 to 1.75); the odds of AIS developing increased as the child's frequency of training, number of years of experience, and duration of training in ballet increased. The OR for AIS was 1.5 times higher for participants whose mothers had scoliosis. AIS was also associated with a low body mass index (BMI). These associations remained even after mutual adjustment was performed. CONCLUSIONS: No association was found between AIS and lifestyle-related factors. However, classical ballet training, a family history of scoliosis, and low BMI may be associated with AIS. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Shi L
Background: The link between body weight status and spinal diseases has been suggested by a number of cross-sectional and cohort studies with a limited range of patient populations. No population-representative samples have been used to examine the link between obesity and spinal diseases. The present study is based on a nationally representative sample drawn from the Medical Expenditure Panel Survey. Methods: Using the cross-sectional sample of the 2014 Medical Expenditure Panel Study, we built four weighted logistic regression analyses of the associations between body weight status and the following four spinal diseases: low back pain, spondylosis, other cervical disorders and intervertebral disc disorder (IDD). Each respondent's body weight status was used as the key independent variable with three categories: normal/underweight, overweight, and obese. We controlled for marital status, gender, age, smoking status, household income, health insurance coverage, educational attainment and the use of health services for other major categories of diseases. Results: A total sample of 23,048 respondents was used in our analysis. Overweight and obese respondents, as compared to normal/underweight respondents, were more likely to develop lower back problems (Overweight: logged odds = 0.218, p < 0.01; Obese: logged odds = 0.395, p < 0.001) and IDD (Overweight: logged odds = 0.441, p < 0.05; Obese: logged odds = 0.528, p < 0.001). The associations between bodyweight status and spondylitis were statistically insignificant (Overweight: logged odds = 0.281, p = 0.442; Obese: logged odds = 0.680, p = 0.104). The associations between body weight status and other cervical disorders (Overweight: logged odds = -0.116, p = 0.304; Obese: logged odds = -0.160, p = 0.865) were statistically insignificant. Conclusions: As the first study using a national sample to study bodyweight and spinal diseases, our paper supports the hypothesis that obesity adds to the burden of low back pain and IDD. Longitudinal and interventional studies are needed to understand the specific mechanisms behind these positive associations.
McCabe JP
BACKGROUND CONTEXT: Over the last decade, the emergence of social networking websites such as Facebook have revolutionized information dissemination and broadened opportunities to engage in discussions. In particular, having been widely adopted in the younger generation, the use of this medium has become more prevalent in health disorders such as scoliosis in the adolescent population. However, the quality of information on Facebook is unregulated and variable, which may mislead patients in their decision making. PURPOSE: To document the various types of information available and assess the quality of information on Facebook discussion boards using recognized scoring systems. STUDY DESIGN: To evaluate the quality of information on the social network. PATIENT SAMPLE: A search for the keyword "scoliosis" on Facebook was performed and the first 100 pages generated were reviewed. OUTCOMES MEASURED: SCSS and DISCERN score. METHODS: Content analysis was performed on discussion boards and personal blogs. Two independent examiners evaluated each site according to scoliosis-specific content score (SCSS) and the DISCERN criteria, both previously used instruments to judge the quality of information on the Internet pertaining to scoliosis. The SCSS range from 0 to 32 (higher score better) and the DISCERN 16 to 80 (higher score better). RESULTS: Of the 100 sites reviewed, 33 were discussion boards and personal blogs. Of these, the overall average SCSS was 5.7 (SD 5.8, range 0-20) and the DISCERN was 22.5 (SD 7.6, range 16-45), indicating that using general scoring systems the quality of information provided was overall poor. CONCLUSION: Using recognized scoring systems to analyze Facebook pages used as discussion forums or blogs, we showed that the quality in general was poor. For modern practices to adapt to an era of information exchange via the social network, the orthopedic community should develop ways to incorporate the social media in future patient education.
Sanders JO
BACKGROUND: Spondylolysis is common among the pediatric population, yet no formal systematic literature review regarding diagnostic imaging has been performed. The Scoliosis Research Society (SRS) requested an assessment of the current state of peer reviewed evidence regarding pediatric spondylolysis. METHODS: Literature was searched professionally and citations retrieved. Abstracts were reviewed and analyzed by the SRS Evidence-Based Medicine Committee. Level I studies were considered to provide Good Evidence for the clinical question. Level II or III studies were considered Fair Evidence. Level IV studies were considered Poor Evidence. From 947 abstracts, 383 full texts reviewed. Best available evidence for the questions of diagnostic methods was provided by 27 studies: no Level I sensitivity/specificity studies, five Level II and two Level III evidence, and 19 Level IV evidence. RESULTS: Pain with hyperextension in athletes is the most widely reported finding in history and physical examination. Plain radiography is considered a first-line diagnostic test for suspected spondylolysis, but validation evidence is lacking. There is consistent Level II and III evidence that pars defects are detected by advanced imaging in 32% to 44% of adolescents with spondylolysis based on history and physical. Level III evidence that single-photon emission computed tomography (SPECT) is superior to planar bone scan and plain radiographs but limited by high rates of false-positive and false-negative results and by high radiation dose. Computed tomography (CT) is considered the gold standard and most accurate modality for detecting the bony defect and assessment of osseous healing but exposes the pediatric patient to ionizing radiation. Magnetic resonance imaging (MRI) is reported to be as accurate as CT and useful in detecting early stress reactions of the pars without a fracture. CONCLUSION: Plain radiographs are widely used as screening tools for pediatric spondylolysis. CT scan is considered the gold standard but exposes the patient to a significant amount of ionizing radiation. Evidence is fair and promising that MRI is comparable to CT.
Zhu Z
OBJECTIVE: To investigate whether posterior fossa decompression (PFD) could improve denervation of the paraspinal muscles in patients with Chiari I malformation (CMI). BACKGROUND: Paraspinal muscle denervation is one of the essential elements in the pathophysiology of CMI/syringomyelia-related scoliosis. Although PFD has been widely used for managing CMI, whether denervation of the paraspinal muscles may benefit from this neurosurgical procedure remains ambiguous. Bax and Bcl-2 are two regulators of apoptosis that are closely related to the innervation status of skeletal muscles, and denervation is associated with upregulated Bax and downregulated Bcl-2. METHODS: Thirty-seven patients who underwent PFD and subsequent deformity correction for CMI-associated scoliosis were enrolled. Biopsy specimens were obtained from bilateral erector spinae muscles during both procedures with an average interval of 6.5 months. The biopsy site was located within the spinal innervation region involved by the syrinx and near the level of upper instrumented vertebra. The expression levels of Bax and Bcl-2 as well as histological features of the muscle fibres were examined at the two time points. RESULTS: After PFD, the mRNA level of antiapoptotic Bcl-2 was elevated by 178% and 260% in the convex and concave muscles, respectively, with a coincident decrease of 69% and 73% for proapoptotic Bax at the corresponding sites (p<0.001). Consistent with the mRNA data, the Bcl-2 protein in the paraspinal muscles was increased by 75% on the convex and by 169% on the concave side following PFD. For Bax protein, decreases of 45% and 52% were detected in the convex and concave muscles, respectively (p<0.001). On average, these changes led to a 60% decrease in the Bax/Bcl-2 ratio, suggesting reduced apoptotic signalling and improved innervation of the paraspinal muscles. Histologically, the specimens demonstrated improvements in denervation-associated changes of the muscle fibres following PFD, with the number of atrophic and necrotic/degenerated fibres decreasing significantly from 6.7 and 8.5 before surgery to 3.2 (p=0.012) and 4.2 (p<0.001) after surgery, respectively. CONCLUSION: In patients with CMI, treatment with PFD led to a decrease in the Bax/Bcl-2 ratio at both the mRNA and protein levels, indicating an attenuated susceptibility to apoptotic cell death. These data, coupled with the observed improvements in histopathological features of the myofibres, suggest that PFD in Chiari I ameliorates denervation of the paraspinal muscles.
Bartels RHMA
OBJECTIVE Although there is increasing recognition of the importance of cervical spinal sagittal balance, there is a lack of consensus as to the optimal method to accurately assess the cervical sagittal alignment. Cervical alignment is important for surgical decision making. Sagittal balance of the cervical spine is generally assessed using one of two methods; namely, measuring the angle between C-2 and C-7, and drawing a line between C-2 and C-7. Here, the best method to assess sagittal alignment of the cervical spine is investigated. METHODS Data from 138 patients enrolled in a randomized controlled trial (Procon) were analyzed. Two investigators independently measured the angle between C-2 and C-7 by using Harrison's posterior tangent method, and also estimated the shape of the sagittal curve by using a modified Toyama method. The mean angles of each quantitative assessment of the sagittal alignment were calculated and the results were compared. The interrater reliability for both methods was estimated using Cronbach's alpha. RESULTS For both methods the interrater reliability was high: for the posterior tangent method it was 0.907 and for the modified Toyama technique it was 0.984. For a lordotic cervical spine, defined by the modified Toyama method, the mean angle (defined by Harrison's posterior tangent method) was 23.4 degrees +/- 9.9 degrees (range 0.4 degrees -52.4 degrees ), for a kyphotic cervical spine it was -2.2 degrees +/- 9.2 degrees (range -16.1 degrees to 16.9 degrees ), and for a straight cervical spine it was 10.5 degrees +/- 8.2 degrees (range -11 degrees to 36 degrees ). CONCLUSIONS An absolute measurement of the angle between C-2 and C-7 does not unequivocally define the sagittal cervical alignment. As can be seen from the minimum and maximum values, even a positive angle between C-2 and C-7 could be present in a kyphotic spine. For this purpose, the modified Toyama method (drawing a line from the posterior inferior part of the vertebral body of C-2 to the posterior upper part of the vertebral body of C-7 without any measurements) is a better tool for a global assessment of cervical sagittal alignment. Clinical trial registration no.: ISRCTN41681847 ( https://www.isrctn.com ).
Hancock MJ
BACKGROUND: Low back pain (LBP) in older adults is poorly understood because the vast majority of the LBP research has focused on the working aged population. The aim of this study was to compare older adults consulting with chronic LBP to middle aged and young adults consulting with chronic LBP, in terms of their baseline characteristics, and pain and disability outcomes over 1 year. METHODS: Data were systematically collected as part of routine care in a secondary care spine clinic. At initial presentation patients answered a self-report questionnaire and underwent a physical examination. Patients older than 65 were classified as older adults and compared to middle aged (45-65 years old) and younger adults (17-44 years old) for 10 baseline characteristics. Pain intensity and disability were collected at 6 and 12 month follow-ups and compared between age groups. RESULTS: A total of 14,479 participants were included in the study. Of these 3087 (21%) patients were older adults, 6071 (42%) were middle aged and 5321 (37%) were young adults. At presentation older adults were statistically different to the middle aged and younger adults for most characteristics measured (e.g. less intense back pain, more leg pain and more depression); however, the differences were small. The change in pain and disability over 12 months did not differ between age groups. CONCLUSIONS: This study found small baseline differences in older people with chronic LBP compared to middle aged and younger adults. There were no associations between age groups and the clinical course. SIGNIFICANCE: Small baseline differences exist in older people with chronic low back pain compared to middle aged and younger adults referred to secondary care for chronic low back pain. Older adults present with slightly less intense low back pain but slightly more intense leg pain. Changes in pain intensity and disability over a 12 month period were similar across all age groups.
Lin CC
BACKGROUND: Sciatica can be disabling, and evidence regarding medical treatments is limited. Pregabalin is effective in the treatment of some types of neuropathic pain. This study examined whether pregabalin may reduce the intensity of sciatica. METHODS: We conducted a randomized, double-blind, placebo-controlled trial of pregabalin in patients with sciatica. Patients were randomly assigned to receive either pregabalin at a dose of 150 mg per day that was adjusted to a maximum dose of 600 mg per day or matching placebo for up to 8 weeks. The primary outcome was the leg-pain intensity score on a 10-point scale (with 0 indicating no pain and 10 the worst possible pain) at week 8; the leg-pain intensity score was also evaluated at week 52, a secondary time point for the primary outcome. Secondary outcomes included the extent of disability, back-pain intensity, and quality-of-life measures at prespecified time points over the course of 1 year. RESULTS: A total of 209 patients underwent randomization, of whom 108 received pregabalin and 101 received placebo; after randomization, 2 patients in the pregabalin group were determined to be ineligible and were excluded from the analyses. At week 8, the mean unadjusted leg-pain intensity score was 3.7 in the pregabalin group and 3.1 in the placebo group (adjusted mean difference, 0.5; 95% confidence interval [CI], -0.2 to 1.2; P=0.19). At week 52, the mean unadjusted leg-pain intensity score was 3.4 in the pregabalin group and 3.0 in the placebo group (adjusted mean difference, 0.3; 95% CI, -0.5 to 1.0; P=0.46). No significant between-group differences were observed with respect to any secondary outcome at either week 8 or week 52. A total of 227 adverse events were reported in the pregabalin group and 124 in the placebo group. Dizziness was more common in the pregabalin group than in the placebo group. CONCLUSIONS: Treatment with pregabalin did not significantly reduce the intensity of leg pain associated with sciatica and did not significantly improve other outcomes, as compared with placebo, over the course of 8 weeks. The incidence of adverse events was significantly higher in the pregabalin group than in the placebo group. (Funded by the National Health and Medical Research Council of Australia; PRECISE Australian and New Zealand Clinical Trials Registry number, ACTRN12613000530729 .).
Rodondi PY
BACKGROUND: Chronic pain patients often use complementary medicine (CM) to alleviate their pain; however, little is known about the use of CM by chronic low back pain (cLBP) patients. We investigated the frequency of use of CM by cLBP patients, the perceived effects of these therapies, patients' knowledge regarding CM, and patient-physician communication regarding CM. METHOD: A cross-sectional survey was conducted from November 2014 to February 2015. A questionnaire was distributed by physicians to 238 consecutive patients consulting for cLBP at the Pain Center of Lausanne University Hospital, Switzerland. Poisson regression model was used to analyze patients' level of knowledge regarding various CMs, and the logistic regression model was used to assess CM use for cLBP. RESULTS: The questionnaire was returned by 168 cLBP patients (response rate: 70.6%). Lifetime prevalence of CM use for cLBP was 77.3%. The most commonly used therapies were osteopathy (48.8%), massage (45.2%) and acupuncture (31.6%), rated for their usefulness on a 0-10 scale as a mean +/- SD of 5.4 +/- 2.7, 5.9 +/- 2.5 and 3.8 +/- 3.2, respectively. The CM treatment best known by patients was osteopathy, followed by massage and acupuncture. If their doctors proposed CM as a treatment for cLBP, 78% of participants reported being very or somewhat likely to try CM. Respondents with CM health insurance were more likely to use CM (OR = 2.26; 95%CI: 1.07-4.78; p = 0.031) for cLBP. Respondents having experienced cLBP for more than five years were more likely to use CM to treat their cLBP than respondents having experienced cLBP for one year or less (OR = 2.84; 95%CI: 1.02-7.88; p = 0.044). CONCLUSIONS: More than three-quarters of cLBP patients in our sample did use CM to treat their cLBP. The results showed that the most commonly used therapies were not necessarily the highest rated in terms of perceived usefulness. These results highlight the importance of developing integrative pain centers in which patients may obtain advice regarding CM treatments.
Meeus M
Background: To date, a clear differentiation of disability, cognitive deficits, and central sensitization between chronic neck pain of a traumatic nature and that of a nontraumatic nature is lacking. Objective: This study aimed to examine differences in disability, cognitive deficits, and central sensitization between women with traumatic and idiopathic (nontraumatic) chronic neck pain and women who were healthy. In addition, interrelationships among these variables were investigated. Design: This was a case-control study. Methods: Ninety-five women (28 women who were healthy [controls], 35 women with chronic idiopathic neck pain [CINP], and 32 women with chronic whiplash-associated disorders [CWAD] [traumatic]) were enrolled in the study. First, all participants completed standardized questionnaires to investigate pain-related disability and health-related quality of life. Next, cognitive performance was assessed. Finally, pressure pain thresholds and conditioned pain modulation were examined to investigate central sensitization. Results: Pain-related disability, reduced health-related quality of life, and cognitive deficits were present in participants with CWAD and, to a significantly lesser extent, in participants with CINP. Local hyperalgesia was demonstrated in participants with CWAD and CINP but not in women who were healthy. However, distant hyperalgesia and decreased conditioned pain modulation efficacy were shown only in participants with CWAD; this result is indicative of the presence of central sensitization. Moderate to strong Spearman correlations (rho=.456-.701) among disability, cognitive deficits, and hyperalgesia (local and distant) were observed in participants with CWAD. In participants with CINP, only local hyperalgesia and subjective cognitive deficits were moderately (rho=.463) correlated. Limitations: No conclusions about the causality of the observed correlations can be drawn. Conclusions: This innovative research revealed important differences between women with CWAD and women with CINP and thus provided evidence of the clinical importance of distinguishing the assessment and rehabilitation approaches for both pain conditions.
Angulo-Barroso R
BACKGROUND: Chronic low back pain (CLBP) has been associated with altered trunk muscle responses as well as increased muscle fatigability. CLBP patients and fatigued healthy subjects could experience similar neuromuscular strategies to attempt to protect the spine. The current study examined muscle activation differences between healthy and CLBP subjects following a perturbation. In addition, the possible role of muscle fatigue was evaluated by investigating the healthy control subjects in a non-fatigued and a fatigued condition. Both experiments were combined to evaluate possible similar strategies between CLBP and fatigued samples. METHODS: Cross-sectional study where 24 CLBP subjects and 26 healthy subjects were evaluated. Both groups (CLBP vs. healthy) and both conditions (non-fatigued and a fatigued condition) were evaluated while a weight was suddenly dropped on a held tray. Erector spinae, multifidus, obliques and biceps brachii were recorded using surface electromyography. Variables describing the bursts timing and variables describing the amount of muscle activity (number of bursts and amplitude increase) post impact were studied. The analysis between groups and conditions was carried out using ANOVAs with repeated measurements for the muscle factor. RESULTS: CLBP subjects reacted similarly to healthy subjects regarding muscle activity post impact. However, the CLBP group showed temporal characteristics of muscle activity that were in between the fatigued and non-fatigued healthy group. Clear differences in muscle activity were displayed for healthy subjects. Fatigued healthy subjects presented more reduced activity after impact (upper limb and trunk muscles) than non-fatigued healthy subjects and different temporal characteristic in the same way than CLBP patients. This same temporal characteristic with CLBP and healthy fatigued people was a delay of the first burst of muscle activity after impact. CONCLUSION: Though similar muscle pattern existed between CLBP and healthy people, CLBP temporal characteristics of muscle activity showed a pattern in between healthy people and fatigued healthy people. While the temporal muscle pattern dysfunction used by CLBP subjects could be related to maladaptive patterns, temporal and muscle activity characteristics used by healthy fatigued people may lead to back injuries.
Pelaez CA
BACKGROUND: Older adults represent a growing proportion of trauma patients treated in the United States, and cervical spine (c-spine) fracture is an injury that is increasingly common in this population. Neck pain is a major component of current clinical clearance guidelines, but some older adults with c-spine fractures report no neck pain after injury. The objective of this study was to investigate the frequency at which c-spine fractures were unassociated with neck pain in an aging population. METHODS: A retrospective review was performed for patients 55 years or older with a c-spine fracture during a 4-year study period. All patients had a Glasgow Coma Scale score of 15 and were considered asymptomatic if they did not complain of neck pain on initial presentation, denied tenderness to palpation of the c-spine on examination, and were without neurologic deficit. Differences between groups were assessed with Kruskal-Wallis and chi tests. RESULTS: Of 173 patients with c-spine fractures, 36 (21%) were asymptomatic and reported no neck pain on presentation or on examination. The group without neck pain had higher median injury severity scores (15 vs 10; p < 0.001), were more likely to have another injured body region (69% vs 42%; p = 0.004), and had longer hospitalization (7 vs 5 days; p = 0.008) than patients with neck pain. Twenty-two percent of the symptomatic group and 19% of the asymptomatic group required halo, fusion, or other surgical intervention. DISCUSSION: Study results indicate that one fifth of patients with a c-spine fracture reported no pain on initial presentation and denied tenderness to palpation on examination. The presence or absence of pain may be an unreliable indicator of c-spine fracture in an aging population. When used in conjunction with existing clearance guidelines, denial of pain may lead to missed injury. We recommend liberal c-spine imaging for older trauma patients with significant mechanism of trauma. LEVEL OF EVIDENCE: Therapeutic study, level III.
Cramer H
Background: Mindfulness-based stress reduction (MBSR) is frequently used to treat pain-related conditions, but its effects on low back pain are uncertain. Purpose: To assess the efficacy and safety of MBSR in patients with low back pain. Data Sources: Searches of MEDLINE/PubMed, Scopus, the Cochrane Library, and PsycINFO to 15 June 2016. Study Selection: Randomized controlled trials (RCTs) that compared MBSR with usual care or an active comparator and assessed pain intensity or pain-related disability as a primary outcome in patients with low back pain. Data Extraction: Two reviewers independently extracted data on study characteristics, patients, interventions, outcome measures, and results at short- and long-term follow-up. Risk of bias was assessed using the Cochrane risk-of-bias tool. Data Synthesis: Seven RCTs involving 864 patients with low back pain were eligible for review. Compared with usual care, MBSR was associated with short-term improvements in pain intensity (4 RCTs; mean difference [MD], -0.96 point on a numerical rating scale [95% CI, -1.64 to -0.34 point]; standardized mean difference [SMD], -0.48 point [CI, -0.82 to -0.14 point]) and physical functioning (2 RCTs; MD, 2.50 [CI, 0.90 to 4.10 point]; SMD, 0.25 [CI, 0.09 to 0.41 point]) that were not sustained in the long term. Between-group differences in disability, mental health, pain acceptance, and mindfulness were not significant at short- or long-term follow-up. Compared with an active comparator, MBSR was not associated with significant differences in short- or long-term outcomes. No serious adverse events were reported. Limitation: The number of eligible RCTs was limited; only 3 evaluated MBSR against an active comparator. Conclusion: Mindfulness-based stress reduction may be associated with short-term effects on pain intensity and physical functioning. Long-term RCTs that compare MBSR versus active treatments are needed in order to best understand the role of MBSR in the management of low back pain. Primary Funding Source: None.
Wang ZY
BACKGROUND: Whether brace-treated adolescents with idiopathic scoliosis (AIS) have improved quality of life (QoL) is still unknown. Thus, we conducted a meta-analysis to compare the QoL of brace-treated AIS patients with untreated AIS patients. The pain, self-image/appearance, mental health, function/activity, satisfaction with management, total score without satisfaction, and total score of patients were used to measure the QoL after the intervention. METHODS: Multiple electronic databases including PubMed, Web of Science, and Embase were searched for all years up to June 30, 2016. Articles in English that used the Scoliosis Research Society-22 (SRS-22) or a modified version of the SRS-22 questionnaire to evaluate the QoL differences between brace-treated AIS patients and untreated AIS patients were included in the meta-analysis. The Newcastle-Ottawa Scale was used in the quality of literature evaluation. The pooled standardized mean difference (SMD) with its corresponding 95% confidence interval (CI) for each parameter was computed. Egger test and Begg test were used to test for publication bias. RESULTS: The SRS-22 or a modified SRS-22 questionnaire was used to evaluate the QoL after surgery. There was no significant difference in pain (SMD = 0.123, 95% CI: -0.101 to 0.347, P = .282), self-image/appearance (SMD = 0.108, 95% CI: -0.116 to 0.332, P = .334), mental health (SMD = 0.031, 95% CI: -0.130 to 0.201, P = .365), function/activity (SMD = 0.202, 95% CI: -0.022 to 0.425, P = .077), and total score without satisfaction (SMD = 0.123, 95% CI: -0.232 to 0.478, P = .497) between the untreated (observation) and brace-treated AIS patients, whereas a significant difference was observed in satisfaction with management (SMD = 0.393, 95% CI: 0.127-0.659, P = .004) and total score (SMD = 0.312, 95% CI: 0.054-0.571, P = .018) between the 2 groups. CONCLUSION: Our meta-analysis indicated that brace-treated AIS patients had a higher QoL. However, further analysis could not be performed because of insufficient data, such that we were unable to make subgroup analysis of QoL for different types of AIS and the therapeutic methods chosen by brace-treated AIS patients.
Meeus M
BACKGROUND: The impairment in musculoskeletal structures in patients with low back pain (LBP) is often disproportionate to their complaint. Therefore, the need arises for exploration of alternative mechanisms contributing to the origin and maintenance of non-specific LBP. The recent focus has been on central nervous system phenomena in LBP and the pathophysiological mechanisms underlying the various symptoms and characteristics of chronic pain. Knowledge concerning changes in pain processing in LBP remains ambiguous, partly due to the diversity in the LBP population. OBJECTIVE: The purpose of this study is to compare quantitative sensory assessment in different groups of LBP patients with regard to chronicity. Recurrent low back pain (RLBP), mild chronic low back pain (CLBP), and severe CLBP are compared on the one hand with healthy controls (HC), and on the other hand with fibromyalgia (FM) patients, in which abnormal pain processing has previously been reported. STUDY DESIGN: Cross-sectional study. SETTING: Department of Rehabilitation Sciences, Ghent University, Belgium. METHODS: Twenty-three RLBP, 15 mild CLBP, 16 severe CLBP, 26 FM, and 21 HC participated in this study. Quantitative sensory testing was conducted by manual pressure algometry and computer-controlled cuff algometry. A manual algometer was used to evaluate hyperalgesia as well as temporal summation of pain and a cuff algometer was used to evaluate deep tissue hyperalgesia, the efficacy of the conditioned pain modulation and spatial summation of pain. RESULTS: Pressure pain thresholds by manual algometry were significantly lower in FM compared to HC, RLBP, and severe CLBP. Temporal summation of pain was significantly higher in FM compared to HC and RLBP. Pain tolerance thresholds assessed by cuff algometry were significantly lower in FM compared to HC and RLBP and also in severe CLBP compared to RLBP. No significant differences between groups were found for spatial summation or conditioned pain modulation. LIMITATIONS: No psychosocial issues were taken into account for this study. CONCLUSION: The present results suggest normal pain sensitivity in RLBP, but future research is needed. In mild and severe CLBP some findings of altered pain processing are evident, although to a lesser extent compared to FM patients. In conclusion, mild and severe CLBP presents within a spectrum, somewhere between completely healthy persons and FM patients, characterized by pain augmentation.
Dewan MC, Mummareddy N, Bonfield C
PURPOSE: The study's aim was to address three fundamental questions related to pregnancy and adolescent idiopathic scoliosis (AIS), and provide clinically applicable answers to spine specialists and general practitioners alike. METHODS: The authors performed a systematic literature review using MEDLINE, EMBASE, Google Scholar, and Cochrane Database of Systematic Reviews to identify articles published between 1980 and 2015 that described pregnancy-related characteristics and outcomes in AIS patients. The search was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and evidence was classified according to the Oxford CEBM (Centre for Evidence-Based Medicine) appraisal tool. RESULTS: Twenty-two articles incorporating more than 3125 AIS patients were included. All studies concluded level 2b evidence or lower. iparity rates were slightly higher among AIS patients, and more frequent infertility treatment was required. Pregnancy-related back pain was common, and while non-disabling, may have been more severe than in healthy women. Minor curve progression often occurred during pregnancy, though its permanence was questioned and significance unknown. Back pain and curve progression occurred independent of AIS treatment modality. With modern technology, anesthetic and obstetric complications in the perinatal period were not elevated in AIS mothers. CONCLUSIONS: Women with AIS experience slightly elevated rates of iparity, infertility treatment, prepartum back pain, and peripartum curve progression. However, most women are able to have children and are not at increased risk of pregnancy-related complications. Higher quality evidence is needed to better define these relationships and allow more guided counseling and treatment.
Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW
Importance: Radiofrequency denervation is a commonly used treatment for chronic low back pain, but high-quality evidence for its effectiveness is lacking. Objective: To evaluate the effectiveness of radiofrequency denervation added to a standardized exercise program for patients with chronic low back pain. Design, Setting, and Participants: Three pragmatic multicenter, nonblinded randomized clinical trials on the effectiveness of minimal interventional treatments for participants with chronic low back pain (Mint study) were conducted in 16 multidisciplinary pain clinics in the Netherlands. Eligible participants were included between January 1, 2013, and October 24, 2014, and had chronic low back pain, a positive diagnostic block at the facet joints (facet joint trial, 251 participants), sacroiliac joints (sacroiliac joint trial, 228 participants), or a combination of facet joints, sacroiliac joints, or intervertebral disks (combination trial, 202 participants) and were unresponsive to conservative care. Interventions: All participants received a 3-month standardized exercise program and psychological support if needed. Participants in the intervention group received radiofrequency denervation as well. This is usually a 1-time procedure, but the maximum number of treatments in the trial was 3. Main Outcomes and Measures: The primary outcome was pain intensity (numeric rating scale, 0-10; whereby 0 indicated no pain and 10 indicated worst pain imaginable) measured 3 months after the intervention. The prespecified minimal clinically important difference was defined as 2 points or more. Final follow-up was at 12 months, ending October 2015. Results: Among 681 participants who were randomized (mean age, 52.2 years; 421 women [61.8%], mean baseline pain intensity, 7.1), 599 (88%) completed the 3-month follow-up, and 521 (77%) completed the 12-month follow-up. The mean difference in pain intensity between the radiofrequency denervation and control groups at 3 months was -0.18 (95% CI, -0.76 to 0.40) in the facet joint trial; -0.71 (95% CI, -1.35 to -0.06) in the sacroiliac joint trial; and -0.99 (95% CI, -1.73 to -0.25) in the combination trial. Conclusions and Relevance: In 3 randomized clinical trials of participants with chronic low back pain originating in the facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks, radiofrequency denervation combined with a standardized exercise program resulted in either no improvement or no clinically important improvement in chronic low back pain compared with a standardized exercise program alone. The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources. Trial Registration: trialregister.nl Identifier: NTR3531.
Passias PG, Jalai CM, Line BG, Poorman GW, Scheer JK, Smith JS, Shaffrey CI, Burton DC, Fu KG, Klineberg EO, Hart RA, Schwab F, Lafage V, Bess S
BACKGROUND CONTEXT: Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. PURPOSE: This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. STUDY DESIGN/SETTING: A retrospective review was carried out. PATIENT SAMPLE: A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. OUTCOME MEASURES: Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. METHODS: Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). RESULTS: Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9 degrees vs. 3.1 degrees , p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI>/=40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI>/=40 (OR: 5.57, p=.007) were at increased crossover risk. CONCLUSIONS: High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings.
Kyrola K, Repo J, Mecklin JP, Ylinen J, Kautiainen H, Hakkinen A
STUDY DESIGN: Cross-sectional, observational study. OBJECTIVE: To study the occurrence of sagittal malalignment, the adaptability of a simplified sagittal modifiers grading of the Scoliosis Research Society (SRS)-Schwab adult spinal deformity classification (ASD), and the deformity-specific SRS questionnaire version 30 (SRS-30) in an unselected adult cohort with symptomatic degenerative spinal disorders. SUMMARY OF BACKGROUND DATA: The sagittal modifiers of the SRS-Schwab ASD classification correlate with health-related quality of life (HRQoL) measures in patients with ASD. The deformities and disabilities caused by sagittal malalignment in patients with common degenerative spinal disorders of multiple etiologies are rarely studied. A simplified and categorizing version of the SRS-Schwab ASD classification in relation to the Oswestry Disability Index (ODI) and the SRS-30 outcomes has not yet been developed. METHODS: We recruited 874 consecutive patients with degenerative spinal disorders between March 2013 and February 2014. Full spine radiographs were taken and the patients divided into sagittal deformity severity groups: mild or none, moderate, and marked deformity. Participants completed the ODI, SRS-30, and a general health questionnaire. RESULTS: We included 637 patients in the analysis. The severity of sagittal deformity was mild or none in 407 (63.9%) patients, moderate in 159 (25.0%), and marked in 71 (11.1%). Linearity across the modifier grades and deformity classes was found for ODI total score (p = 0.033), and the function/activity (p = 0.004) and self-image/appearance (p = 0.030) domains of the SRS-30. Age, body mass index, duration of symptoms, and the use of painkillers increased while physical activity, working, and educational status decreased significantly with deformity severity. CONCLUSIONS: Sagittal spinopelvic malalignment is significantly related to deterioration of the ODI and the SRS-30 in symptomatic adults with degenerative spinal disorders. The SRS-Schwab classification sagittal modifiers categorized into 3 groups is a practical tool to detect various clinically significant grades of deformity in a cohort with no recognized ASD. LEVEL OF EVIDENCE: 3.
Cobetto N, Aubin CE, Parent S, Barchi S, Turgeon I, Labelle H
BACKGROUND: Recent studies showed that finite element model (FEM) combined to CAD/CAM improves the design of braces for the conservative treatment of adolescent idiopathic scoliosis (AIS), using 2D measurements from in-brace radiographs. We aim to assess the immediate effectiveness on curve correction in all three planes of braces designed using CAD/CAM and numerical simulation compared to braces designed with CAD/CAM only. METHODS: SRS standardized criteria for bracing were followed to recruit 48 AIS patients who were randomized into two groups. For both groups, 3D reconstructions of the spine and patient's torso, respectively built from bi-planar radiographs and surface topography, were obtained and braces were designed using the CAD/CAM approach. For the test group, 3D reconstructions of the spine and patient's torso were additionally used to generate a personalized FEM to simulate and iteratively improve the brace design with the objective of curve correction maximization in three planes and brace material minimization. RESULTS: For the control group (CtrlBraces), average Cobb angle prior to bracing was 29 degrees (thoracic, T) and 25 degrees (lumbar, L) with the planes of maximal curvature (PMC) respectively oriented at 63 degrees and 57 degrees on average with respect to the sagittal plane. Average apical axial rotation prior to bracing was 7 degrees (T) and 9 degrees (L). For the test group (FEMBraces), initial Cobb angles were 33 degrees (T) and 28 degrees (L) with the PMC at 68 degrees (T) and 56 degrees (L) and average apical axial rotation prior to bracing at 9 degrees (T and L). On average, FEMBraces were 50% thinner and had 20% less covering surface than CtrlBraces while reducing T and L curves by 47 and 48%, respectively, compared to 25 and 26% for CtrlBraces. FEMBraces corrected apical axial rotation by 46% compared to 30% for CtrlBraces. CONCLUSION: The combination of numerical simulation and CAD/CAM approach allowed designing more efficient braces in all three planes, with the advantages of being lighter than standard CAD/CAM braces. Bracing in AIS may be improved in 3D by the use of this simulation platform. This study is ongoing to recruit more cases and to analyze the long-term effect of bracing. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02285621.
Lou EH, Hill DL, Donauer A, Tilburn M, Hedden D, Moreau M
BACKGROUND: Four factors have been reported to affect brace treatment outcome: (1) growth or curve based risk, (2) the in-brace correction, (3) the brace wear quantity, and (4) the brace wear quality. The quality of brace design affects the in-brace correction and comfort which indirectly affects the brace wear quantity and quality. This paper reported the immediate benefits and results on using ultrasound (US) to aid orthotists to design braces for the treatment of scoliosis. METHODS: Thirty-four AIS subjects participated in this study with 17 (2 males, 15 females) in the control group and 17 (2 males, 15 females) in the intervention (US) group. All participants were prescribed full time TLSO, constructed by either of the 2 orthotists in fabrication of spinal braces. For the control group, the Providence brace design system was adopted to design full time braces. For the intervention group, the custom standing Providence brace design system, plus a medical ultrasound system, a custom pressure measurement system and an in-house software were used to assist brace casting. RESULTS: In the control group, 8 of 17 (47%) subjects needed a total of 11 brace adjustments after initial fabrication requiring a total of 28 in-brace radiographs. Three subjects (18%) required a second adjustment. For the US group, only 1 subject (6%) required adjustment. The total number of in-brace radiographs was 18. The p value of the chi-square for requiring brace adjustment was 0.006 which was a statistically significant difference between the two groups. In the intervention group, the immediate in-brace correction as measured from radiographs was 48 +/- 17%, and in the control group the first and second in-brace correction was 33 +/- 19% and 40 +/- 20%, respectively. The unpaired 2 sided Student's t test of the in-brace correction was significantly different between the US and the first follow-up of the control group (p = 0.02), but was not significant after the second brace adjustment (p = 0.22). CONCLUSIONS: The use of the 3D ultrasound system provided a radiation-free method to determine the optimum pressure level and location to assist brace design, resulting in decreased radiation exposure during follow-up brace evaluation, increased the in-brace correction, reduced the patients' visits to both brace adjustment and scoliosis clinics. However, the final outcomes could not be reported yet as some of patients are still under brace treatment. TRIAL REGISTRATION: NCT02996643, retrospectively registered in 16 December 2016.
Shanthanna H, Gilron I, Rajarathinam M, AlAmri R, Kamath S, Thabane L, Devereaux PJ, Bhandari M
BACKGROUND AND OBJECTIVE: Chronic Low Back Pain (CLBP) is very common, with a lifetime prevalence between 51% and 80%. In majority, it is nonspecific in nature and multifactorial in etiology. Pregabalin (PG) and Gabapentin (GB) are gabapentinoids that have demonstrated benefit in neuropathic pain conditions. Despite no clear rationale, they are increasingly used for nonspecific CLBP. They necessitate prolonged use and are associated with adverse effects and increased cost. Recent guidelines from the National Health Service (NHS), England, expressed concerns on their off-label use, in addition to the risk of misuse. We aimed to assess the effectiveness and safety of gabapentinoids in adult CLBP patients. METHODS: Electronic databases of MEDLINE, EMBASE, and Cochrane were searched from their inception until December 20th, 2016. We included randomized control trials reporting the use of gabapentinoids for the treatment of CLBP of >3 months duration, in adult patients. Study selection and data extraction was performed independently by paired reviewers. Outcomes were guided by Initiative on Methods, Measurement and Pain Assessment in Clinical Trials guidelines, with pain relief and safety as the primary outcomes. Meta-analyses were performed for outcomes reported in 3 or more studies. Outcomes were reported as mean differences (MDs) or risk ratios (RRs) with their corresponding 95% confidence intervals (CIs), and I2 in percentage representing the percentage variability in effect estimates that could be explained by heterogeneity. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to assess the quality of evidence. RESULTS: Out of 1,385 citations, eight studies were included. Based on the interventions and comparators, studies were analyzed in 3 different groups. GB compared with placebo (3 studies, n = 185) showed minimal improvement of pain (MD = 0.22 units, 95% CI [-0.5 to 0.07] I2 = 0%; GRADE: very low). Three studies compared PG with other types of analgesic medication (n = 332) and showed greater improvement in the other analgesic group (MD = 0.42 units, 95% CI [0.20 to 0.64] I2 = 0; GRADE: very low). Studies using PG as an adjuvant (n = 423) were not pooled due to heterogeneity, but the largest of them showed no benefit of adding PG to tapentadol. There were no deaths or hospitalizations reported. Compared with placebo, the following adverse events were more commonly reported with GB: dizziness-(RR = 1.99, 95% CI [1.17 to 3.37], I2 = 49); fatigue (RR = 1.85, 95% CI [1.12 to 3.05], I2 = 0); difficulties with mentation (RR = 3.34, 95% CI [1.54 to 7.25], I2 = 0); and visual disturbances (RR = 5.72, 95% CI [1.94 to 16.91], I2 = 0). The number needed to harm with 95% CI for dizziness, fatigue, difficulties with mentation, and visual disturbances were 7 (4 to 30), 8 (4 to 44), 6 (4 to 15), and 6 (4 to 13) respectively. The GRADE evidence quality was noted to be very low for dizziness and fatigue, low for difficulties with mentation, and moderate for visual disturbances. Functional and emotional improvements were reported by few studies and showed no significant improvements. CONCLUSIONS AND RELEVANCE: Existing evidence on the use of gabapentinoids in CLBP is limited and demonstrates significant risk of adverse effects without any demonstrated benefit. Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for CLBP merits caution. There is need for large high-quality trials to more definitively inform this issue. TRIAL REGISTRATION: PROSPERO CRD42016034040.
Haddas R, Lieberman IH, Block A
STUDY DESIGN: A prospective cohort study. OBJECTIVE: The current study utilized quantitative gait analysis to examine the relationship of fear-avoidance beliefs to gait patterns in patients with adult degenerative scoliosis (ADS). SUMMARY OF BACKGROUND DATA: Among patients with chronic spine pain, fear-avoidance beliefs are predictive of behavioral deficiencies, poor work and surgery outcomes. The impact of such beliefs on patients with major spinal deformity has yet to be investigated. Patients with ADS have previously been shown to have an altered gait pattern. Utilizing quantified gait analysis, this study aims to examine correlations between fear-avoidance and various aspects of gait in patients with ADS. METHODS: Twenty-five ADS patients completed the Tampa Scale for Kinesiophobia (TSK) questionnaire and the Fear Avoidance Beliefs Questionnaire (FABQ). Each patient performed a series of over-ground gait trials at a self-selected comfortable speed. Pearson's Product Correlation analysis was used to determine the relationship between the self-reported fear of movement measures and the objective gait analysis biomechanical data. RESULTS: TSK score correlated strongly with gait speed, stride, step, double support times, and step length, and correlated moderately with cadence, and stride length. The FABQ physical portion strongly correlated with stride length and step length. The FABQ physical portion was moderately correlated with gait speed, and single support time. The FABQ work portion was correlated with stride length and step length. CONCLUSIONS: This study demonstrates a strong correlation between biomechanical gait parameters, as measured with gait analysis, and fear-avoidance of movement, as measured with the TSK and FABQ. Further, it demonstrates quantified gait analysis can be a useful tool to evaluate patients with spine deformity and to assess the outcomes of treatments in this group of patients. This study extends previous research on the role of fear-avoidance to include patients with spinal deformity. LEVEL OF EVIDENCE: 3.
Shin G
Repetitive or prolonged head flexion posture while using a smartphone is known as one of risk factors for pain symptoms in the neck. To quantitatively assess the amount and range of head flexion of smartphone users, head forward flexion angle was measured from 18 participants when they were conducing three common smartphone tasks (text messaging, web browsing, video watching) while sitting and standing in a laboratory setting. It was found that participants maintained head flexion of 33-45 degrees (50th percentile angle) from vertical when using the smartphone. The head flexion angle was significantly larger (p < 0.05) for text messaging than for the other tasks, and significantly larger while sitting than while standing. Study results suggest that text messaging, which is one of the most frequently used app categories of smartphone, could be a main contributing factor to the occurrence of neck pain of heavy smartphone users. Practitioner Summary: In this laboratory study, the severity of head flexion of smartphone users was quantitatively evaluated when conducting text messaging, web browsing and video watching while sitting and standing. Study results indicate that text messaging while sitting caused the largest head flexion than that of other task conditions.
de Bie RA
BACKGROUND: Exercise is an effective treatment for patients with sub-acute and chronic non-specific low back pain (NSLBP). Previous studies have shown that a subgroup of patients with NSLBP and movement control impairment (MCI) can be diagnosed with substantial reliability. However, which type of exercises are most beneficial to this subgroup is still unknown. OBJECTIVES: The effectiveness of a specific exercise treatment to improve movement control was tested in this study. METHODS: Using a multicentre randomised controlled trial (RCT), we compared exercises that targeted MCI (MC) with a general exercise (GE) treatment. After randomisation, patients in both groups n(MC = 52; GE = 54) were treated in eight private physiotherapy practices and five hospital outpatient physiotherapy centres. Follow-up measurements were taken at post-treatment, six months and 12 months. The primary outcome measurement was the Patient Specific Function Scale (PSFS). RESULTS: PSFS showed no difference between groups after treatment, or at six months and 12 months. Secondary outcome analysis for pain and disability, measured with the Graded Chronic Pain scale and the Roland Morris Disability Questionnaire respectively, showed that a small improvement post-treatment levelled off over the long term. Both groups improved significantly (p < 0.001) over the course of one year. CONCLUSION: This study found no additional benefit of specific exercises targeting MCI.
Vlamis J
PURPOSE: Thoracolumbar Injury Classification and Severity Score (TILCS), facilitates the communication between physicians, and guides to treatment decision with better outcome. A composite injury severity score is calculated from these characteristics stratifying patients into operative and non-operative treatment. Aim of this study is to identify the effectiveness of TLICS scoring for thoracolumbar vertebral fractures without neurological deficits and the efficacy of conservative treatment in patients with TILCS 4. METHODS: 58 patients with thoracolumbar fracture were included. 38 patients with TLICS 1-3 (group A) and 20 patients with TLICS 4 (group B) treated conservatively, were evaluated with traditional two-plain radiographic examination, CT-scan and MRI. The pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Mean follow-up period was 28 months. Post-fracture and follow-up values were compared. Functional scores and clinical outcomes of the groups were compared. RESULTS: The mean pain (1 = worse pain, reverse-VAS) and functional scores at the final follow-up were 8.2 and 86 points, respectively (group A), 6.4 and 76 points (group B). The mean period for returning to work was 3.2 (group A) and 3.8 months (group B). Comparing the two groups did not demonstrate any statistical difference of their clinical and functional outcomes. CONCLUSION: The study's results demonstrate that conservative treatment for TLICS 4 thoracolumbar fractures can be safely applied. The conservative treatment of cases scoring TLICS 4 is equally effective to those scoring
Ni B
BACKGROUND: There are still no clearly defined clinical-practice guidelines related to surgical intervention for chronic low back pain (CLBP) in the absence of serious structural problems such as instability, spinal stenosis, spondylolysis, infection, or neoplasm. There is also a lack of high-quality evidence regarding CLBP treatment. OBJECTIVE: To compare the clinical effectiveness of lumbar surgery vs. nonsurgical treatment for chronic low back pain. METHODS: A search was conducted using MEDLINE(R), Embase, and reference lists of articles and personal files. After a systematic search, studies were selected on the basis of inclusion criteria. Six articles (904 patients) met the inclusion criteria for the study. Pooled estimates of clinical results were calculated with 95% confidence intervals. RESULTS: All six eligible studies were independent randomized clinical trials. Pooled data revealed that, compared with surgical treatment, nonsurgical treatment was associated with better Oswestry Disability Index scores. Both groups had similar Visual Analogue Scale and Emotional Distress Scale scores as well as General Function Scores. CONCLUSIONS: For chronic low back pain, nonsurgical treatment was shown to be effective, feasible, and safe during the follow-up period. More randomized controlled trials are needed to compare surgical and nonsurgical treatment of chronic low back pain.
Hita-Contreras F
PURPOSE: To determine the short- and long-term effectiveness of the application of Clinical Pilates in addition to physical therapy versus a physical therapy treatment alone in a population of postmenopausal women with chronic low back pain (CLBP). METHODS: A single-blind randomized controlled trial with repeated measures and a follow-up period. One hundred and one patients were randomly allocated to a Pilates + physical therapy (PPT) group or to a physical therapy (PT) only group for six weeks. Pain and disability were measured by visual analog scale (VAS) and the Oswestry disability index respectively preintervention, after 6 weeks of treatment and after 1-year follow-up. RESULTS: There were significant differences between groups in pain and disability after 6 weeks of treatment, with better results in the PPT group with an effect size of d = 3.14 and d = 2.33 for pain and disability. After 1-year follow-up, only PPT group showed better results compared with baseline with an effect size of d = 2.49 and d = 4.98 for pain and disability. CONCLUSION: The results suggest that using Clinical Pilates in addition to physical therapy provides improved results on pain management and functional status for postmenopausal woman with CLBP and that its benefits still linger after one year. IMPLICATIONS FOR REHABILITATION: Chronic Low Back Pain could benefit from the Pilates practice in postmenopausal women. Improvement in pain and disability derived from CLBP seem to be maintained over time due to Pilates practice. Pilates constitutes a safe tool to be applied in older population with CLBP due to its ability to be adapted to every performance and physical level.
van der Beek AJ
BACKGROUND: Neck and low back pain are significant health problems due to their high prevalence among the general population. Educational intervention commonly aims to reduce the symptoms and risk for additional problems by increasing the participant's knowledge, which in turn will alter the person's behavior. The primary aim of this study was to review randomize controlled trials (RCTs) to gain insights into the effectiveness of education for the prevention and treatment of non-specific neck and low back pain. METHODS: Publications were systematically searched from 1982 to March 2015 in several databases. Relevant RCTs were retrieved and assessed for methodological quality. Meta-analysis was conducted to examine the effectiveness of education for the prevention and treatment of non-specific neck and low back pain. The overall quality of evidence was assessed using the GRADE system. RESULTS: Thirty-six RCTs (30 high-quality studies) were identified. A total of 15 RCTs, which compared education programs to no education program, were included for further analysis. All studies included investigated the effectiveness of education with intermediate- and long-term follow-ups. The results showed that education programs were not effective in preventing and treating neck pain as well as treating low back pain. Conflicting evidence was found for the effectiveness of education on prevention of low back pain. CONCLUSIONS: Evidence suggests that education programs are not recommended in preventing or treating neck pain as well as treating low back pain, unless supplementary high-quality studies provide evidence to the contrary.
Yusof MI
INTRODUCTION: This retrospective review aimed to examine the relationship between preoperative pulmonary function and the Cobb angle, location of apical vertebrae and age in adolescent idiopathic scoliosis (AIS). To our knowledge, there have been no detailed analyses of preoperative pulmonary function in relation to these three factors in AIS. METHODS: A total of 38 patients with thoracic or thoracolumbar scoliosis were included. Curvature of spinal deformity was measured using the Cobb method. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were used to evaluate preoperative pulmonary function. Statistical methods were used to analyse the relationship between preoperative pulmonary function and the factors that may contribute to poor pulmonary function. RESULTS: The mean age of the patients was 16.68 +/- 6.04 years. An inverse relationship was found between the degree of the Cobb angle and FVC as well as FEV1; however, the relationships were not statistically significant (p = 0.057 and p = 0.072, respectively). There was also a trend towards a significant negative correlation between the thoracic curve and FVC (p = 0.014). Patients with larger thoracic curves had lower pulmonary function. A one-year increase in age significantly decreased FVC by 1.092 units (p = 0.044). No significant relationship between age and preoperative FEV1 was found. The median FVC was significantly higher in patients with affected apical vertebrae located at levels L1-L3 than at T6-T8 or T9-T12 (p = 0.006). CONCLUSION: Lung function impairment was seen in more severe spinal deformities, proximally-located curvature and older patients.
Zhang XB
Intracutaneous sterile water injection (ISWI) is used for relief of low back pain during labor, acute attacks of urolithiasis, chronic neck and shoulder pain following whiplash injuries, and chronic myofascial pain syndrome. We conducted a randomized, double-blinded, placebo-controlled trial to evaluate the effect of ISWI for relief of acute low back pain (aLBP). A total of 68 patients (41 females and 27 males) between 18 and 55 years old experiencing aLBP with moderate to severe pain (scores >/=5 on an 11-point visual analogue scale [VAS]) were recruited and randomly assigned to receive either ISWIs (n=34) or intracutaneous isotonic saline injections (placebo treatment; n=34). The primary outcome was improvement in pain intensity using the VAS at 10, 45, and 90 min and 1 day after treatment. The secondary outcome was functional improvement, which was assessed using the Patient-Specific Functional Scale (PSFS) 1 day after treatment. The mean VAS score was significantly lower in the ISWI group than in the control group at 10, 45, and 90 min, and 1 day after injection (P<0.05, t-test). The mean increment in PSFS score of the ISWI group was 2.9+/-2.2 1 day after treatment, while that in the control group was 0.9+/-2.2. Our study showed that ISWI was effective for relieving pain and improving function in aLBP patients at short-term follow-up. ISWI might be an alternative treatment for aLBP patients, especially in areas where medications are not available, as well as in specific patients (e.g., those who are pregnant or have asthma), who are unable to receive medications or other forms of analgesia because of side effects.
Pourahmadi MR
INTRODUCTION: The aim was to compare core stability and general exercises (GEs) in chronic low back pain (LBP) patients based on lumbopelvic stability (LPS) assessment through three endurance core stability tests. There is a controversy about preference of core stability exercise (CSE) over other types of exercise for chronic LBP. Studies which have compared these exercises used other outcomes than those related to LPS. As it is claimed that CSE enhances back stability, endurance tests for LPS were used. MATERIALS AND METHODS: A 16-session CSE program and a GE program with the same duration were conducted for two groups of participants. Frequency of interventions for both groups was three times a week. Forty-three people (aged 18-60 years) with chronic non-specific LBP were alternately allocated to core stability (n = 22) or GE group (n = 21) when admitted. The primary outcomes were three endurance core stability tests including: (1) trunk flexor; (2) trunk extensor; and (3) side bridge tests. Secondary outcomes were disability and pain. Measurements were taken at baseline and the end of the intervention. RESULTS: After the intervention, test times increased and disability and pain decreased within groups. There was no signi fi cant difference between two groups in increasing test times (p = 0.23 to p = 0.36) or decreasing disability (p = 0.16) and pain (p = 0.73). CONCLUSIONS: CSE is not more effective than GE for improving endurance core stability tests and reducing disability and pain in chronic non-specific LBP patients.
Garfin SR
Gabapentin is prescribed for analgesia in chronic low back pain, yet there are no controlled trials supporting this practice. This randomized, 2-arm, 12-week, parallel group study compared gabapentin (forced titration up to 3600 mg daily) with inert placebo. The primary efficacy measure was change in pain intensity from baseline to the last week on treatment measured by the Descriptor Differential Scale; the secondary outcome was disability (Oswestry Disability Index). The intention-to-treat analysis comprised 108 randomized patients with chronic back pain (daily pain for >/=6 months) whose pain did (43%) or did not radiate into the lower extremity. Random effects regression models which did not impute missing scores were used to analyze outcome data. Pain intensity decreased significantly over time (P < 0.0001) with subjects on gabapentin or placebo, reporting reductions of about 30% from baseline, but did not differ significantly between groups (P = 0.423). The same results pertained for disability scores. In responder analyses of those who completed 12 weeks (N = 72), the proportion reporting at least 30% or 50% reduction in pain intensity, or at least "Minimal Improvement" on the Physician Clinical Global Impression of Change did not differ significantly between groups. There were no significant differences in analgesia between participants with radiating (n = 46) and nonradiating (n = 62) pain either within or between treatment arms. There was no significant correlation between gabapentin plasma concentration and pain intensity. Gabapentin appears to be ineffective for analgesia in chronic low back pain with or without a radiating component.
Perez R
BACKGROUND: Although the prevalence of sacroiliac joint (SIJ) pain is relatively high (15 - 30%), there is no unambiguous reference standard to diagnose SIJ pain. Pressure tenderness in the SIJ region is used for diagnostic purposes, but the clinimetric properties of this procedure remain to be determined. OBJECTIVES: The aim of this study is to determine the reliability of pain pressure threshold (PPT) measurements in the SIJ region and the difference in PPTs in the SIJ region between healthy volunteers and PPTs in patients with SIJ pain. STUDY DESIGN: Prospective cohort study. SETTING: Outpatient pain clinic VU University Medical Center. METHODS: Forty-one healthy volunteers and 31 patients diagnosed with SIJ pain were included. PPTs were obtained from 5 measurement points in the region of the SIJ with a pressure pain algometer using a standardized protocol. The inter-rater reliability of this method was calculated by means of the Intraclass Correlation Coefficients (ICC) of individual assessment performed by 2 individual raters of SIJs of healthy volunteers on both sides. PPTs of healthy volunteers were compared to those of the affected side in patients with SIJ pain. RESULTS: PPT measurement showed moderate to good inter-rater reliability (ICC 0.6 - 0.82).The median PPTs of 5 points was comparable for both sides in healthy volunteers (right: 8.5 kg/cm2 [IQR 6.0 - 10.0]; left 8.3 kg/cm2 (5.8 - 10.0]). Median PPTs for the affected sides of patients with SIJ pain were significantly lower compared to the same side of healthy volunteers (right: 2.4 kg/cm2 [IQR 2.2 - 3.2, n = 15]; left: 2.5 kg/cm2 [2.3 - 3.2, n = 16]; P < 0.001 for both sides). LIMITATIONS: Only the SIJ on one side of was measured in patients with SIJ pain, where both sides would be desirable. CONCLUSIONS: Pressure pain algometry appears to be a reliable method to establish differences in PPTs between healthy volunteers and patients with SIJ pain. The diagnostic accuracy of this test should be investigated further.
Sahin HG
BACKGROUND Pregnancy-related low back pain is a common condition during pregnancy. Kinesio tape is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems. The aim of this study was to investigate the short-term effects of lumbar Kinesio taping on pain intensity and disability in women with pregnancy-related low back pain. MATERIAL AND METHODS A total of 65 patients with pregnancy-related low back pain were randomly allocated into either Kinesio taping (n=33) or control (n=32) groups. The intervention group was treated with paracetamol plus Kinesio taping, while the control group received only paracetamol. Kinesio taping was applied in the lumbar flexion position, and four I-shaped bands were used. Two bands were attached horizontally, with space correction technique. The remaining 2 bands, 1 on each side of the lumbar spine, were placed vertically, with inhibition technique. Low back pain intensity was measured on a 10-cm visual analogue scale (VAS), and the Roland-Morris Disability Questionnaire (RMDQ) was used for evaluation of disability. RESULTS Pain intensity and RMDQ scores improved significantly in both groups at 5 days compared with baseline. Considering the degree of treatment effect (the change from baseline to day 5), the Kinesio taping group was significantly superior than the control group in all outcome measures (for all, P<0.001). CONCLUSIONS The results of this study indicate that Kinesio taping can be used as a complementary treatment method to achieve effective control of pregnancy-related low back pain.
Bagley C
STUDY DESIGN: A longitudinal cohort study. OBJECTIVE: In this study, we set out to assess the association between racial differences and health outcomes after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Although racial disparities in the use of surgical procedures are well established, relationships between race and patient-reported outcomes measures after ACDF have not been previously assessed. METHODS: Sixty adult patients (black patients: 28, white patients: 32) undergoing ACDF at Duke University Medical Center were included in this study. Enrollment criteria included available demographic, surgical, and clinical outcome data. All patients had prospectively collected patient-reported outcomes measures and a minimum 1-year follow-up. Patients completed the Neck Disability Index (NDI), Short-Form 12 (SF-12), and Visual Analog Pain Scale (VAS) before surgery, and then at 3, 6, and 12 months after surgery. Clinical outcomes and complication rates were compared between both patient cohorts. RESULTS: Baseline characteristics were similar between both cohorts. The median [interquartile range] number of levels fused was similar between both patient cohorts 2 [1-2], P = 0.41. There was no significant difference between cohorts in the incidence of nerve root injury (P = 0.99) or incidental durotomy (P = 0.31). At 3 months postoperatively, both cohorts demonstrated similar improvement in VAS-neck pain (P = 0.75), NDI (P = 0.31), SF-12 physical component score (PCS) (P = 0.82), and SF-12 mental component score (MCS) (P = 0.43). These results were durable through 1 year. At 1 year, both the black and white patients demonstrated similar improvement from baseline in NDI (P = 0.36), VAS neck pain (P = 0.35), SF-12 PCS (P = 0.18), and SF-12 MCS (P = 0.56). CONCLUSION: Our study suggests that at 1 year, there were no substantial differences in between races in patient-reported outcomes measures after ACDF. Both black and white patients expressed similar improvement from baseline in all outcomes metrics. LEVEL OF EVIDENCE: 3.
Mota J
This article reviews the effectiveness of physical activity (PA) interventions at the workplace to reduce musculoskeletal pain among employees and assesses the effect size of these programs using meta-analysis. Four databases (i.e., PubMed, EBSCO, Web of Science, and Cochrane) were searched for research trials, which included comparison groups of employees that assessed PA programs, musculoskeletal pain, and health-related behaviors, published between January 1990 and March 2013. The meta-analysis estimates of standardized mean differences (Hedges' g) present significant evidence of less general pain (g = -.40 with a 95% confidence interval [CI] = [-0.78, -0.02]) and neck and shoulder pain (g = -.37 with a 95% CI = [-0.63, -0.12]) in intervention groups. The few studies of low back pain and arm, elbow, wrist, hand, or finger pain did not present sufficient statistically significant evidence. Consistent evidence demonstrates that workplace PA interventions significantly reduce general musculoskeletal pain and neck and shoulder pain. More studies are needed to determine the effectiveness of work-related PA interventions for arm, elbow, wrist, hand or finger, and low back pain.
Ferreira PH
OBJECTIVE: To investigate the chronic low back pain and coronary heart disease relationship, after adjusting for relevant confounders, including genetics. METHODS: In a cross-sectional design, 2148 twins were recruited from the Murcia Twin Registry, Spain. The exposure was chronic LBP and the outcomes were myocardial infarction and other coronary heart diseases-lifetime and in the last 2 years-based on standardized health-related questionnaires. First, logistic regression analysis investigated associations of the total sample followed by a matched co-twin control analyses, with all complete twin pairs discordant for chronic LBP utilised, separated for zygosity-dizygotic (DZ) and monozygotic (MZ) pairs, which adjusted for shared familial factors, including genetics. RESULTS: Chronic LBP pain is associated with lifetime myocardial infarction [odds ratio (OR) = 2.69, 95% confidence interval (CI) = 1.35-5.36], other coronary heart diseases over a lifetime (OR = 2.58, 95% CI: 1.69-3.93) and in the last two years (OR = 2.19, 95% CI: 1.33-3.60), while there was a borderline association with myocardial infarction in the last 2 years (OR = 2.64, 95% CI: 0.98-7.12). Although the magnitude of the association remained or increased in the co-twin control analyses, none reached statistical significance. CONCLUSION: Chronic LBP is associated with a higher prevalence of myocardial infarction and coronary heart disease. It is possible that this association remains even when controlling for genetics and early shared environment, although this should be investigated with larger samples of twins discordant for LBP.
Kessler C
OBJECTIVES: We aimed to evaluate the effectiveness of an 8-week meditation program (focused meditation) in patients with chronic low-back pain. DESIGN: A randomized clinical trial was conducted on 68 patients (55 years;75% female) with chronic low-back pain who scored >40mm on a 100mm Visual-Analogue-Scale. Subjects were allocated to an 8-week meditation program (focused meditation) with weekly 75min classes or to a self-care exercise program with a wait-list offer for meditation. Both groups were instructed to practice at home. Outcomes were assessed baseline and after 4 and 8 weeks. The primary outcome measure was the change in mean back pain at rest after 8 weeks. Secondary outcomes included function, pain-related bothersomeness, perceived stress, quality-of-life (QOL), and psychological outcomes. RESULTS: Twelve (meditation) and 4 (exercise) patients were lost to follow-up. The primary outcome, pain at rest after 8 weeks, was reduced from 59.3+/-13.9mm to 40.8+/-21.8mm with meditation vs. 52.9+/-11.8mm to 37.3+/-18.2mm with exercise (adjusted group difference: -1.4 (95%CI:11.6;8.8;p=n.s.) Perceived stress was significantly more reduced with meditation (p=0.011). No significant treatment effects were found for other secondary outcomes as pain-related bothersomeness, function, quality-of-life and psychological scores, although the meditation group consistently showed non-significant better improvements compared to the exercise group. CONCLUSIONS: Focused meditation and self-care exercise lead to comparable, symptomatic improvements in patients with chronic low back pain. Future studies should include longer-term follow-ups and develop guided meditation programs to support compliance.
Kellmann M
OBJECTIVE: In the general population, physical and mental stress factors are linked to chronic low back pain (LBP). The aim of the present study was to examine this association among athletes. DESIGN: Longitudinal study with a six-month interval between measurements. SETTING: Questionnaires were filled out at home, either in paper-pencil version or online. PARTICIPANTS: Eighty-two male and 57 female athletes (N = 139, MAge = 32.24) who exercise on a competitive (n = 102) or recreational level (n = 37), with a weekly training volume of at least 3 h. MAIN OUTCOME MEASURES: At T0, stress parameters were assessed via the Recovery-Stress Questionnaire (RESTQ-Basic-48) and the Screening Scale of the Trier Inventory for the Assessment of Chronic Stress (TICS-SSCS). At T0 and T1, different chronification indicators were measured. Based on these assessments, the sample was split into a chronification and no-chronification group. RESULTS: ANCOVAs were used to conduct group comparisons with regard to stress levels. The chronification groups showed higher stress values for all chronification indicators. For the variables Physical Complaints and Overall Stress-TICS, the group differences became significant (p < .05). CONCLUSION: A relationship between stress parameters and LBP chronification was demonstrated among athletes for the first time.
Javanshir K
BACKGROUND: Neck pain is an important cause of disability. In spite of its high prevalence rate, treatment of the disorder is a challenging topic. Stabilization exercise has been the topic of many studies. OBJECTIVE: To compare the effects of stabilization and routine exercises on chronic neck pain. METHODS: Forty patients were randomly assigned into either stabilization or routine exercise groups and undertook a 10-week training program. Electromyographic (EMG) activity was recorded from Sternocleidomastoid (SCM), Anterior Scalene (AS) and Splenius Capitis (SC) muscles bilaterally. Endurance time of deep flexor muscles was measured by chronometer.Pain and disability were measured using Visual Analogue Scale (VAS) and neck disability index (NDI) questionnaire, respectively before and after training period. RESULTS: Findings revealed significant decreased pain and disability in both groups after intervention (P< 0/001). Flexor muscles endurance of stabilization group was significantly increased compared with that of routine (P< 0/001). Also EMG activity of SCM, AS and SC muscles were significantly decreased in stabilization group compared with routine (P< 0/001). CONCLUSION: Increased deep flexor endurance and decreased EMG activity of SCM, AS and SC muscles suggest an important role for stabilizing exercises on reducing the activity of superficial muscles in chronic neck pain.
Solovieva S
OBJECTIVE: To examine whether heavy physical workload in young adulthood increases the risk of local and radiating low back pain (LBP) in midlife. METHODS: Longitudinal nationally representative Young Finns Study data among women (n=414) and men (n=324), aged 18-24 years in 1986 (baseline), were used. Physical heaviness of work was reported at baseline and follow-up (2007), and local and radiating LBP at follow-up. Covariates were age, smoking and body mass index. Logistic regression was used to examine the associations between physical heaviness of work and LBP. Additionally, the mediating effect of back pain at baseline was examined (the Sobel test). RESULTS: After adjustment for the covariates, and as compared with sedentary/light physical workload, heavy physical workload was associated with radiating LBP among women (OR 4.09, 95% CI 1.62 to 10.31) and men (OR 2.01, 95% CI 1.06 to 3.82). Among men, early back pain mediated the association (p value from the Sobel test=0.006). Among women, early exposure to physically heavy work showed the most consistent associations, while early and late exposures were associated with radiating and local LBP among men. Persistently heavy physical work was associated with radiating LBP among women and men. CONCLUSIONS: Physically heavy work at a young age can have a long-lasting effect on the risk of LBP, radiating LBP in particular. These results highlight the need to consider early and persistent exposures to prevent the adverse consequences of physical workload for the low back.
Falla D
Chronic neck pain attributed to a myofascial pain syndrome is characterized by the presence of muscle contractures referred to as myofascial trigger points. In this randomized, parallel-group, blinded, controlled clinical trial, we examined the effectiveness of deep dry needling (DDN) of myofascial trigger points in people with chronic nonspecific neck pain. The study was conducted at a public Primary Health Care Centre in Madrid, Spain, from January 2010 to December 2014. A total of 130 participants with nonspecific neck pain presenting with active myofascial trigger points in their cervical muscles were included. These participants were randomly allocated to receive: DDN plus stretching (n = 65) or stretching only (control group [n = 65]). Four sessions of treatment were applied over 2 weeks with a 6-month follow-up after treatment. Pain intensity, mechanical hyperalgesia, neck active range of motion, neck muscle strength, and perceived neck disability were measured at baseline, after 2 sessions of intervention, after the intervention period, and 15, 30, 90, and 180 days after the intervention. Significant and clinically relevant differences were found in favour of dry needling in all the outcomes (all P < 0.001) at both short and long follow-ups. Deep dry needling and passive stretching is more effective than passive stretching alone in people with nonspecific neck pain. The results support the use of DDN in the management of myofascial pain syndrome in people with chronic nonspecific neck pain.
Scalvini S
OBJECTIVE: To investigate if a structured physician-directed, nurse-managed, home-based telemedicine (HBT) program, consisting of scheduled/unscheduled phone surveillance, can reduce pain in patients with chronic neck pain. DESIGN: This is a prospective randomized controlled study conducted on outpatients. Following outpatient rehabilitation, patients (n = 100) were consecutively randomized to a 6-month HBT program (HBT group) or no HBT but only the recommendation to continue exercising at home (control group). At baseline and after 6 months, pain severity (visual analog scale) and disability (Neck Disability Index) were evaluated. RESULTS: At 6 months, neck pain and disability declined in both groups (P < 0.001 for both groups, both parameters), but the decline was significantly more marked in the HBT group (P = 0.001, both parameters). At 6 months, 87.2% of HBT patients and 65.9% of control subjects were performing home exercises (in the range of 2-7 exercise sessions/wk). Pain and disability scores were correlated to participation in the HBT program, patients' perception of HBT, and adherence to home exercises. CONCLUSIONS: Home-based telemedicine may be a useful additional tool to help physicians in the management of chronic neck pain.
Sterling M
Synopsis Recovery from a whiplash injury is varied and complex. Some individuals recover quickly and fully, while others experience ongoing pain and disability. Three distinct patterns of predicted recovery (trajectories) have been identified using disability and psychological outcome measures. These trajectories are not linear, and show that recovery, if it is going to occur, tends to happen within the first 3 months of the injury, with little improvement after this period. Identification of factors associated with poor recovery is accumulating, and since 2000 there have been at least 10 published systematic reviews on prognostic factors for whiplash-associated disorder. Poor recovery has been consistently reported to be associated with high initial neck pain intensity and neck-related disability, posttraumatic stress symptoms, pain catastrophizing, and, to a lesser extent, low self-efficacy and cold hyperalgesia. Evidence regarding factors, including compensation status, psychological factors, structural pathology, and preinjury health status, remains equivocal. Given the huge number of predictive factors and various interpretations of recovery, adapting these data for use in clinical practice is difficult. Tools such as clinical prediction rules (CPRs), by statistically quantifying relevant data, may help to predict the probability of diagnosis, prognosis, or response to treatment. Numerous CPRs have been derived for individuals with whiplash; however, to date, only 3 prognostic CPRs have undergone external validation, and none have yet undergone impact analysis, a necessary step in providing information about the rules' ability to improve clinically relevant outcomes. J Orthop Sports Phys Ther 2016;46(10):851-861. Epub 3 Sep 2016. doi:10.2519/jospt.2016.6918.
Meuser T
BACKGROUND: Neck reflex points (NRP) are tender soft tissue areas of the cervical region that display reflectory changes in response to chronic inflammations of correlated regions in the visceral cranium. Six bilateral areas, NRP C0, C1, C2, C3, C4 and C7, are detectable by palpating the lateral neck. We investigated the inter-rater reliability of NRP to assess their potential clinical relevance. METHODS: 32 consecutive patients with chronic neck pain were examined for NRP tenderness by an experienced physician and an inexperienced medical student in a blinded design. A detailed description of the palpation technique is included in this section. Absence of pain was defined as pain index (PI) = 0, slight tenderness = 1, and marked pain = 2. Findings were evaluated either by pair-wise Cohen's kappa (k) or by percentage of agreement (PA). RESULTS: Examiners identified 40% and 41% of positive NRP, respectively (PI > 0, physician: 155, student: 157) with a slight preference for the left side (1.2:1). The number of patients identified with >6 positive NRP by the examiners was similar (13 vs. 12 patients). k values ranged from 0.52 to 0.95. The overall kappa was k = 0.80 for the left and k = 0.74 for the right side. PA varied from 78.1% to 96.9% with strongest agreement at NRP C0, NRP C2, and NRP C7. Inter-rater agreement was independent of patients' age, gender, body mass index and examiner's experience. CONCLUSION: The high reproducibility suggests the clinical relevance of NRP in women.
Arab AM
The aim of this study was to systematically review the evidence on respiratory function changes in patients with chronic neck pain. MEDLINE, Elsevier, ProQuest, PubMed, Scopus, Springer, and Google scholar electronic databases were explored thorough December 2015. English-language studies investigating cervical musculoskeletal and respiratory parameters in patients with chronic neck pain were included. Characteristics of the patients, sampling method and size, musculoskeletal and respiratory parameters studied, and appropriateness of the statistical tests were considered. Studies were rated based on study design and performance. Of the 68 studies reviewed, 9 observational studies met our inclusion criteria. Significant difference in maximum inspiratory and expiratory pressures were reported in patients with chronic neck pain compared to asymptomatic subjects. Some of the respiratory volumes were found to be lower in patients with chronic neck pain. Muscle strength and endurance, cervical range of motion, and psychological states were found to be significantly correlated with respiratory parameters. Lower Pco2 in patients and significant relationship between chest expansion and neck pain were also shown. Respiratory retraining was found to be effective in improving some cervical musculoskeletal and respiratory impairment. Functional pulmonary impairments accompany chronic neck pain. Based on the observed association, investigation of the effectiveness of management of CNP on respiratory function is strongly suggested.
Arcanjo FL
AIM: We performed a systematic review with a meta-analysis to examine the efficacy of stabilization exercises versus general exercises or manual therapy in patients with low back pain. DESIGN: We searched MEDLINE, Cochrane Controlled Trials, Scielo, and CINAHL (from the earliest date available to November 2014) for randomized controlled trials that examined the efficacy of stabilization exercises compared to general exercises or manual therapy on pain, disability, and function in patients with low back pain. Weighted mean differences (WMD) and 95% confidence intervals were calculated. RESULTS: Eleven studies met the inclusion criteria (413 stabilization exercises patients, 297 general exercises patients, and 185 manual therapy patients). Stabilization exercises may provide greater benefit than general exercise for pain reduction and improvement in disability. Stabilization exercise improved pain with a WMD of -1.03 (95% CI: -1.29 to -0.27) and improved disability with a WMD of -5.41 (95% CI: -8.34 to -2.49). There were no significant differences in pain and disability scores among participants in the stabilization exercise group compared to those in the manual therapy group. CONCLUSIONS: Stabilization exercises were as efficacious as manual therapy in decreasing pain and disability and should be encouraged as part of musculoskeletal rehabilitation for low back pain.
Negrini S
BACKGROUND: Scoliosis is a three dimensional deformity, and brace correction should be 3D too. There is a lack of knowledge of the effect of braces, particularly in the sagittal and transverse plane. The aim of this study is to analyse the Sforzesco Brace correction, through all the parameters provided by Eos 3D imaging system. METHOD: Design: This is a cross sectional study from a prospective database started in March 2003. Participants: 16 AIS girls (mean age 14.01) in Sforzesco brace treatment, with EOS x-rays, at start, in brace after 1 month and out of brace after the first 4 months of treatment. Outcome measures: All the parameters and the Torsio-Index obtained from 3D Eos System, in and out of brace, in the three planes. Statistical analysis: the variability of the parameters and the mean differences were analyzed and compared using paired T test. ANOVA was used for multiple comparisons. Critical P value was set at 0.05. RESULTS: In the comparison of in-brace vs start of treatment, the mean Cobb angle changed significantly from 36.44 +/- 4 to 28.99 + -3.9 degrees (p = 0.01). Significant changes in all the sagittal parameters were found (p = 0.02). In the axial plane, the Torsio Index changed significantly in-brace for thoracolumbar and lumbar curves (P < 0.05). The analysis of the single vertebral tilt demonstrated that the effect of the brace is mostly concentrated at specific segments: T4-T5, T10-T12, L1 and L5 in the axial plane and T3-T6 and T10-L1 in the frontal plane. CONCLUSION: The Sforzesco brace mostly modifies the middle of the spine and preserves the sagittal balance. The single vertebral orientation in each plane should be considered together with the typically used values to assess brace effect.
Negrini S
BACKGROUND: Despite its importance in affecting adult pain, and disability, there is a lack of universal criteria for the diagnosis and evaluation of thoraco-lumbar Junctional Kyphosis (JK) and a gold standard measurement and diagnostic system does not exist. This study aims to verify the sensibility and specificity of clinical, and Formetric surface topography (FST) data in identifying Junctional Kyphosis in respect to the radiographical standard references. METHODS: Design: This is a cross sectional study from a prospective database started in March 2003. Participants: 38 subjects. Inclusion criteria: Patients selected by age according to Risser score 1, at first visit with lateral x-rays and FST. Diagnostic test used to detect JK:FST criteria: level of thoraco-lumbar inflexion point in percentage compared to the total height of the spine.X-ray criteria: lower limit of thoracic kyphosis below T12. Statistics: sensitivity, specificity, positive (PPV) and negative predictive values (NPV), ROC curve. RESULTS: FST showed a good reliability in detecting JK: with a threshold of 75 %, PPV was 100 %, NPV was 86 % and the Area Under the Curve was 83 %. CONCLUSION: The need for a useful criteria able to characterize JK to allow diagnosis and monitoring of the deformity is still lacking, and further studies will deepen this issue.
Sogaard K
OBJECTIVE: To evaluate the longer term efficacy of the interventions Tailored Physical Activity (TPA) and Chronic Pain Self-management Program (CPSMP) against a reference group on return-to-work for sick-listed subjects with pain in the back or upper body. DESIGN: A randomized controlled trial. SUBJECTS: A total of 141 sick-listed subjects with pain in the back or upper body. METHODS: All participants received health guidance for 1.5 h and were randomly assigned to TPA (n = 47), CPSMP (n = 47) or a reference group (n = 47). The primary end-point was the proportion of participants returning to work and the co-primary end-point was the duration of the sickness absence period retrieved 11 months after the first day on sick leave. Secondary outcomes were pain level, body mass index, aerobic capacity, work ability and kinesiophobia. RESULTS: TPA and CPSMP were no more effective than the reference group as regards return-to-work. Compared with the reference group no other benefits of TPA and CPSMP were evident regarding pain, work ability, kinesiophobia or physical capacity. CONCLUSION: After 11 months TPA, the reference group, and CPSMP show similar patterns of facilitating return-to-work. This is additional knowledge, compared with the 3-month findings reported previously, showing that TPA seems to facilitate a faster return-to-work.
Friis E
BACKGROUND: While adolescent idiopathic scoliosis (AIS) produces well characterized deformation in spinal form, the effect on spinal function, namely mobility, is not well known. Better understanding of scoliotic spinal mobility could yield better treatment targets and diagnoses. The purpose of this study was to characterize the spinal mobility differences due to AIS. It was hypothesized that the AIS group would exhibit reduced mobility compared to the typical adolescent (TA) group. METHODS: Eleven adolescents with right thoracic AIS, apices T6-T10, and eleven age- and gender-matched TAs moved to their maximum bent position in sagittal and coronal plane bending tasks. A Trakstar (Ascension Technologies Burlington, VT) was used to collect position data. The study was approved by the local IRB. Using MATLAB (MathWorks, Natick, MA) normalized segmental angles were calculated for upper thoracic (UT) from T1-T3, mid thoracic (MT) from T3-T6, lower thoracic (LT) from T6-T10, thoracolumbar (TL) from T10-L1, upper lumbar (UL) from L1-L3, and thoracic from T1-L1 by subtracting the standing position from the maximum bent position and dividing by number of motion units in each segment. Mann Whitney tests (alpha = 0.05) were used to determine mobility differences. RESULTS: The findings indicated that the AIS group had comparatively increased mobility in the periapical regions of the spine. The AIS group had an increase of 1.2 degrees in the mid thoracic region (p = 0.01) during flexion, an increase of 1.0 degrees in the mid thoracic region (p = 0.01), 1.5 degrees in the thoracolumbar region (p = 0.02), and 0.7 degrees in thoracic region (p = 0.04) during left anterior-lateral flexion, an increase of 6.0 degrees in the upper lumbar region (p = 0.02) during right anterior-lateral flexion, and an increase of 2.2 degrees in the upper lumbar region during left lateral bending (p < 0.01). CONCLUSIONS: Participants with AIS did not have reduced mobility in sagittal or coronal motion. Contrarily, the AIS group often had a greater mobility, especially in segments directly above and below the apex. This indicates the scoliotic spine is flexible and may compensate near the apex.
Xu L
PURPOSES: To determine the relationship between low body mass index (BMI) and the outcome of brace treatment in patients with adolescent idiopathic scoliosis (AIS). METHODS: 350 braced female AIS patients were included in this study. The baseline characteristics of the patient were recorded at their first visit, including age, Risser sign, digital skeletal age, BMI, curve pattern, and curve magnitude. Underweight was defined as lower than the 5th percentile of the sex- and age-specific BMI. The treatment was considered as a failure if the curve progressed more than 5 degrees , or if patients underwent surgery. According to the final outcome of brace treatment, the cohort was divided into the success group and the failure group. A logistic regression model was created to determine the independent predictors of the bracing outcome. RESULTS: 24.5% (86/350) of the patients were identified as underweight at their initial visit, which was significantly higher than the rate of 13.1% (46/350) at the final follow-up (p < 0.001). At the initial visit of the patients, the rate of underweight was 17.6% (45/255) in the success group, which was significantly lower than the rate of 43.1% (41/95) in the failure group (p < 0.001). Logistic regression analysis showed that low BMI was significantly associated with bracing failure (p < 0.001). CONCLUSION: The low BMI could be predictive of bracing failure in AIS patients, which should be taken into account when surgeons prescribe brace treatment to such patients.
Sharifi Rad MR
OBJECTIVE: This study aims to evaluate the spinal sagittal balance and the spinopelvic parameters in patients with degenerative lumbar spinal stenosis and healthy controls in Iranian population. METHODS: We performed a case-control study in which 48 patients with lumbar spine stenosis and 54 age- and sex-matched healthy subjects with back pain were eligible for participation. We used INFINITT picture archiving and communication systems (PACS) of the Chamran Hospital for selecting the patients for the study group. The sagittal balance, pelvic incidence, lumbar lordosis, and sacral slope were measured in all the patients and controls using thoracolumbosacral radiographies in the standing position. RESULTS: There was no significant difference between the 2 groups regarding the baseline characteristics. The prevalence of sagittal imbalance was significantly higher in the patients with lumbar spine stenosis in comparison with the controls (31.2% vs. 14.8%; P<0.001). The sacral slope was significantly lower in patients with lumbar canal stenosis than the healthy controls (31.39 degrees +/-11.2 vs. 43.7 degrees +/-8.4; P<0.001). The lumbar lordosis was significantly lower in patients with lumbar canal stenosis than the controls (31.27 degrees +/-12.4 vs. 45.8 degrees +/-10.7; P < 0.001). The pelvic incidence was not significantly different between the 2 groups (50.16 degrees +/-11.9 vs. 52 degrees +/-9.6; P=0.342). CONCLUSION: The degenerative lumbar canal stenosis is associated with increased sagittal imbalance and decreased lumbar lordosis and sacral slope in a sample of the Iranian adult population.
Catanzariti JF
PURPOSE: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of the spinal column of unknown etiology. Multiple factors could be involved, including neurosensory pathways and, potentially, an elective disorder of dynamic proprioception. The purpose of this study was to determine whether routine balance tests could be used to demonstrate an elective alteration of dynamic proprioception in AIS. METHODS: This was a multicentre case-control study based on prospectively collected clinical data, in three hospitals pediatric, with spine consultation, from January 2013 through April 2015. From an original population of 547 adolescents, inclusion and non-inclusion criteria indentified 114 adolescents with right thoracic AIS (mean age 14.5 +/- 1.9 years, Cobb angle 35.7 +/- 15.3 degrees ) and 81 matched adolescents without scoliosis (mean age 14.1 +/- 1.9 years). Participants performed three routine clinical balance tests to assess the static and dynamic proprioception: the Fukuda-Utenberger stepping test (angle of rotation in degrees and distance of displacement in cm) to assess dynamic balance; the sharpened Romberg test and the unipedal stance test (eyes closed) to assess static balance. RESULTS: There was no significant difference between AIS subjects and controls for the static tests, but there was a significant difference for the dynamic test for both measures: distance of displacement (p < 0.01) and angle of rotation (p < 0.0001). This result confirms our initial these: the dynamic proprioception is altered electively in AIS. CONCLUSION: These findings confirm recent AIS studies. Our results might be related to immature central integration of dynamic proprioceptive input leading to a poorly adapted motor response, particularly for postural control of the, in AIS. These balance tests can be performed in routine practice. Their validity as a biomarker for screening and monitoring purposes should be assessed.
Siemionow K
BACKGROUND: Electronic rulers on computer screen are used to measure the Cobb angle (CA) instead of traditional methods with rulers, protractors and pens. The variety of software used to assess radiographs might make the CA measurements cumbersome in everyday clinical practice. OBJECTIVE: The aim of the study was to verify the method of CA measurements on digital radiographs using Bunnell scoliometer (BS). METHODS: Eighty patients with idiopathic scoliosis were enrolled into the study. CA of each curve was measured by use of Centricity software and BS. CA on 30 randomly chosen patients were measured 3 times by one researcher using only scoliometer. Three researchers measured CA on the same 30 radiographs using BS. RESULTS: The mean CA of 224 curves measured by Centricity and BS were 29 degrees +/- 12.2 degrees and 28 degrees +/- 11.7 degrees , respectively. The ICC for agreement for 2 methods was 0.96 with SEM of 1.7 degrees . Excellent intra- and interobserver reliability of CA measurements with scoliometer was noted: ICC of 0.96 with SEM of 1.4 degrees and ICC of 0.93 with SEM of 1.9 degrees , respectively. CONCLUSIONS: The study revealed excellent reliability of CA measurements on digital radiographs using the BS. The proposed method of using the Bunnell scoliometer for CA measurements may be clinically useful.
Thaler M
PURPOSE: The Cobb angle as an objective measure is used to determine the progression of deformity, and is the basis in the planning of conservative and surgical treatment. However, studies have shown that the Cobb angle has two limitations: an inter- and intraobserver variability of the measurement is approximately 3-5 degrees, and high variability regarding the definition of the end vertebra. Scoliosis is a three-dimensional (3D) pathology, and 3D pathologies cannot be completely assessed by two-dimensional (2D) methods, like 2D radiography. The objective of this study was to determine the intraobserver and interobserver reliability of end vertebra definition and Cobb angle measurement using X-rays and 3D computer tomography (CT) reconstructions in scoliotic spines. METHODS: To assess interoberver variation the Cobb angle and the end vertebra were assessed by five observers in 55 patients using X-rays and 3D CT reconstructions. Definition of end vertebra and measurement of the Cobb angle was repeated two times with a three-week interval. Intraclass correlation coefficients (ICC) were used to determine the interobserver and intraobserver reliabilities. 95% prediction limits were provided for measurement errors. RESULTS: Intraclass correlation coefficient (ICC) showed excellent reliability for both methods. The measured Cobb angle was on average 9.2 degrees larger in the 3D CT group (72.8 degrees , range 30-144) than on 2D radiography (63.6 degrees , range 24-152). CONCLUSIONS: In scoliosis treatment it is very essential to determine the curve magnitude, which is larger in a 3D measurement compared to 2D radiography.
Hosoi M
Previous studies have shown differences in the psychosocial factors related to chronic localized pain (CLP) and chronic widespread pain (CWP). However, no studies have done an evaluation of differences between CLP and CWP from the viewpoint of family functioning. We did a cross-sectional study in a tertiary care setting to investigate possible differences in the relation of CWP and CLP to family functioning.Patients with CLP (N = 126) or CWP (N = 75) were assessed for family functioning by the Family Assessment Device (FAD) and a comparison was done. Logistic regression analysis was used to estimate associations of family functioning subscales with pain status (CWP vs CLP), controlling for demographic variables, pain variables; pain duration, pain ratings, pain disability, and psychological factors; depression, anxiety, and catastrophizing. The odds ratios (ORs) for the presence of CWP were calculated.Compared to patients with CLP, patients with CWP showed a lower functional status for Roles and Affective Involvement. The ORs for CWP were significantly higher in lower functioning Roles (OR: 2.38, 95% CI: 1.21-4.65) and Affective Involvement (OR: 2.86, 95% CI: 1.56-5.24) after adjusting for demographic variables. The significant association of CWP to Roles and Affective Involvement remained after controlling for the pain variables and psychological factors.This study shows that the families of patients with CWP have poorer family functioning than those with CLP. Our findings suggest that early identification and interventions for the family dysfunction of chronic pain patients are important to the treatment and prevention of CWP.
Scholten-Peeters GG
OBJECTIVES: To quantify differences in active cervical range of motion (aCROM) between patients with neck pain and those without neck pain, in patients with whiplash-associated disorders (WADs) and nontraumatic neck pain, and in patients with acute complaints versus those with chronic complaints. DATA SOURCES: Seven bibliographic databases were searched from inception to April 2015. In addition, a manual search was performed. STUDY SELECTION: Full articles on a numerical comparison of aCROM in patients with neck pain and asymptomatic control persons of similar ages were included. Two reviewers independently selected studies and assessed risk of bias. DATA EXTRACTION: Two reviewers extracted the data. Pooled mean differences of aCROM were calculated using a random-effects model. DATA SYNTHESIS: The search yielded 6261 hits; 27 articles (2366 participants, 13 low risk of bias) met the inclusion criteria. The neck pain group showed less aCROM in all movement directions compared with persons without neck pain. Mean differences ranged from -7.04 degrees (95% CI, -9.70 degrees to -4.38 degrees ) for right lateral bending (11 studies) to -89.59 degrees (95% CI, -131.67 degrees to -47.51 degrees ) for total aCROM (4 studies). Patients with WADs had less aCROM than patients with nontraumatic neck pain. No conclusive differences in aCROM were found between patients with acute and patients with chronic complaints. CONCLUSIONS: Patients with neck pain have a significantly decreased aCROM compared with persons without neck pain, and patients with WADs have less aCROM than those with nontraumatic neck pain.
Samartzis D
STUDY DESIGN: A prospective radiographic analysis of adolescent idiopathic scoliosis (AIS) patients managed with alternate-level pedicle screw fixation was performed. OBJECTIVE: The objective of this study was to characterize segmental curve flexibility and to determine its predictive value in curve correction in AIS patients. SUMMARY OF BACKGROUND DATA: Little is known regarding the distinct segmental curve characteristics and their ability to predict curve correction in patients with AIS. METHODS: The segmental Cobb angle was measured on posteroanterior standing radiographs and on fulcrum bending radiographs. Radiographs were analyzed preoperatively and at 2 years postoperatively and the curve was divided into upper, mid, and lower segments based on predefined criteria. The segmental flexibility and the segmental fulcrum bending correction index (FBCI) were calculated. RESULTS: Eighty patients were included with mean age of 15 years. Preoperative mean segmental Cobb angles were 18, 31, and 17 degrees in the upper, mid, and lower segments, respectively. Segmental bending Cobb angles were 6, 13, and 4 degrees, respectively, corresponding to segmental flexibilities of 50%, 47%, and 83% in the upper, mid, and lower segments, respectively (P < 0.001). At 2-year follow up, the mean segmental FBCI were 155%, 131%, and 100% in the upper, mid, and lower segments, respectively (P < 0.001), which suggested that the lower segment of the curve was more flexible than the other segments and that higher correction was noted in the upper segments. A significant, positive correlation was noted between the segmental bending Cobb angle and the segmental FBCI (P < 0.05), whereby the strength of the correlation varied based on the curve segment. CONCLUSION: This is the first study to demonstrate the segmental variations in curve flexibility using the fulcrum bending radiograph in AIS patients. Curve flexibility is not uniform throughout the curve and different segments exhibit greater flexibility/correctibility than others. Segmental flexibility should be considered in assessing AIS patients and in the clinical decision-making strategy to optimize curve correction outcomes. LEVEL OF EVIDENCE: 03.
Jasiewicz B
BACKGROUND: The SpineCor dynamic brace for the treatment of idiopathic scoliosis is designed to maintain the correct position of the spine and a new movement strategy for 20 hours per day. The SpineCor exercise system intensifies and complements the brace treatment. This study evaluated the effectiveness of a comprehensive treatment of idiopathic scoliosis involving the SpineCor system. MATERIAL AND METHODS: The study assessed a group of 40 patients (38 girls and 2 boys) with idiopathic scoliosis treated with the SpineCor brace. The average age at beginning of treatment was 13.1 yrs (10-15). Minimum treatment time was 18 months. 28 participants met the SRS criteria. Angles of the curve before and after bracing based on imaging studies were measured at the beginning and end of the treatment, analyzed and compared. Rehabilitation focused on teaching active corrective movement throughout the brace treatment. A control group was formed of 33 patients, including 21 meeting the SRS criteria, who used the SpineCor dynamic brace but did not participate in the associated exercise programme. RESULTS: Among patients from the exercise group who met the SRS criteria, 25% demonstrated reduced curve angles, 35.7% demonstrated curve progression and 39.3% showed stabilization (no change). Among patients meeting the SRS criteria from the control group, a decrease in curve angle was observed in 14.3% of the patients, curve progression in 57.1% and stabilization in 28.6%. CONCLUSIONS: 1. The addition of a dedicated physiotherapy programme to SpineCor dynamic bracing improves the chances of obtaining a positive outcome. 2. It is necessary to further analyse the course of the comprehensive treatment, also with regard to other types of braces and kinesiotherapy programmes.
Negrini S
PURPOSE: Overweight was found to be a negative predictor of brace effectiveness for adolescent idiopathic scoliosis (AIS), with a threefold higher risk of progression than in normal weight patients. The aim of this study is to investigate overweight, as a predictor of brace results in AIS patients. METHODS: Design: retrospective cohort study. POPULATION: 351 AIS patients (306 females), mean age 12.9 +/- 1.4, mean Cobb 35.6 +/- 11.4 degrees , mean ATR 11 +/- 4.3 degrees , BMI 19.7 +/- 3, median Risser: 2. INCLUSION CRITERIA: no previous treatment, full-time prescription of brace at first visit (18-23 h per day), scoliosis physiotherapeutic exercise according to the SEAS protocol associated. OUTCOME: improved, progressed, and stable according to the 5 degrees Cobb agreed threshold. STATISTICS: a stepwise linear regression was used to look for the effect of BMI as a predictor of result. A Chi-square test and logistic regression were used for the overweight category (BMI >/= 85th percentile). Control for possible confounders was applied. RESULTS: BMI is poorly correlated with final results. Confounders' adjustment did not change the correlation, and the predictive model explained about 10% of the result. Brace results were not statistically different in overweight and normal weight: 44 vs 52% improved, 52 vs 41% stable, and 3 vs 7% worsened, respectively. DISCUSSION: Brace results were similar in overweight and normal weight subjects. These findings subvert the previous results and disprove the role of overweight as a negative predictor. Treatment management, brace type and effectiveness may play a major role in reducing the risks of scoliosis progression.
Qiu Y
STUDY DESIGN: A retrospective study to determine whether brace treatment is appropriate for adolescent idiopathic scoliosis patients with Cobb angle between 40 and 50 degrees who utterly refuse surgery. OBJECTIVE: To investigate whether it is possible to halt the curve progression of adolescent idiopathic scoliosis patients with Cobb angle between 40 and 50 degrees through bracing, and to identify factors that could influence the effectiveness of brace treatment in such patients. SUMMARY OF BACKGROUND DATA: Despite of the great achievements in treating patients with mild curve, bracing has been considered to be inappropriate for those with curves of >40 degrees. However, in clinical practice surgeons could encounter a series of patients who utterly refused surgery and insisted on wearing brace despite having a curve >40 degrees. METHODS: A cohort of 54 patients with Cobb angle between 40 and 50 degrees were reviewed in the current study. All the patients refused surgery at their first visit and insisted on receiving brace treatment. Each patient was followed up at an interval of 3-6 months. Variants such as initial Risser sign, initial age, sex, curve pattern, and initial curve magnitude were compared between patients with and without curve progression. A logistic regression analysis was performed to determine the independent predictors of the curve progression. RESULTS: On the whole, the curve progressed in 35 patients, remained stable in 12 patients, and improved in the else 7 patients. All the patients with curve progression finally received surgical intervention. The mean grade of initial Risser sign in patients with curve progression was significantly lower than that in patients with stable or improved curve (0.3+/-0.8 vs. 1.2+/-1.4, P=0.02). In terms of sex, age, curve pattern, and curve magnitude, there were no significant differences between the 2 categories. The results of the logistic regression analysis showed that initial Risser sign of grade 0 or 1 had significant associations with the curve progression of patients with curves >40 degrees (odds ratio, 7.51, 95% confidence intervak, 1.27-24.43, P=0.02). CONCLUSIONS: The effectiveness of brace treatment significantly decreases when applied to patients with curve magnitude between 40 and 50 degrees. Although a majority of these patients will inevitably undergo a surgical intervention, and thus wearing a brace may not be the best alternative to surgical intervention; there are patients who will stabilize with the brace until skeletal maturity thus warranting this option for those patients refusing surgical intervention with curves between 40 and 50 degrees.
Simunic B
OBJECTIVE: To investigate the effect of a supervised, structured exercise programme on the occurrence and severity of pregnancy-related lumbopelvic pain. DESIGN: Randomized controlled trial. SUBJECTS: A total of 45 pregnant women were randomly assigned to 2 groups: an experimental group (n = 20; mean age 32.8 (standard deviation (SD) 3.6) years) and a control group (n = 22; mean age 32.2 years (SD 4.9)). METHODS: Exercise intervention for the experimental group consisted of aerobic and resistance exercises performed bi-weekly from the date of inclusion into the study until the end of pregnancy, together with at least 30 min of brisk daily walks. A numeric rating scale, Roland-Morris Disability Questionnaire (RMDQ), and Pelvic Girdle Questionnaire (PGQ) were used to measure outcomes. The control group received only standard antenatal care. RESULTS: There were significant differences between the 2 groups on the numeric rating scale, PGQ and RMDQ scores in the 36th week of pregnancy (p = 0.017; p = 0.005; p < 0.001, respectively) in favour of the experimental group. CONCLUSION: The exercise programme had a beneficial effect on the severity of lumbopelvic pain in pregnancy, reducing the intensity of pain and the level of disability experienced as a result.
Guirro RR
OBJECTIVE: To assess the additional effect of static ultrasound and diadynamic currents on myofascial trigger points in a manual therapy program to treat individuals with chronic neck pain. DESIGN: A single-blind randomized trial was conducted. Both men and women, between ages 18 and 45, with chronic neck pain and active myofascial trigger points in the upper trapezius were included in the study. Subjects were assigned to 3 different groups: group 1 (n = 20) was treated with manual therapy; group 2 (n = 20) was treated with manual therapy and static ultrasound; group 3 (n = 20) was treated with manual therapy and diadynamic currents. Individuals were assessed before the first treatment session, 48 hours after the first treatment session, 48 hours after the tenth treatment session, and 4 weeks after the last session. RESULTS: There was no group-versus-time interaction for Numeric Rating Scale, Neck Disability Index, Pain-Related Self-Statement Scale, pressure pain threshold, cervical range of motion, and skin temperature (F-value range, 0.089-1.961; P-value range, 0.106-0.977). Moreover, we found no differences between groups regarding electromyographic activity (P > 0.05). CONCLUSION: The use of static ultrasound or diadynamic currents on myofascial trigger points in upper trapezius associated with a manual therapy program did not generate greater benefits than manual therapy alone.
Wang CH
OBJECTIVE: Neuroimaging studies have revealed that low-back pain (LBP) alters spatiotemporal dynamics of the blood oxygen level-dependent signal in response to persistent noxious stimulus. This study aimed to investigate changes in spontaneous neural activity of various brain regions in acute LBP using resting-state functional magnetic resonance imaging and amplitude of low-frequency fluctuation (ALFF). DESIGN: Twelve healthy subjects underwent two separate resting-state functional magnetic resonance imaging scans at health status as baseline and after intramuscular injection of hypertonic saline (0.5 mL, 5%) into the back muscles to induce acute LBP. RESULTS: Compared with baseline, acute LBP showed decreased ALFF in the right posterior cingulate cortex/precuneus and left primary somatosensory cortex (S1) but increased ALFF in the right medial prefrontal cortex, right middle temporal gyrus, bilateral inferior temporal gyrus, bilateral insula, right anterior cingulate cortex, and left cerebellum. In addition, significant negative correlations were observed between visual analog scale scores and ALFF of the bilateral medial prefrontal cortex, left inferior frontal gyrus, left S1, right anterior cingulate cortex, and left middle temporal gyrus. CONCLUSIONS: These findings suggest that abnormally spontaneous neural activity involving some brain regions are responsible for sensory, affective, and cognitive functions, which may be implicated in the underlying pathophysiology of acute LBP.
Sponseller PD
BACKGROUND: Bracing can effectively treat adolescent idiopathic scoliosis (AIS), but patient outcomes have not been compared by brace type. We compared outcomes of AIS patients treated with Rigo Cheneau orthoses (RCOs) or custom-molded Boston-style thoracolumbosacral orthoses (TLSOs). METHODS: We retrospectively reviewed patient records from one scoliosis center from 1999 through 2014. Patients were studied from initial treatment until skeletal maturity or surgery. Inclusion criteria were a diagnosis of AIS, initial major curve between 25 degrees and 40 degrees , use of an RCO or TLSO, and no previous scoliosis treatment. RESULTS: The study included 108 patients (93 girls) with a mean (+/-standard deviation) age at brace initiation of 12.5 +/- 1.3 years. Thirteen patients wore an RCO, and 95 wore a TLSO. Mean pre-bracing major curves were 32.7 degrees +/- 4.8 degrees in the RCO group and 31.4 degrees +/- 4.4 degrees in the TLSO group (p = 0.387). Mean brace wear time was similar between groups. Mean differences in major curve from baseline to follow-up were -0.4 degrees +/- 9.9 degrees in the RCO group and 6.9 degrees +/- 12.1 degrees in the TLSO group (p = 0.028). Percent changes in major curve from baseline to follow-up were 0.0% +/- 30.5% for the RCO group and 21.3% +/- 38.8% for the TLSO group (p = 0.030). No RCO patients and 34% of TLSO patients progressed to spinal surgery (p = 0.019). At follow-up, major curves improved by 6 degrees or more in 31% of the RCO group and 13% of the TLSO group (p = 0.100). CONCLUSIONS: Patients treated with RCOs compared with Boston-style TLSOs had similar baseline characteristics and brace wear time yet significantly lower rates of spinal surgery. Patients with RCOs also had lower mean and percent major curve progression versus those with TLSOs.
Qiu Y
STUDY DESIGN: A retrospective radiographic study. OBJECTIVE: To evaluate the asymmetry of breast volume (BV) and shape in female adolescent idiopathic scoliosis (AIS) patients and to define their relationship with deformed components of the anterior chest wall and curved spine. SUMMARY OF BACKGROUND DATA: The higher incidence of asymmetric breast development in AIS was described by prior studies. However, the interplay between scoliosis curve magnitude and severity of breast asymmetry (BA) are unknown. METHODS: A total of 73 surgically treated female right thoracic AIS patients classified as Lenke type I were enrolled in this study, with the average Cobb angle being 52.08+/-11.68 degrees. The Image J software was utilized to calculate BV. Both concave and convex radiographic parameters of breast shape were measured including the extraversion angle (EA), the coverage angle (CA), the axial breast height, the vertical breast height (VBH), and the nipple-to-sternum distance. The inclination angles of the concave and convex anterior chest wall were also assessed. BA was calculated according to the formula as follows: BA=(concave-convex)xBV/[(concave+convex)xBV]/2. The measurements of spinal deformity parameters included the Cobb angle, the RAsag angle, and the RAml angle. Paired t test was performed to analyze the asymmetry of breast shape, and Pearson correlation analysis was utilized to define the correlation between the breast shape, spinal deformity, and the inclination of anterior chest wall. RESULTS: The concave BV, EA, axial breast height, and vertical breast height were significantly larger than those of the convex side (P<0.05), whereas the concave CA and the inclination angle of the anterior chest wall were significantly smaller than those of the convex side (P<0.05). No difference was detected between the concave and the convex nipple-to-sternum distance (P>0.05). The averaged BA was 11.4%, with the ratio of asymmetry beyond 10% being 52.1%. No statistically significant relationships between BA and Cobb angle, RAsag angle, RAml angle were detected (P>0.05). The inclination angle of the anterior chest wall demonstrated significant correlation with EA (P<0.001) and CA (P<0.001), respectively. CONCLUSIONS: The incidence of BA in AIS is notable, with the concave breast being larger, more extroversive, and more concentrated than the convex breast. The discrepancy between concave and convex anterior chest wall inclination bound to scoliosis could have a major influence on breast orientation and profile, suggesting a synergistic role of anterior chest wall deformity and bilateral BV discrepancy in the formation of BA.
Rudnick SB, Zabriskie H, Ho J, Gurnett CA, Dobbs MB
Does scoliosis severity increase scoliosis risk or severity in relatives? In a cohort of 1257 severe idiopathic scoliosis patients, the percentage with at least one affected relative was compared across the categories of patient sex, major curve severity (Cobb angle), and treatment method. In total, 138 (11%) of 1257 patients had at least one affected first-degree relative and 59 (5%) had at least one affected second-degree relative. As expected, males were more likely to have affected first-degree relatives than females (18 vs. 10% with a risk difference of -0.0864) [95% confidence interval (CI): -0.14 to -0.03; P=0.0002]. However, the major curve severity of the patient (<25 degrees , 25 degrees -49 degrees , and >/=50 degrees ) did not impact the prevalence of having at least one affected relative (P=0.69). Surgically treated patients had no greater risk than nonsurgically treated patients of having either an affected relative or a surgically treated relative [11 vs. 11% (odds ratio: 0.912; 95% CI: 0.640-1.299, P=0.61), 6 vs. 5% (OR: 0.788; 95% CI: 0.485-1.280, P=0.34), respectively]. Therefore, our data suggest that scoliosis severity does not independently influence the risk of either scoliosis or its severity in family members.
Lonner BS, Ren Y, Yaszay B, Cahill PJ, Shah SA, Betz RR, Samdani AF, Shufflebarger HL, Newton PO
STUDY DESIGN: Retrospective review of a prospective Adolescent Idiopathic Scoliosis (AIS) registry OBJECTIVE.: To study the evolution of the operative approach, outcomes and complication rates in AIS surgery over the past 20 years. METHODS: 1819 AIS patients (1995-2013) with 2-year F/U were studied. Operative approach, perioperative parameters, major complication rates, and SRS outcomes were assessed. Linear regression was used to assess the trend of changes over 5-year quartiles. RESULTS: Mean age at surgery was 14.6 +/- 2.1years, 80.2% were females and this remained consistent throughout. Operative time, EBL/level and LOS decreased over the 20 years (p < 0.0001). The use of antifibrinolytic (AF) increased from 6.7 to 68.8% in the past 10 years (p < 0.0001). # levels fused increased and LIV was more distal (in relation to stable vertebrae) over time in Lenke 1&2 curves (levels fused 7.97 to 9.94, p < 0.0001 and 9.8 to 11.0, p=0.0134, respectively). Anterior spinal fusion (ASF) in Lenke 1 curves decreased from 81% in the 1 quartile to 0% in the last (p = 0.0429). ASF for Lenke 5 curves evolved from 78% in the 2 quartile to 0 in the last. Thoracoplasty performance decreased from 76% to 20.3% (p = 0.1632). All screw constructs in PSF cases increased from 0 to 98.4% (p = 0.0095). 2-year major complication rates decreased over time (18.7% to 5.1%; p = 0.0173). Increased improvement in SRS scores were observed in pain, image, function and total domains. CONCLUSION: Evolution of surgical technique in AIS over the past 20 years has resulted in a cessation of anterior only surgery, increasing use of all screw constructs, less blood loss, greater use of AF, shorter operative times and LOS, lower major complications rates and greater improvements in SRS scores. LEVEL OF EVIDENCE: 2.
Cohen SP, Hooten WM
Neck pain imposes a considerable personal and socioeconomic burden-it is one of the top five chronic pain conditions in terms of prevalence and years lost to disability-yet it receives a fraction of the research funding given to low back pain. Although most acute episodes resolve spontaneously, more than a third of affected people still have low grade symptoms or recurrences more than one year later, with genetics and psychosocial factors being risk factors for persistence. Nearly half of people with chronic neck pain have mixed neuropathic-nociceptive symptoms or predominantly neuropathic symptoms. Few clinical trials are dedicated solely to neck pain. Muscle relaxants and non-steroidal anti-inflammatory drugs are effective for acute neck pain, and clinical practice is mostly guided by the results of studies performed for other chronic pain conditions. Among complementary and alternative treatments, the strongest evidence is for exercise, with weaker evidence supporting massage, acupuncture, yoga, and spinal manipulation in different contexts. For cervical radiculopathy and facet arthropathy, weak evidence supports epidural steroid injections and radiofrequency denervation, respectively. Surgery is more effective than conservative treatment in the short term but not in the long term for most of these patients, and clinical observation is a reasonable strategy before surgery.
Turgut E, Gur G, Ayhan C, Yakut Y, Baltaci G
The scapula plays a critical role in supporting shoulder function. Considering the closed anatomical relationship between the scapula and the thoracic cage, the presence of postural disturbances could be linked to alterations in the scapular position and orientation in adolescent idiopathic scoliosis (AIS). However, currently there is a lack of descriptive research and detailed assessment of scapular kinematics in AIS. The aim of this study was to investigate the three-dimensional scapular kinematics in AIS. Nineteen AIS patients and fourteen healthy controls participated in this study. Bilateral shoulder kinematics were measured with an electromagnetic tracking device during shoulder elevation in the sagittal, scapular, and frontal planes. Data for the scapular orientation were analyzed in the resting position and at 30 degrees , 60 degrees , 90 degrees , and 120 degrees of humerothoracic elevation. Scapular behavior was different in participants with AIS, compared to healthy controls, with different patterns observed on convex and concave sides. While examining all three planes of elevation, the scapula was more internally and anteriorly tilted on the convex side, while the scapula was more externally, downwardly rotated, and posteriorly tilted on the concave side in participants with AIS. Furthermore, there was a decreased peak humerothoracic elevation and altered scapular posterior tilt in participants with AIS in the resting position. These findings increase our knowledge and understanding of scapular alterations and the reported scapular alterations can be considered as adaptive compensation strategies in AIS.
Gomez JA, Grzywna A, Miller PE, Karlin LI, Garg S, Sanders JO, Sturm PF, Sponseller PD, D'Astous JL, Glotzbecker MP
BACKGROUND: Cast treatment for infantile idiopathic scoliosis patients ultimately corrects deformity in varying amounts. As the reasons for these differential outcomes are not fully elucidated, the aim of this study was to identify clinical and radiographic variables correlated with better cast correction. METHODS: Patients in the Children's Spine Study Group and Growing Spine Study Group registries who underwent cast treatment for idiopathic scoliosis between 2005 and 2013 with 1-year minimum follow-up were included. Data including major curve and rib-vertebra angle difference before cast, initial in-cast application, after cast treatment, and at most recent follow-up were collected. Univariable and multivariable regression analyses were used to identify factors associated with lower major curves at most recent follow-up. RESULTS: A total of 68 patients were identified and followed for a mean of 2.5 (range, 1.1 to 5.4) years after cast treatment. Cast treatment lasted an average of 16.7 months, with a median of 6 cast applications (range, 2 to 19). Twenty-five subjects (37%) had a most recent major curve <15 degrees (success), whereas 43 had a curve that was >15 degrees (unresolved). Multivariable linear regression determined that younger age (P=0.02), smaller precast major curve (P<0.001), and greater percent major curve correction in initial cast (P=0.006) were associated with smaller major curve at most recent follow-up. Multivariable logistic regression determined that success patients were younger than unresolved patients (average age, 1.4 vs. 2.1 y; P=0.003), and had smaller in-cast major curves after initial cast application (average, 18 vs. 27 degrees; P=0.002). CONCLUSIONS: Infantile idiopathic scoliosis patients casted at an earlier age, with smaller major curves, and greater percent major curve correction in initial cast have the best prognosis. Patients' percent major curve correction, which may represent curve flexibility and/or cast quality, is a predictor of treatment success when age and precast major curve are also taken into account. LEVEL OF EVIDENCE: Level III-retrospective study.
Lutz GE
OBJECTIVE: To determine whether single injections of autologous platelet-rich plasma (PRP) into symptomatic degenerative intervertebral disks will improve participant-reported pain and function. DESIGN: Prospective, double-blind, randomized controlled study. SETTING: Outpatient physiatric spine practice. PARTICIPANTS: Adults with chronic (>/=6 months), moderate-to-severe lumbar diskogenic pain that was unresponsive to conservative treatment. METHODS: Participants were randomized to receive intradiskal PRP or contrast agent after provocative diskography. Data on pain, physical function, and participant satisfaction were collected at 1 week, 4 weeks, 8 weeks, 6 months, and 1 year. Participants in the control group who did not improve at 8 weeks were offered the option to receive PRP and subsequently followed. MAIN OUTCOME MEASURES: Functional Rating Index (FRI), Numeric Rating Scale (NRS) for pain, the pain and physical function domains of the 36-item Short Form Health Survey, and the modified North American Spine Society (NASS) Outcome Questionnaire were used. RESULTS: Forty-seven participants (29 in the treatment group, 18 in the control group) were analyzed by an independent observer with a 92% follow-up rate. Over 8 weeks of follow-up, there were statistically significant improvements in participants who received intradiskal PRP with regards to pain (NRS Best Pain) (P = .02), function (FRI) (P = .03), and patient satisfaction (NASS Outcome Questionnaire) (P = .01) compared with controls. No adverse events of disk space infection, neurologic injury, or progressive herniation were reported following the injection of PRP. CONCLUSION: Participants who received intradiskal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared with controls. Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up. Although these results are promising, further studies are needed to define the subset of participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP injectate.
Battistella LR
BACKGROUND: The lumbar back and hip muscles are important for a normal functioning of the human spine and they are considered to be of etiological significance in chronic nonspecific low back pain (nCLBP). Inactivity and a lower level of physical activity in patients with nCLBP may change muscle characteristics and may be associated with pain and disability. Pressure algometry has been found to be non-invasive, efficient and reliable in the exploration of physio-pathological mechanisms involved in muscle pain syndromes. The subjective characteristic of the pressure pain thresholds (PPTs) cannot be avoided once it is the very objective of the measurement, i.e. the minimum pain perceptible by the person, is a subjective factor. Most studies have revealed gender differences between PPTs, with females showing lower thresholds. OBJECTIVE: to determine whether demographic variables and PPTs, are related pain intensity and a disability in patients with nCLBP. METHODS: One hundred and twenty-four patients with nCLBP were included in the study. The Visual Analogue Scale (VAS) and the Roland-Morris Questionnaire for Low Back Pain (RM) were used to evaluate the intensity of pain and degree of disability. The PPT was performed from L1 up to S2 dermatomes, at the muscles over the Gluteus medius, minimus and maximus, including a point located at the level of the piriformis, at the Quadratus lumborum, at the Iliopsoas and points of reference located at the level of the L1 up to L5 ligaments. The pain intensity was assessed by visual analogue scale (VAS) and the lumbar function by Roland Morris questionnaire (RM). Multiple linear regression models were used for both the VAS and the RM. RESULTS: No significant differences were found between the PPTs measured at either left or right limb. The mean VAS value was 7.3 (+/- 1.5) and the RM score was 14.2 (+/- 5.3). The PPT-values showed significant negative correlations to the VAS and the RM. The highest correlation between the mean VAS and PPT-values were found at the level of the Gluteus medius (r= -0.34, p< 0.001), which was the only measurement correlated to the intensity of pain (r2 = 0.11, p< 0.001). The RM was correlated to the BMI, the level of education and the PPT values at the level of the Iliopsoas muscle and the L4-L5 supraspinous ligament. CONCLUSIONS: This study showed that most PPT values are correlated to the VAS and the RM. Nevertheless, the variability explained by PPT values and demographic characteristics was low for pain intensity and function.
Friedly JL
STUDY DESIGN: Secondary analysis of lumbar epidural steroid injections for spinal stenosis randomized controlled trial data. OBJECTIVE: To reevaluate whether outcomes for older adults receiving epidural steroid injections with or without corticosteroid improve after using patient-prioritized Roland-Morris Disability Questionnaire (RDQ) items. SUMMARY OF BACKGROUND DATA: Epidural corticosteroid injections are commonly used to treat lumbar spinal stenosis symptoms, despite limited evidence for their effectiveness in clinical trials. It is unclear whether evaluating patient-prioritized outcomes would alter results of a large clinical trial. METHODS: Outcomes from the trial of lumbar epidural corticosteroid injections for spinal stenosis (LESS) trial were reanalyzed using RDQ, Sickness Impact Profile (SIP) weights assigned to the RDQ items, and patient-prioritized RDQ items. Differences between corticosteroid + lidocaine versus lidocaine-alone groups and 95% confidence intervals (CI) were calculated using analysis of covariance with adjustment for baseline values of the RDQ and recruitment site. RESULTS: At 6 weeks, both the corticosteroid + lidocaine group and the lidocaine-alone group had improvement in the RDQ scores (RDQ, RDQ using SIP weights, patient-prioritized RDQ) as compared with baseline scores (corticosteroid + lidocaine: -4.2 points, -4.1 points, -4.2; lidocaine-alone: -3.1 points, -2.9 points, and -3.1 points, respectively). However, there was no significant between-group difference in the RDQ or patient-prioritized RDQ (average treatment effect -1.0 points, 95% CI -2.1 to 0.1, P = 0.07; -1.0 points, 95% CI -2.0 to 0.1, P = 0.08, respectively). Although the between-group difference of RDQ using SIP weights was statistically significant (average treatment effect -1.1, 95% CI -2.2 to -0.1, P = 0.04), this was not clinically important. CONCLUSION: Results of the LESS trial did not substantively differ based on reanalysis of data using RDQ with SIP weights or patient-prioritized RDQ outcomes. This provides additional evidence that epidural injection of corticosteroid + lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone for older adults with lumbar spinal stenosis. LEVEL OF EVIDENCE: 2.
Lee CS
BACKGROUND: Failed back surgery syndrome (FBSS) is a frequently encountered disease entity following lumbar spinal surgery. Although many plausible reasons have been investigated, the exact pathophysiology remains unknown. Various medications, reoperations, interventions such as spinal cord stimulation, epidural adhesiolysis or epidural injection, exercise therapy, and psychotherapy have been suggested treatment options. However, the evidence of the clinical outcome for each treatment has not been clearly determined. OBJECTIVES: To evaluate the outcomes of each treatment modality and to present treatment guidelines for patients with FBSS. STUDY DESIGN: A systematic review of each treatment regimen in patients with FBSS. METHODS: The available literature regarding each modality for the treatment of refractory back pain or radiating pain for FBSS was reviewed. The quality assessment and the level of evidence were analyzed using the "Methodology Checklist" of SIGN (Scottish Intercollegiate Guidelines Network). Data sources included relevant English language literature identified through searches of Pubmed, EMBASE, and Cochrane library from 1980 to Feb 2016. The primary outcome measure was pain relief of back pain or radiating pain for at least 3 months. Secondary outcome measures were improvement of the patient's functional status, health-related quality of life, return to work, and reduction of opioid use. RESULTS: Twenty-three articles were finally identified and reviewed. Based on our analysis, epidural adhesiolysis showed a short-term (6 to 24 months) effect (grade A) and spinal cord stimulation showed a mid-term (2 or 3 years) effect (grade B). Epidural injections showed a short-term (up to 2 years) effect (grade C). However, other treatments were recommended as grade D or inconclusive. LIMITATIONS: The limitations of this systematic review included the rarity of relevant literature. CONCLUSIONS: Epidural adhesiolysis or spinal cord stimulation can be effective in order to control chronic back pain or leg pain due to FBSS, and its recommendation grades are A and B, respectively. Other treatments showed poor or inconclusive evidence.Key words: Failed back surgery syndrome, post spinal surgery syndrome, chronic low back pain, post lumbar surgery syndrome, epidural adhesiolysis, spinal cord stimulation, epidural injection, revision.
Forciea MA
Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain. Methods: Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects. Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain. Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation). Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation). Recommendation 3: In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).