Endplate defect is an MRI trait, found to be associated with intervertebral disc degeneration. There is a lack of understanding regarding the mechanism underlying lumbar disc degeneration (LDD). This large-scale longitudinal population-based study aimed to determine the order of appearance of degenerative change in the vertebral body and intervertebral disc, the influence of endplate degeneration on LBP and whether there is a genetic influence on endplate damage. Individuals from the TwinsUK spine study having longitudinal T2-weighted lumbar MRI scans at baseline (n=996) and a decade later (n=438) were included. LDD, vertebral endplate defect expressed as a total endplate (TEP) score and Modic change (MC) were assessed using standard techniques. Mixed-effects models were used to determine the association between spine pathology features adjusted for covariates. Endplate defect heritability was estimated using variance component analysis.Background
Methods
The aim of this study was to investigate the agreement of physician assistants (PAs) in the triaging of patients with Low Back Pain (LBP) based on self-reported data. A cross sectional vignette study among four PAs was carried out. Vignettes (cases) were constructed including 26 factors that can be self-reported, identified in literature that have predictive value in treatment outcomes (for example red flags indicating serious underlying conditions and yellow flags indicating psychosocial factors). All vignettes were randomly assigned to the PAs who should determine what intervention would be most optimal to the patient (rehabilitation, injections, medications, surgery, primary care psychology, primary care physical therapy). PAs were allowed to advise more than one intervention. Per vignette, 3 PAs were assigned randomly to advise on intervention. Fleish kappas were calculated to determine the interrater reliability.Aims
Patients and methods
The behavioural change wheel methodology and social cognitive theory were combined to inform and develop a rehabilitation programme following lumbar fusion surgery (REFS). This qualitative study evaluated participant's experiences of lumbar fusion surgery, including REFS, to identify valued programme content (‘active ingredients’). A feasibility-RCT suggested REFS achieved a meaningful impact in disability and pain self-efficacy compared to ‘usual care’ (p=0.014, p=0.007). In keeping with MRC guidance a qualitative evaluation was undertaken to understand possible mechanisms of action.Purpose
Background
Back pain guidelines endorse giving advice to enable people to self-manage and continue normal activities. Little is known however, about the content of advice that clinicians give and this project aimed to identify the advice given by physiotherapists to patients with back pain at their initial consultation. Twenty-five audio-recordings of patients with back pain and physiotherapists in a primary care outpatient department were collected, transcribed, coded and thematically analysed using a Framework approach to identify the content of advice given.Purpose and background
Patients and methods
Patients with Neck and/or Low Back Pain (NLBP) constitute a heterogeneous group with the prognosis and precise mix of factors involved varying substantially between individuals. This means that a one-size-fits-all approach is not recommended, but methods to tailor treatment to the individual needs are still relatively under-developed. Moreover, the fragmentation of disciplines involved in its study hampers achieving sound answers to clinical questions. Data mining techniques open new horizons by combining data from existing datasets, in order to select the best treatment at each moment in time to a patient based on the individual characteristics. Within the Back-UP project (H2020 #777090) a multidisciplinary consortium is creating a prognostic model to support more effective and efficient management of NLBP, based on the digital representation of multidimensional clinical information. Patient-specific models provide a personalized evaluation of the patient case, using multidimensional health data from the following sources: (1) psychological, behavioral, and socioeconomic factors, (2) biological patient characteristics, including musculoskeletal structures and function, and molecular data, (3) workplace and lifestyle risk factors.Background
Method
The aim of this study was to explore the prognostic factors for postoperative neurological recovery and survival in patients with complete paralysis due to neoplastic epidural spinal cord compression. The medical records of 135 patients with complete paralysis due to neoplastic cord compression were retrospectively reviewed. Potential factors including the timing of surgery, muscular tone, and tumour characteristics were analyzed in relation to neurological recovery using logistical regression analysis. The association between neurological recovery and survival was analyzed using a Cox model. A nomogram was formulated to predict recovery.Aims
Patients and Methods
During revision procedures for aseptic reasons, there remains a suspicion that failure may have been the result of an undetected subclinical infection. However, there is little evidence available in the literature about unexpected positive results in presumed aseptic revision spine surgery. The aims of our study were to estimate the prevalence of unexpected positive culture using sonication and to evaluate clinical characteristics of these patients. All patients who underwent a revision surgery after instrumented spinal surgery at our institution between July 2014 and August 2016 with spinal implants submitted for sonication were retrospectively analyzed. Only revisions presumed as aseptic are included in the study. During the study period, 204 spinal revisions were performed for diagnoses other than infection. In 38 cases, sonication cultures were not obtained, leaving a study cohort of 166 cases. The mean age of the cohort was 61.5 years (Aims
Patients and Methods
HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients’ CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them. Between January 2014 and December 2015, 63 consecutive cases of spontaneous spondylodiscitis were identified from a single-centre, prospectively maintained database. Demographics, presenting symptoms, blood results, HIV status, bacteriology, imaging, and procedure undertaken were reviewed and comparisons made of TB, non-TB, and HIV groups. There were 63 patients (22 male, 41 female) with a mean age of 42.0 years (11 to 78; Aims
Patients and Methods
The aims of this study were to determine the rates of surgical complications, reoperations, and readmissions following herniated lumbar disc surgery, and to investigate the impact of sociodemographic factors and comorbidity on the rate of such unfavourable events. This was a longitudinal observation study. Data from herniated lumbar disc operations were retrieved from a large medical database using a combination of procedure and diagnosis codes from all public hospitals in Norway from 1999 to 2013. The impact of age, gender, geographical affiliation, education, civil status, income, and comorbidity on unfavourable events were analyzed by logistic regression.Aims
Patients and Methods
The aim of this study was to determine the diagnostic utility of histological analysis in spinal biopsies for spondylodiscitis (SD). Clinical features, radiology, results of microbiology, histology, and laboratory investigations in 50 suspected SD patients were evaluated. In 29 patients, the final (i.e. treatment-based) diagnosis was pyogenic SD; in seven patients, the final diagnosis was mycobacterial SD. In pyogenic SD, the neutrophil polymorph (NP) infiltrate was scored semi-quantitatively by determining the mean number of NPs per (×400) high-power field (HPF).Aims
Patients and Methods
Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients. We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100).Aims
Patients and Methods
The aim of this study was to determine the influence of developmental spinal stenosis (DSS) on the risk of re-operation at an adjacent level. This was a retrospective study of 235 consecutive patients who had undergone decompression-only surgery for lumbar spinal stenosis and had a minimum five-year follow-up. There were 106 female patients (45.1%) and 129 male patients (54.9%), with a mean age at surgery of 66.8 years (Aims
Patients and Methods
The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation. A total of 134 haemodialyzed patients aged more than 50 years who underwent surgical treatment for pyogenic spondylodiscitis were included in the study. Their mean age was 66.4 years (50 to 83); 66 were male (49.3%) and 68 were female (50.7%). They were divided into two groups according to whether spinal instrumentation was used or not. Propensity score matching was used to attenuate the potential selection bias. The outcome of treatment was compared between these two groups.Aims
Patients and Methods
The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12).Aims
Patients and Methods
The aim of this study was to investigate the impact of maturity status at the time of surgery on final spinal height in patients with an adolescent idiopathic scoliosis (AIS) using the spine-pelvic index (SPI). The SPI is a self-control ratio that is independent of age and maturity status. The study recruited 152 female patients with a Lenke 1 AIS. The additional inclusion criteria were a thoracic Cobb angle between 45° and 70°, Risser 0 to 1 or 3 to 4 at the time of surgery, and follow-up until 18 years of age or Risser stage 5. The patients were stratified into four groups: Risser 0 to 1 and selective fusion surgery (Group 1), Risser 0 to 1 and non-selective fusion (Group 2), Risser 3 to 4 and selective fusion surgery (Group 3), and Risser 3 to 4 and non-selective fusion (Group 4). The height of spine at follow-up (HOSf) and height of pelvis at follow-up (HOPf) were measured and the predicted HOS (pHOS) was calculated as 2.22 (SPI) × HOPf. One-way analysis of variance (ANOVA) was performed for statistical analysis.Aims
Patients and Methods
The purpose of this retrospective study was to investigate the
clinical relevance of increased facet joint distraction as a result
of anterior cervical decompression and fusion (ACDF) for trauma. A total of 155 patients (130 men, 25 women. Mean age 42.7 years;
16 to 87) who had undergone ACDF between 1 January 2001 and 1 January
2016 were included in the study. Outcome measures included the Neck
Disability Index (NDI) and visual analogue scale (VAS) for pain.
Lateral cervical spine radiographs taken in the immediate postoperative
period were reviewed to compare the interfacet distance of the operated
segment with those of the facet joints above and below.Aims
Patients and Methods
Magnetically controlled growing rod (MCGR) systems use non-invasive
spinal lengthening for the surgical treatment of early-onset scoliosis
(EOS). The primary aim of this study was to evaluate the performance
of these devices in the prevention of progression of the deformity.
A secondary aim was to record the rate of complications. An observational study of 31 consecutive children with EOS, of
whom 15 were male, who were treated between December 2011 and October
2017 was undertaken. Their mean age was 7.7 years (2 to 14). The
mean follow-up was 47 months (24 to 69). Distractions were completed
using the tailgating technique. The primary outcome measure was
correction of the radiographic deformity. Secondary outcomes were
growth, functional outcomes and complication rates.Aims
Patients and Methods
The surgical treatment of tuberculosis (TB) of the spine consists
of debridement and reconstruction of the anterior column. Loss of
correction is the most significant challenge. Our aim was to report
the outcome of single-stage posterior surgery using bone allografts
in the management of this condition. The study involved 24 patients with thoracolumbar TB who underwent
single-stage posterior spinal surgery with a cortical bone allograft
for anterior column reconstruction and posterior instrumentation
between 2008 and 2015. A unilateral approach was used for 21 patients
with active TB, and a bilateral approach with decompression and closing-opening
wedge osteotomy was used for three patients with healed TB.Aims
Patients and Methods
There is little information about the optimum number of implants
to be used in the surgical treatment of idiopathic scoliosis. Retrospective
analysis of prospectively collected data from the Swedish spine
register was undertaken to discover whether more implants per operated
vertebra (implant density) leads to a better outcome in the treatment of
idiopathic scoliosis. The hypothesis was that implant density is
not associated with patient-reported outcomes, the correction of
the curve or the rate of reoperation. A total of 328 patients with idiopathic scoliosis, aged between
ten and 20 years at the time of surgery, were identified in the
Swedish spine register (Swespine) and had patient reported outcomes
including the Scoliosis Research Society 22r instrument (SRS-22r)
score, EuroQol 5 dimensions quality of life, 3 level (EQ-5D-3L)
score and a Viual Analogue Score (VAS) for back pain, at a mean
follow-up of 3.1 years and reoperation data at a mean follow-up
of 5.5 years. Implant data and the correction of the curve were
assessed from radiographs, preoperatively and a mean of 1.9 years
postoperatively. The patients were divided into tertiles based on
implant density. Data were analyzed with analysis of variance, logistic
regression or log-rank test. Some analyses were adjusted for gender,
age at the time of surgery, the flexibility of the major curve and
follow-up.Aims
Patients and Methods
The aim of this study was to compare the outcomes of surgery
using growing rods in patients with severe A review of a multicentre EOS database identified 107 children
with severe EOS (major curve ≥ 90°) treated with growing rods before
the age of ten years with a minimum follow-up of two years and three
or more lengthening procedures. From the same database, 107 matched
controls with moderate EOS were identified.Aims
Patients and Methods
Although we often encounter patients with an aortic aneurysm
who also have diffuse idiopathic skeletal hyperostosis (DISH), there
are no reports to date of an association between these two conditions
and the pathogenesis of DISH remains unknown. This study therefore
evaluated the prevalence of DISH in patients with a thoracic aortic
aneurysm (AA). The medical records of 298 patients who underwent CT scans for
a diagnosis of an AA or following high-energy trauma were retrospectively
examined. A total of 204 patients underwent surgery for an AA and
94 had a high-energy injury and formed the non-AA group. The prevalence
of DISH was assessed on CT scans of the chest and abdomen and the
relationship between DISH and AA by comparison between the AA and
non-AA groups.Aims
Patients and Methods
The aim of this study was to investigate the clinical and radiographic
outcomes of microendoscopic laminotomy in patients with lumbar stenosis
and concurrent degenerative spondylolisthesis (DS), and to determine
the effect of this procedure on spinal stability. A total of 304 consecutive patients with single-level lumbar
DS with concomitant stenosis underwent microendoscopic laminotomy
without fusion between January 2004 and December 2010. Patients
were divided into two groups, those with and without advanced DS
based on the degree of spondylolisthesis and dynamic instability. A
total of 242 patients met the inclusion criteria. There were 101
men and 141 women. Their mean age was 68.1 years (46 to 85). Outcome
was assessed using the Japanese Orthopaedic Association and Roland
Morris Disability Questionnaire scores, a visual analogue score
for pain and the Short Form Health-36 score. The radiographic outcome
was assessed by measuring the slip and the disc height. The clinical
and radiographic parameters were evaluated at a mean follow-up of
4.6 years (3 to 7.5).Aims
Patients and Methods
The aim of this study was to compare the peak pull-out force
(PPF) of pedicle-lengthening screws (PLS) and traditional pedicle
screws (TPS) using instant and cyclic fatigue testing. A total of 60 lumbar vertebrae were divided into six groups:
PLS submitted to instant pull-out and fatigue-resistance testing
(groups A1 and A2, respectively), TPS submitted to instant pull-out
and fatigue-resistance testing (groups B1 and B2, respectively)
and PLS augmented with 2 ml polymethylmethacrylate, submitted to
instant pull-out and fatigue-resistance testing (groups C1 and C2,
respectively). The PPF and normalized PPF (PPFn) for bone mineral density
(BMD) were compared within and between all groups.Aims
Materials and Methods
The primary aim of this study was to evaluate the performance
and safety of magnetically controlled growth rods in the treatment
of early onset scoliosis. Secondary aims were to evaluate the clinical
outcome, the rate of further surgery, the rate of complications,
and the durability of correction. We undertook an observational prospective cohort study of children
with early onset scoliosis, who were recruited over a one-year period
and followed up for a minimum of two years. Magnetically controlled
rods were introduced in a standardized manner with distractions
performed three-monthly thereafter. Adverse events which were both related
and unrelated to the device were recorded. Ten children, for whom
relevant key data points (such as demographic information, growth
parameters, Cobb angles, and functional outcomes) were available,
were recruited and followed up over the period of the study. There
were five boys and five girls. Their mean age was 6.2 years (2.5
to 10).Aims
Patients and Methods
The aim of this study was to evaluate improvements in the quality
and safety of paediatric spinal surgery following the implementation
of a specialist Paediatric Spinal Surgical Team (PSST) in the operating
theatre. A retrospective consecutive case study of paediatric spinal operations
before (between January 2008 and December 2009), and after (between
January 2012 and December 2013) the implementation of PSST, was
performed. A comparative analysis of outcome variables including
surgical site infection (SSI), operating time (ORT), blood loss (BL),
length of stay (LOS), unplanned staged procedures (USP) and transfusion
rates (allogenic and cell-saver) was performed between the two groups.
The rate of complications during the first two postoperative years
was also compared between the groups.Aims
Patients and Methods
Low back pain (LBP) is a major health challenge globally. Research has identified common trajectories of pain over time. We aimed to investigate whether trajectories described in one primary care cohort can be confirmed in another, and to determine the prognostic value of factors collected 5 years prior to the identification of the trajectory. The study was carried out on 281 patients who had consulted primary care for LBP, at that point completed a baseline questionnaire, and then returned a questionnaire at 5-years follow-up plus at least 3 (of 6) subsequent monthly questionnaires. Baseline factors were measured using validated tools. Pain intensity scores from the 5-year follow-up and monthly questionnaires were used to cluster participants into 4 previously derived pain trajectories (no or occasional mild, persistent mild, fluctuating, persistent severe), using latent class analysis. Posterior probabilities of belonging to each cluster were estimated for each participant. The posterior probabilities for the assigned clusters were very high (>0.90) for each cluster except for the smallest ‘fluctuating’ cluster (0.74). Lower social class (OR 2.9; 95% CI 1.2, 7.0), higher pain intensity (1.6 per unit; 1.2, 2.2), and pain duration greater than 3 years (2.7; 1.0, 7.3), were significantly associated with a more severe trajectory 5-years later, as were higher physical disability, emotional impact of pain, and perception pain will last a long time.Background and objectives
Methods and results
Chronic pain is a complex condition that demonstrates better outcomes in multidisciplinary rehabilitation, typically delivered to groups of patients by tertiary healthcare teams. An inter-disciplinary pain management course for individual patients was developed to increase the scope of physical therapists working in primary care by integrating osteopathic manual therapy with psychological interventions from Acceptance and Commitment Therapy (ACT), a form of ‘3rd wave’ Cognitive Behaviour Therapy. A single cohort study with pre-course (n=180) and post-course (n=79) self-report measures (44% response rate) evaluated six week interventions which combined individual manual therapy with self-management, delivered by teams of qualified and student osteopaths. Data included: quality of life (European Quality of Life Questionnaire); pain, mood and coping (Bournemouth Questionnaire); psychological flexibility (Revised Acceptance and Action Questionnaire); and mindfulness (Freiburg Mindfulness Inventory). Participants were predominantly female (68%), unemployed (59%), with an average age of 49 and pain duration of more than 12 months (86%). Commonly reported symptoms were low back pain (82%), neck pain (60%) and multiple sites (86%). At six months, there were statistically significant improvements in all four outcome measures (p<0.0005), with promising effect sizes in quality of life and pain coping (r=0.52) which appeared to be mediated by changes in psychological flexibility.Background
Method and Results
Patients with sciatica experience high levels of disability and poor outcomes and treatment has demonstrated, at best, only modest success. To be effective, management strategies must be informed by patients' perceptions about ‘what matters’ about experiencing this condition. The aim of this paper is to explore the lived experience of sciatica and to consider the implications for clinical practice. In this qualitative study, based on the principles of interpretative phenomenological analysis, 14 participants with a clinical presentation of sciatica of likely nerve root origin were purposively recruited from an NHS, Primary Care Musculoskeletal Service in the UK. Individual, semi-structured interviews were used to collect data, which were audio-recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically. Sciatica was experienced as a protracted journey of acute exacerbations of uncontrolled and incapacitating symptoms that were overwhelming and difficult to make sense of. Adversely affecting almost all aspects of life, participants struggled to maintain their physical, functional and financial independence; their important relationships; social networks and the roles and activities that provided joy and purpose. The impact of sciatica was a ‘life on hold’; an altered sense of self and an uncertain future. For three participants, the experience of sciatica was sufficiently distressing for them to contemplate suicide.Background and purpose of the study
Methods and results
This research project explored the experiences, attitudes, beliefs, and perceptions of healthcare professionals (physiotherapists and orthopaedic surgeons) and people with chronic low back pain (CLBP) regarding the barriers and facilitators to activity normalisation following physiotherapy. A qualitative study of the perspectives of patients, physiotherapists and orthopaedic surgeons on CLBP was undertaken in Saudi Arabia. One focus group discussion was conducted with seven patients who had received physiotherapy for CLBP, along with one focus group discussion with eight physiotherapists and seven individual interviews with orthopaedic surgeons. The focus group discussions and interviews were transcribed and analysed using framework analysis.Purpose
Methods
Given the predominant functional role which aggrecan has in the intervertebral disc, particularly within the nucleus pulposus, it is necessary to evaluate the quality of aggrecan produced by cells within tissue engineered disc constructs. The aim here was to characterise the nanostructure of aggrecan synthesised by nucleus pulposus cells treated with growth differentiation factor [GDF]-6) seeded in hydrogels in comparison to aggrecan isolated from healthy disc. Aggrecan was isolated from bovine nucleus pulposus (NP) tissue (n=3 [<18 months old]) and primary bovine NP cells cultured with (+GDF6) or without GDF6 (−GDF6) for 28 days (n=2) in type I collagen hydrogels. Isolated aggrecan monomers were visualised by atomic force microscopy and categorised as either intact (globular domains visible at both the N and C termini) or non-intact. Core protein contour length (LCP) was calculated for intact molecules. The proportion of non-intact/fragmented to intact aggrecan and the molecular area of all monomers was determined.Introduction
Methods
The use of Patient Reported Outcome Measures (PROMs) to measure effectiveness of care, and supporting patient management is being advocated increasingly. When evaluating outcome it is important to identify a PROM with good measurement properties. To review the measurement properties of the low back and neck versions of the Bournemouth Questionnaire.Background to the study
Purpose of the study
Pain related distress is associated with poor low back pain outcomes, and is challenging for practitioners to address. This study investigated osteopaths' beliefs about the relationship between chronic pain (CP) and distress (D). The research aimed to explore how patient's distress is understood and managed by osteopath educator clinicians with an interest in the field. A qualitative research design using a constructivist grounded theory analytical approach was used to analyse semi-structured interviews. A purposive sample of seven osteopaths working at the British School of Osteopathy (BSO) with experience with CP-D was recruited. Data collection and analysis were carried out simultaneously. Audio-recording, verbatim-transcriptions, memos-writing and diary-keeping were used to develop themes and theory. Three main themes were identified: osteopaths understanding of the CP-D presentation, evaluation and assessment of the CP-D patient, the role of the osteopath and therapist-patient interaction in CP-D treatment. Three sub-themes were developed for each theme.Purpose and background
Methods and results
Numerous approaches are recommended for the management of non-specific neck pain (NS-NP). However, the extent to which approaches are used is unclear. This survey investigated current UK physiotherapists' measurement and management of patients with NS-NP. Physiotherapists were invited to participate in an online survey if they were practicing in the UK and had experience of managing NS-NP. 2101 responses were received. Analysis of the results indicated the overall popularity of active treatment approaches with 84% and 61% of respondents employing exercise and patient education respectively. 48% of respondents reported using a multimodal approach (that is, combination of exercise and manual therapy with/without patient education). Over a third of respondents reported not using outcome measures (OMs) for NS-NP. Of the two-thirds who reported using OMs, the majority reported using pain and range of motion measures. Physical and functional limitations, psychological distress, and quality of life constructs, which are frequently associated with NS-NP, were rarely measured.Background and objectives
Methods and results
While the human embryonic, foetal and juvenile intervertebral disc (IVD) is composed of large vacuolated notochordal cells, these morphologically distinct cells are lost with skeletal maturity being replaced by smaller nucleus pulpous cells. Notochordal cells are thought to be fundamental in maintaining IVD homeostasis and, hence, their loss in humans may be a key initiator of degeneration, leading ultimately to back pain. Therefore, it is essential to understand the human notochordal cell phenotype to enable the development of novel biological/regenerative therapies. CD24+ notochordal cells and CD24- sclerotomal cells were sorted from enzymatically-digested human foetal spines (7.5–14 WPC, n=5) using FACS. Sorting accuracy was validated using qPCR for known notochordal markers and Affymetrix cDNA microarrays performed. Differential gene expression was confirmed (qPCR) and Interactive Pathway Analysis (IPA) performed.Background
Methods
Work disability due to low back pain (LBP) is a global concern, resulting in significant healthcare costs and welfare payments. In recognition of this, recent UK policy calls for healthcare to become more ‘work-focused’. However, an ‘evidence-policy’ gap has been identified, resulting in uncertainty about how this is to be achieved. Clear, evidence-based recommendations relevant to both policy-makers and healthcare practitioners are required. A policy theory approach combining scientific evidence with governance principles in a pragmatic manner was undertaken. This entailed extracting evidence from a recent review of the system influences on work disability due to LBP* (focused specifically on the healthcare system) and appraising it alongside the most recent review evidence on the implementation of clinical guidance, and policy material aimed at developing work-focused healthcare.Background
Methods
Currently, there is a focus on the development of cell based therapies to treat intervertebral disc (IVD) degeneration, particularly for regenerating/repairing the central region, the nucleus pulposus (NP). Recently, we demonstrated that GDF6 promotes NP-like differentiation in mesenchymal stem cells (MSCs). However, bone marrow- (BM-MSCs) and adipose- (Ad-MSCs) showed differential responses to GDF6, with Ad-MSCs adopting a more NP-like phenotype. Here, we investigated GDF6 signalling in BM-MSCs and Ad-MSCs, with the aim to improve future IVD stem cell therapies. GDF6 receptor expression in patient-matched BM-MSCs and Ad-MSCs (N=6) was profiled through western blot and immunocytochemistry (ICC). GDF6 signal transduction was investigated through stimulation with 100 ng ml−1 GDF6 for defined time periods. Subsequently smad1/5/9 phosphorylation and alternative non-smad pathway activation (phospho-p38; phospho-Erk1/2) was analysed (western blot, ELISA). Their role in inducing NP-like gene expression in Ad-MSCs was examined through pathway specific inhibitors.Background
Methods
Identifying features in nonspecific low back pain (NSLBP) subjects that distinguish them from controls, or for elucidating subgroups, has proved elusive. Yet these would be helpful to monitor progress, improve management, and understand the nature of the condition. Previous work using quantitative videofluoroscopy (QF) has indicated that the distribution of motion between lumbar intervertebral joints is more uneven in those with a history of NSLBP. However, there maybe other features of these complex motion patterns yet to be revealed. A multivariate analysis was therefore carried out to explore other possible differences. Intervertebral motion data of L2/3 to L4/5, from a previously published study was used. This examined 40 patients with NSLBP and 40 healthy controls, matched for gender, age and body mass index, who underwent passive recumbent QF in the coronal and sagittal planes. For each motion direction, principal components analysis was carried out and salient dimensions selected. Using a lower dimensional principal components (PC) representation, groups were compared using Hoteling's T test. Linear and quadratic discriminant analysis (LDA and QDA) was carried out using PC representations to examine group differences. The features most clearly distinguishing groups from the LDA was examined graphically. An analysis of the sensitivity of the results to the number of PC dimensions was carried out. The performance of the LDA and QDA classifiers were examined using leave-one-out cross-validation.Purpose and background
Methods and results
Previous research in people with musculoskeletal low back pain (MLBP) in primary care shows that a reliable and valid measure of consultation-based reassurance enables testing reassurance against patient' outcomes. Little is known about the role of reassurance in people with MLBP consulting spinal surgeons, especially in cases where surgeons recommend not to have surgery. There might be several reasons to exclude surgery as a treatment option, that range from positive messages about symptoms resolving to negative messages, suggesting that all reasonable avenue of treatment have been exhausted. AIM to explore patient's experience of consultation-based reassurance in people with MLBP who have been recently advised not to have surgery. Semi-structured interviews were conducted with 30 low back pain patients who had recently consulted for spinal surgery and were advised that surgery is not indicated. Interview were audio recorded and transcribed, and then coded using NVIVO qualitative software and analysed using the Framework Analysis.Background
Methods
Although pain is usually described as a private experience, how pain is understood and responded to by others is important. A crucial feature of this process is empathy. The aim of this study was to examine the relationship between empathy for pain and observers' health anxiety and fear of pain. The role of the observer's sex and age were also examined. In this study 159 participants (73 males, mean age=41, SD=19.6) were presented with 16 images of individuals in pain (8 female, 8 male), and subsequently rated their empathy towards them. Participants then completed the fear of pain and health anxiety measures. Both fear of pain and health anxiety were positively associated with empathy for pain, but in the regression model only fear of pain was a significant positive predictor of empathy for pain (Purpose of the study and background
Methods and results
During development the central disc contains large, vacuolated notochordal (NC) cells which in humans are replaced by mature nucleus pulposus (NP) cells during aging, but are maintained in certain breeds of dogs. During degeneration the disc becomes less hydrated which affects its normal function. Aquaporins (AQP) are a family of 13 transmembrane channel proteins that allow passage of water and are responsible for maintaining water homeostasis. AQP1, 2, 3 and 5 have been identified in the intervertebral disc (IVD). Here, expression of AQPs in human and canine IVDs to determine expression in NC v/s NP cells and whether expression changes during degeneration. Gene expression of all 13 AQPs, were investigated in 102 human NP samples using RT-qPCR. AQPs which were expressed at gene level were further investigated by Immunohistochemistry in human and canine IVD samples.Introduction
Methods
Healthcare practitioners' (HCPs) attitudes and beliefs about MSK pain influence their practice behaviour. The Pain Attitudes and Beliefs Scale (PABS), developed for use in the context of LBP, consists of two subscales (biomedical and biopsychosocial) is the most widely used measure. However, poor performance of the biopsychosocial orientation scale is attributed, in part, to inadequate conceptualisation of the orientation. To develop a new biopsychosocial scale and adapt the PABS to assess HCPs' attitudes and beliefs about common MSK pain.Purpose of the study and background
Purpose
Stem cell therapy has been suggested as a potential regenerative strategy to treat IVD degeneration and GDF6 has been shown to differentiate adipose-derived stem cells (ASCs) into an NP-like phenotype. However, for clinical translation, a delivery system is required to ensure controlled and sustained GDF6 release. This study aimed to investigate the encapsulation of GDF6 inside novel microparticles (MPs) to control delivery and assess the effect of the released GDF6 on NP-like differentiation of human ASCs. GDF6 release from PLGA-PEG-PLGA MPs over 14 days was determined using BCA and ELISA. The effect of MP loading density on collagen gel formation was assessed through SEM and histological staining. ASCs were cultured in collagen hydrogels for 14 days with GDF6 delivered exogenously or via microspheres. ASC differentiation was assessed by qPCR for NP markers, glycosaminoglycan production (DMMB) and immunohistochemistry.Background
Methods
The study aim is to evaluate the efficacy of dynamic MRI scanning in identifying radiological causes of positional sciatica over a 5-year period. We describe the results of a prospective series of patients who completed open MRI scanning, indicated for lower back pain and positional sciatica. 40 open MRI scans were requested between March 2012 and March 2017. 31 patients were intolerant to conventional MRI Scanning due to either claustrophobia or the inability to lie flat. 9 patients were identified as having positional sciatica. All patients completed the Oswestry Disability Index as part of their clinical assessment. The MRI images and radiology report were reviewed to identify surgically relevant causes. Dynamic foraminal narrowing and a progressive disc protrusion were identified in 2 patients who presented with positional sciatica. 23% of patients who were scanned had positional sciatica. 5% of patients indicated for open MRI scanning demonstrated surgically relevant changes on dynamic MRI scanning. 22% of those with positional sciatica demonstrated surgically relevant pathology on dynamic scanning.Purposes of study and background
Summary of methods used and the results
Patients with low back-related leg pain (LBLP) can present with neuropathic pain; it is not known but is often assumed that neuropathic pain persists over time. This research aimed to identify cases with neuropathic pain that persisted at short, intermediate and longer-term time points, in LBLP patients consulting in primary care. LBLP patients in a primary care cohort study (n=606) completed the self-report version of Leeds Assessment for Neurological Symptoms and Signs (s-LANSS, score of ≥12 indicates possible neuropathic pain) at baseline, 4-months, 12-months and 3-years. S-LANSS scores and percentages of patients with score of ≥12 are described at each time-point. Multiple imputation was used to account for missing data.Background
Methods
This review aims to explore the methodologies used for estimating the direct and indirect costs attributed to back pain in developed countries. Six databases were searched to uncover studies about the direct and indirect costs of back pain published in English upto November 2016. Data extracted included study characteristics, cost categories and analysis methods. Results were synthesised descriptively.Purpose
Methods
Pulsed electromagnetic field (PEMF) stimulation was evaluated after anterior cervical discectomy and fusion (ACDF) procedures in a randomized, controlled clinical study performed for United States Food and Drug Administration (FDA) approval. PEMF significantly increased fusion rates at six months, but 12-month fusion outcomes for subjects at elevated risk for pseudoarthrosis were not thoroughly reported. The objective of the current study was to evaluate the effect of PEMF treatment on subjects at increased risk for pseudoarthrosis after ACDF procedures. Two evaluations were performed that compared fusion rates between PEMF stimulation and a historical control (160 subjects) from the FDA investigational device exemption (IDE) study: a Objectives
Methods
Lumbar spinal fusion (LSF) is frequently and increasingly used in lumbar degenerative disorders despite conflicting results and recommendations. Further understanding of patient outcomes after LSF is required to inform decisions regarding surgery and to improve post-surgery management. The objective was to evaluate the course of pain and disability in patients with degenerative disorders of the lumbar spine (spinal stenosis, spondylolisthesis, disc herniation, discogenic low back pain) after first-time LSF. A systematic review and meta-analysis of pain and disability outcomes in prospective cohort studies after first time LSF for degenerative disorders. Two independent researchers searched key databases, determined study eligibility, extracted data and assessed risk of bias (modified Quality in Prognostic Studies tool). A third reviewer mediated at each stage. N weighted pooled estimates were calculated. Twenty-five articles (n=1,777 participants) were included. 17 studies were at unclear risk of bias and 8 at high risk. Back pain (12 studies) decreased modestly and irregularly at follow-up intervals. The n weighted mean VAS back pain decreased from 65.4 (±3.3) pre-surgery to 22.2 (±3.1) at 23 months, but then 45.0 (±not reported; 2 studies at risk of bias) at 42 months. In contrast, leg pain (12 studies) improved substantially short and long-term. Disability (20 studies) improved steadily over time with the exception of the 42-months and 48-months intervals.Purpose and background
Methods and results
Pain is an expected and appropriate experience following traumatic musculoskeletal injury. By contrast, chronic pain and disability are unhelpful yet common sequelae of trauma-related injuries. Presently, the mechanisms that underlie the transition from acute to chronic disabling post-traumatic pain are not fully understood. The aim of this study is to identify prognostic factors for risk of developing chronic pain and disability following acute musculoskeletal trauma. A prospective observational study will recruit two temporally staggered cohorts (n=250 each cohort; 10 cases per candidate predictor) of consecutive acute musculoskeletal trauma patients aged ≥16 years, who are emergency admissions into a Major Trauma Centre in the United Kingdom, with an episode inception defined as the traumatic event. The first cohort will identify prognostic factors to develop a screening tool to predict development of chronic and disabling pain, and the second will allow evaluation of the predictive performance of the tool (validation). The outcome being predicted is an individual's absolute risk of poor outcome measured at 6-months follow-up using the Chronic Pain Grade Scale (poor outcome ≥Grade II). Candidate predictors encompass the four primary mechanisms of pain: Introduction
Methods
Strengthening the lumbar extensor musculature is a common recommendation for CLBP. Although reported as effective, variability in response in CLBP populations is not well investigated. This study investigated variability in responsiveness to isolated lumbar extension (ILEX) resistance training in CLBP participants by retrospective analysis of 3 RCTS. Data from 77 intervention participants was available (males = 43, females = 34) 37 control participants (males = 20, females = 17). Intervention participants all underwent 12wks of ILEX resistance training and changes in ILEX strength, pain (VAS) and disability (ODI) measured. True inter-individual response variability was examined through calculation of difference in the standard deviation of change scores for both control and intervention. Intervention participants were classified into using Purpose and Background
Methods and Results
Intervertebral disc (IVD) degeneration is a major cause of Low back pain (LBP). We have reported an injectable hydrogel (NPgel), which following injection into bovine NP explants, integrates with NP tissue and promotes NP cell differentiation of delivered mesenchymal stem cells (MSCs) without growth factors. Here we investigated the injection of NPgel+MSCs into bovine NP explants under degenerate culture conditions to mimic the hMSCs were incorporated within liquid NPgel and injected into bovine NP explants alongside controls. Explants were cultured for 6 weeks under hypoxia (5%) with ± calcium 5.0mM CaCl2 or IL-1β individually or in combination to mimic the degenerate microenvironment. Cell viability was assessed by caspase 3 immunohistochemistry. Histological and immunohistochemical analysis was performed to investigate altered matrix synthesis and matrix degrading enzyme expression.Background
Methods
To investigate associations between sagittal thoracolumbar spine shape with sex and measures of adiposity throughout adulthood. Thoracolumbar spine shape was characterised using statistical shape modelling on lateral dual-energy x-ray absorptiometry images, recorded for vertebral fracture analysis, of the spine from 1529 participants of the MRC National Survey of Health and Development, acquired at age 60–64 years. Associations between spine shape modes (SM) and 1) sex, 2) contemporaneous measures of overall and central adiposity (indicated by body mass index and waist circumference, respectively), 3) changes in total and central adiposity during earlier stages of adulthood and age at onset of overweight, were investigated.Purpose
Methods
To develop an online self-assessment and self-management tool (BACKonLINE™) for discerning between people with characteristics of predominantly centrally (CD) or peripherally (PD) driven LBP. Low back pain (LBP) may worsen with time, making appropriate treatment important. In the NHS Physiotherapy services LBP patients may wait for 14–24 weeks for treatments. Many factors contribute to LBP, but it is predominantly initially viewed as a result of peripheral tissue damage. However, evidence show that persistent LBP is associated with amplification in pain processing in the central nervous system (central sensitisation). Sometimes, this may drive symptoms, resulting in poorer outcomes and requiring longer management. Timely assessment and appropriate management is therefore paramount.Purpose of the Study
Background
The co-ordinated contraction of the kinetic chain is responsible for the dissipation of force. Weakness in the kinetic chain, such as the posterior oblique sling (POS), may increase the demand on additional muscles, such as the hamstrings, to compensate. The lumbar extensors may be particularly vulnerable in the kinetic chain, as they appear difficult to strengthen due to the dominant hip extensors. Therefore, this study aimed to investigate whether participants with a history of hamstring injuries presented with low back pain because of greater deficits in lumbar extensor strength, and impaired co-ordination of the POS. Twenty male footballers were recruited (n: Injured- 9, Controls- 11). Isolated lumbar extension strength, low back pain, and the contraction time of muscles within the POS during a hip extension test were recorded. Participants were then grouped in either the injury or control group.Background & Purpose
Methods
The aim of this study was to determine if positive Waddell signs
were related to patients’ demographics or to perception of their
quality of life. This prospective cross-sectional study included 479 adult patients
with back pain from a university spine centre. Each completed SF-12
and Oswestry Disability Index (ODI) questionnaires and underwent
standard spinal examinations to elicit Waddell signs. The relationship
between Waddell signs and age, gender, ODI, Mental Component Score
(MCS), and Physical Component Score (PCS) scores was determined.Aims
Patients and Methods
The STarT Back risk-stratification approach uses the STarT Back Tool to categorise patients with low back pain (LBP) at low, medium or high-risk of persistent disabling pain, in order to match treatments. The MATCH trial (NCT02286141) evaluated the effect of implementing an adaptation of this approach in a United States healthcare setting. This was a pragmatic cluster randomised trial with a pre-intervention baseline period. Six primary care clinics were pair-randomised, three to an intensive stratified care quality improvement intervention and three as controls. LBP patients were invited to provide outcomes two weeks after their primary care visit, and two and six months later. Primary outcomes were physical function (RMDQ) and pain (0–10 NRS), and secondary outcomes including healthcare use and treatments provided received. Analysis was intention-to-treat.Purpose & Background
Methods
To investigate whether the duration of pain has an influence on the clinical outcomes of patients with low back pain (LBP) managed through the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). The NERBPP is a clinical pathway based upon NICE guidelines (2009) for LBP. Patients with LBP referred onto the NERBPP by their General Practitioner (GP) between May 2015 and January 2017 were included in this evaluation. Data from 635 patients, who provided pre and post data for pain (Numerical rating scale [NRS]), function (Oswestry Disability Index [ODI]) and quality-of-life (EuroQol [EQ5D]), were analysed using a series of covariate adjusted models in SPSS. Patients were categorised into four groups based upon pain duration: <3months, ≥3 to <6months, ≥6months to <12months, ≥12months.Aims
Patients and Methods
We have reported an injectable L-pNIPAM-co-DMAc hydrogel with hydroxyaptite nanoparticles (HAPna) which promotes mesenchymal stem cell (MSC) differentiation to bone cells without the need for growth factors. This hydrogel could potentially be used as an osteogenic and osteoconductive bone filler of spinal cages to improve vertebral body fusion. Here we investigated the biocompatibility and efficacy of the hydrogel Rat sub-cut analysis was performed to investigate safety Background
Methods
Pain of lumbar facet-joint origin is a common cause of low back pain in adults, and may lead to chronic pain and disability. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. The study's objective was to assess the feasibility of carrying out a definitive study to evaluate the clinical- and cost-effectiveness of lumbar facet-joint injections compared to a sham procedure. This was a blinded parallel two-arm pilot randomised controlled trial. Adult patients referred to the pain and orthopaedic clinics at Barts Health NHS Trust with non-specific low back pain of at least three months' duration were considered for inclusion. Participants who had a positive result following diagnostic single medial branch nerve blocks were randomised to receive either intra-articular lumbar facet-joint injections with steroid or a sham procedure. All participants were invited to attend a combined physical and psychological programme. Questionnaires were used to assess a range of pain and disability-related issues. Healthcare utilisation and cost data were also assessed. Of 628 participants screened for eligibility, 9 were randomised to receive the study intervention and 8 participants completed the study.Purposes of the study and background
Summary of methods and results
Signalling by growth differentiation factor 6 (GDF6/BMP13) has been implicated in the development and maintenance of healthy NP cell phenotypes and GDF6 mutations are associated with defective vertebral segmentation in Klippel-Feil syndrome. GDF6 may thus represent a promising biologic for treatment of IVD degeneration. This study aimed to investigate the effect of GDF6 in human NP cells and critical signal transduction pathways involved. BMP receptor expression profile of non-degenerate and degenerate human NP cells was determined through western blot, immunofluorescence and qPCR. Phosphorylation statuses of Smad1/5/9 and non-canonical p38 MAPK and Erk1/2 were assessed in the presence/absence of pathway blockers. NP marker and matrix degrading enzyme gene expression was determined by qPCR following GDF6 stimulation. Glycosaminoglycan and collagen production were assessed through DMMB-assay and histochemical staining.Background
Methods
Population ageing will facilitate an increase in health problems common in older adults, such as musculoskeletal conditions. Musculoskeletal conditions are the fourth largest contributor to disease burden in older adults; affecting quality of life, physical activity, mental wellbeing and independence. Therefore primary care health services must provide appropriate and efficacious management and treatment. However there are a number of complexities specific to older adults that are essential to address. In order to identify these complexities, a review of the background literature was undertaken in addition to a Patient and Public Involvement and Engagement (PPIE) session. The PPIE group consisted of eight older adults who experience chronic musculoskeletal pain. This session was used to discuss and explore what factors are important to consider in GP consultations for musculoskeletal pain for older adults, in addition to those identified through background literature. A number of factors were highlighted through these methods, including the difference in mood and aspirations for older adults; taking a holistic approach; the impact of comorbidities; whether the GP is listening and ‘on the same wavelength’, and older adults' expectations regarding their pain and the consultation.Purpose of Study and Background
Methods and Results
Primary cilia are singular structures containing a microtubule-based axoneme which are believed to not only be mechanosensitive but also to co-ordinate many cell functions via signalling pathways including Hedgehog and Wnt. Primary cilia have previously been described on cells of mouse intervertebral discs (IVDs), but not in bovine or human IVDs. Our aim was to examine primary cilia in these species. Nucleus pulposus cells were obtained from cows with no overt disc degeneration and patients following spine surgery (for herniations and/or degenerative disc disease) and cultured until confluent before maintaining with or without serum for 24h. Primary cilia were visualised with antibodies to the axoneme (acetylated α-tubulin and Arl13b) and/or the basal body (pericentrin) using fluorescent secondary antibodies and ≥200 cells per sample were counted.Introduction
Methods
Criticisms about overuse of MRI in low back pain are well documented. Yet, with the exception of suspicion of serious pathology, little is known about factors that influence clinicians' preference for MRI. We investigated the factors associated with physiotherapists' preference for MRI for patients consulting with benign low back and leg pain (LBLP) including sciatica. Data were collected from 607 primary care patients consulting with LBLP and assessed by 7 physiotherapists, in the ATLAS cohort study. Following clinical assessment, physiotherapists documented whether he/she wanted the patient to have an MRI. Factors potentially associated with clinicians' preference for imaging were selected a priori, from patient characteristics and clinical assessment findings. A mixed-effect logistic regression model examined the associations between these factors and physiotherapists' preference for MRI.Background
Methods
Uncertainty remains regarding the optimal method of diagnosing sciatica. Clinical guidelines currently recommend that investigations be used only when they are likely to change management. In clinical practice, considerable variation can occur between patient and clinician, regarding the perceived importance of investigations such as MRI scans. The aim of this study was to explore patients' experiences of investigations and to consider the impact of concordance between clinical presentation and investigation findings. In this qualitative study, based on the principles of interpretative phenomenological analysis, 14 participants with a clinical presentation of sciatica of likely nerve root origin, who had recently undergone investigations, were purposively recruited from an NHS, Primary Care Musculoskeletal Service in the UK. Individual, semi-structured interviews were used to collect data, which were audio-recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically. Although patients reported wanting investigations to understand the cause of symptoms and inform management, access to them was difficult and protracted. When investigations revealed potentially relevant findings, patients experienced relief, validation, empowerment and decisive decision-making. Disappointment emerged, however, regarding treatment waiting times and options, and long-term prognosis. When investigations failed to identify relevant findings, patients were unable to make sense of their symptoms, move forward in their management or relinquish their search to identify the cause.Background and purpose of the study
Methods and results
Recruitment to time and target in clinical trials is a key challenge requiring careful estimation of numbers of potential participants. The SCOPiC trial ((HTA 12/201/09) (ISRCTN75449581)) is investigating the clinical and cost-effectiveness of stratified care for patients with sciatica in primary care. Here, we describe the approaches followed to achieve recruitment of our required sample size (n=470), the challenges encountered and required adaptations. We used recruitment data from the SCOPiC trial and its internal pilot, to show the differences between estimated and actual numbers of patients from consultation to participation in the trial. Patients were consented to the trial if they had a clinical diagnosis of sciatica (with at least 70% confidence) and met the trial eligibility criteria.Background
Methods
To evaluate implementation of the Back Skills Training (BeST) programme in clinical practice within the National Health Service (NHS). The BeST programme is a group Cognitive Behavioural Approach (CBA) for people with persistent (≥6 weeks) low back pain (LBP). This intervention has been shown to be clinically and cost-effective in a large pragmatic trial. To aid implementation of the BeST programme, an online training intervention (iBeST) was developed.Purpose of study
Background
Measurement inconsistency across clinical trials is tackled by the development of a core outcome measurement set. Four core outcome domains were recommended for clinical trials in patients with non-specific LBP (nsLBP): physical functioning, pain intensity, health-related quality of life (HRQoL), and number of deaths. This study aimed to reach consensus on core instruments to measure the first three domains. The Steering Committee overseeing this project selected 17 potential core instruments for physical functioning, three for pain intensity, and five for HRQoL. Evidence on their measurement properties in nsLBP was synthesized in three systematic reviews using COSMIN methodology. Researchers, clinicians, and patients (n = 208) were invited in a Delphi survey to seek consensus on which instruments to endorse as core. Consensus was Background & purpose
Methods & Results
Almost 80% of people experience low back pain at least once in their life. A quarter suffers from Nonspecific Chronic Low Back Pain (NS-CLBP), where symptoms cannot be justified radiologically. There is evidence that imaging negatively impacts outcomes (increased painkillers and doctors' visits) in NS-CLBP patients. Despite clinical guidelines recommending against the use of imaging, healthcare practitioners and patients still request imaging to explain symptoms. Qualitative, semi-structured interviews with NS-CLBP patients, physiotherapists, and doctors conducted using purposeful sampling of 6–11 people from each group. The interviews were recorded, transcribed and analysed using framework analysis. Validity was ensured by data triangulation with participants.Background
Method
Psychosocial (PS) factors have been described as the combination of the individual's cognitive, emotional and social status and they play an important role in the development and recovery from chronic low back pain (CLBP). The aims of the study where to explore/describe physiotherapists' personal beliefs and knowledge in relation to the assessment of PS factors in patients with CLBP in Italy. A qualitative research design with a constructivist grounded theory approach was used for semi-structured interviews and data collection/analysis. A purposive sample of eight physiotherapists practicing in Italy and having experience with patients presenting chronic musculoskeletal problems were recruited from private clinics. Three main categories were constructed:
Conceptions of the biopsychosocial model and its role in CLBP; Evaluation and management of PS factors; Barriers in the assessment and treatment. The study revealed partial identification of these factors, limited understanding of the role they play in CLBP and lack of standardization in this area within the manipulative physiotherapy profession.Background
Methods and results
Intervertebral disc degeneration is implicated as a major cause of chronic lower back pain. Current therapies for lower back pain are aimed purely at relieving the symptoms rather than targeting the underlying aberrant cell biology. As such focus has shifted to development of cell based alternatives. Notochordal cells are progenitors to the adult nucleus pulposus that display therapeutic potential. However, notochordal cell phenotype and suitable culture conditions for research or therapeutic application are poorly described. This study aims to develop a suitable culture system to allow comprehensive study of the notochordal phenotype. Porcine notochordal cells were isolated from 6 week post natal discs using dissection and enzymatic digestion and cultured Background
Methods & Results
Each patient received Cognitive Reassurance appropriate for and proportionate to his/her capacity through evidence informed explanation/education to enhance effective self-care and realistic self-management. Changes to back and neck pain commissioning by our CCG required GPs not to refer to manual therapy until six weeks and upgrade GP care beyond that previous. 100 consecutive patients requesting GP appointment reporting back/neck pain were directed to a pragmatic service provided by an experienced manual therapy practitioner. Cognitive Reassurance reflecting evidenced informed biopsychosocial and salutogenic thinking was given at initial consultation/assessment. Patients were contacted at 10 and 20 days to ascertain their status. One sub-group suggested an opportunity for long-term follow-up.
Providing Cognitive Reassurance for achieving greater levels of patient engagement with self-management Demonstrate full clinical triage by primary care providers is effective/practical Demonstrate a need for appropriate contracting models ————————–
OSummary
Background and pathway
Wait time
2d
Inappropriate self-referral directed to GPs
25%
DNAs
7%
Referral for medication –
28%
Prescribed AQP manual therapy
35%
Treatments averaged Patients deciding no treatment needed beyond initial consultation Patients requesting further consultation during the 12 months following:
Loss of motion following spine segment fusion results in increased strain in the adjacent motion segments. However, to date, studies on the biomechanics of the cervical spine have not assessed the role of coupled motions in the lumbar spine. Accordingly, we investigated the biomechanics of the cervical spine following cervical fusion and lumbar fusion during simulated whiplash using a whole-human finite element (FE) model to simulate coupled motions of the spine. A previously validated FE model of the human body in the driver-occupant position was used to investigate cervical hyperextension injury. The cervical spine was subjected to simulated whiplash exposure in accordance with Euro NCAP (the European New Car Assessment Programme) testing using the whole human FE model. The coupled motions between the cervical spine and lumbar spine were assessed by evaluating the biomechanical effects of simulated cervical fusion and lumbar fusion.Objectives
Methods
Cervical spondylosis is often accompanied by dizziness. It has
recently been shown that the ingrowth of Ruffini corpuscles into
diseased cervical discs may be related to cervicogenic dizziness.
In order to evaluate whether cervicogenic dizziness stems from the
diseased cervical disc, we performed a prospective cohort study
to assess the effectiveness of anterior cervical discectomy and
fusion on the relief of dizziness. Of 145 patients with cervical spondylosis and dizziness, 116
underwent anterior cervical decompression and fusion and 29 underwent
conservative treatment. All were followed up for one year. The primary
outcomes were measures of the intensity and frequency of dizziness.
Secondary outcomes were changes in the modified Japanese Orthopaedic
Association (mJOA) score and a visual analogue scale score for neck
pain.Aims
Patients and Methods
The aim of this study was to report a retrospective, consecutive
series of patients with adolescent idiopathic scoliosis (AIS) who
were treated with posterior minimally invasive surgery (MIS) with
a mean follow-up of two years ( We prospectively collected the data of 70 consecutive patients
with AIS treated with MIS using three incisions and a muscle-splitting
approach by a single surgeon between June 2013 and February 2016
and these were retrospectively reviewed. There were eight male and
62 female patients with a mean age of 15 years (Aims
Patients and Methods
Magnetically controlled growing rods (MCGRs) allow non-invasive
correction of the spinal deformity in the treatment of early-onset
scoliosis. Conventional growing rod systems (CGRS) need repeated
surgical distractions: these are associated with the effect of the
‘law of diminishing returns’. The primary aim of this study was to quantify this effect in
MCGRs over sequential distractions. A total of 35 patients with a maximum follow-up of 57 months
were included in the study. There were 17 boys and 18 girls with
a mean age of 7.4 years (2 to 14). True Distraction (TD) was determined
by measuring the expansion gap on fluoroscopy. This was compared
with Intended Distraction (ID) and expressed as the ‘T/I’ ratio.
The T/I ratio and the Cobb angle were calculated at several time
points during follow-up.Aims
Patients and Methods
We compared the clinical and radiological outcomes of using a
polyetheretherketone cage with (TiPEEK) and without a titanium coating
(PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF). We conducted a randomised clinical pilot trial of 40 patients
who were scheduled to undergo a TLIF procedure at one or two levels
between L2 and L5. The Oswestry disability index (ODI), EuroQoL-5D,
and back and leg pain were determined pre-operatively, and at three,
six, and 12 months post-operatively. Fusion rates were assessed
by thin slice CT at three months and by functional radiography at
12 months.Aims
Materials and Methods
To address the natural history of severe post-tuberculous (TB)
kyphosis, with focus upon the long-term neurological outcome, occurrence
of restrictive lung disease, and the effect on life expectancy. This is a retrospective clinical review of prospectively collected
imaging data based at a single institute. A total of 24 patients
of Southern Chinese origin who presented with spinal TB with a mean
of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria
were reviewed. Plain radiographs were used to assess the degree
of spinal deformity. Myelography, CT and MRI were used when available
to assess the integrity of the spinal cord and canal. Patient demographics,
age of onset of spinal TB and interventions, types of surgical procedure,
intra- and post-operative complications, and neurological status
were assessed. Aims
Patients and Methods
The aim of this study was to determine whether the sequential
application of povidone iodine-alcohol (PVI) followed by chlorhexidine
gluconate-alcohol (CHG) would reduce surgical wound contamination
to a greater extent than PVI applied twice in patients undergoing
spinal surgery. A single-centre, interventional, two arm, parallel group randomised
controlled trial was undertaken, involving 407 patients who underwent
elective spinal surgery. For 203 patients, the skin was disinfected before surgery using
PVI (10% [w/w (1% w/w available iodine)] in 95% industrial denatured
alcohol, povidone iodine; Videne Alcoholic Tincture) twice, and
for 204 patients using PVI once followed by CHG (2% [w/v] chlorhexidine
gluconate in 70% [v/v] isopropyl alcohol; Chloraprep with tint).
The primary outcome measure was contamination of the wound determined
by aerobic and anaerobic bacterial growth from samples taken after
disinfection.Aims
Patients and Methods
We aimed to retrospectively assess the accuracy and safety of
CT navigated pedicle screws and to compare accuracy in the cervical
and thoracic spine (C2-T8) with (COMB) and without (POST) prior
anterior surgery (anterior cervical discectomy or corpectomy and
fusion with ventral plating: ACDF/ACCF). A total of 592 pedicle screws, which were used in 107 consecutively
operated patients (210 COMB, 382 POST), were analysed. The accuracy
of positioning was determined according to the classification of
Gertzbein and Robbins on post-operative CT scans.Aims
Patients and Methods
To evaluate the incidence of primary venous thromboembolism (VTE),
epidural haematoma, surgical site infection (SSI), and 90-day mortality
after elective spinal surgery, and the effect of two protocols for
prophylaxis. A total of 2181 adults underwent 2366 elective spinal procedures
between January 2007 and January 2012. All patients wore anti-embolic
stockings, mobilised early and were kept adequately hydrated. In
addition, 29% (689) of these were given low molecular weight heparin
(LMWH) while in hospital. SSI surveillance was undertaken using the
Centers for Disease Control and Prevention criteria.Aims
Patients and Methods
We present the results of correcting a double or triple curve
adolescent idiopathic scoliosis using a convex segmental pedicle
screw technique. We reviewed 191 patients with a mean age at surgery of 15 years
(11 to 23.3). Pedicle screws were placed at the convexity of each
curve. Concave screws were inserted at one or two cephalad levels
and two caudal levels. The mean operating time was 183 minutes (132
to 276) and the mean blood loss 0.22% of the total blood volume
(0.08% to 0.4%). Multimodal monitoring remained stable throughout
the operation. The mean hospital stay was 6.8 days (5 to 15).Aims
Patients and Methods
The National Institute for Health and Care Excellence
has issued guidelines that state fusion for non-specific low back
pain should only be performed as part of a randomised controlled
trial, and that lumbar disc replacement should not be performed.
Thus, spinal fusion and disc replacement will no longer be routine
forms of treatment for patients with low back pain. This annotation
considers the evidence upon which these guidelines are based. Cite this article:
Minimally invasive transforaminal lumbar interbody fusion (MITLIF)
has been well validated in overweight and obese patients who are
consequently subject to a higher radiation exposure. This prospective
multicentre study aimed to investigate the efficacy of a novel lumbar
localisation system for MITLIF in overweight patients. The initial study group consisted of 175 patients. After excluding
49 patients for various reasons, 126 patients were divided into
two groups. Those in Group A were treated using the localisation
system while those in Group B were treated by conventional means.
The primary outcomes were the effective radiation dosage to the
surgeon and the exposure time.Aims
Patients and Methods
Patients seeking cervical spine surgery are thought to be increasing
in age, comorbidities and functional debilitation. The changing
demographics of this population may significantly impact the outcomes
of their care, specifically with regards to complications. In this
study, our goals were to determine the rates of functionally dependent
patients undergoing elective cervical spine procedures and to assess
the effect of functional dependence on 30-day morbidity and mortality
using a large, validated national cohort. A retrospective analysis of the American College of Surgeons
National Surgical Quality Improvement Program data files from 2006
to 2013 was conducted to identify patients undergoing common cervical
spine procedures. Multivariate logistic regression models were generated
to analyse the independent association of functional dependence
with 30-day outcomes of interest.Aims
Patients and Methods
In the United Kingdom, lower incidences of intraspinal abnormalities
in patients with early onset idiopathic scoliosis have been observed
than in studies in other countries. We aimed to determine the rates
of these abnormalities in United Kingdom patients diagnosed with idiopathic
scoliosis before the age of 11 years. This retrospective study of patients attending an urban scoliosis
clinic identified 71 patients satisfying a criteria of: clinical
diagnosis of idiopathic scoliosis; age of onset ten years and 11 months
or less; MRI screening for intraspinal abnormalities. United Kingdom
census data combined with patient referral data was used to calculate
incidence.Aims
Patients and Methods
Low back pain (LBP) with or without leg pain, is one of the most common causes of pain and disability and a frequent cause of attendance to emergency departments (ED). Increasing numbers of patients create a difficult challenge for clinicians to effectively and appropriately manage patients with LBP in an urgent care setting. To improve the management of atraumatic spinal pain patients admitted onto the emergency assessment unit (EAU) thus improving quality of care, reducing bed stay and facilitating appropriate discharge and follow-up within an interdisciplinary model.Background
Purpose
Low back-related leg pain (LBLP) is clinically diagnosed as referred leg pain or sciatica. Within the spectrum of LBLP there may be unrecognised subgroups of patients. This study aimed to identify and describe clusters of LBLP patients using latent class analysis (LCA). The study population were 609 LBLP primary care consulters. Variables from clinical assessment were included in the LCA. Characteristics of the statistically identified clusters were described and compared to the clinically defined groups of LBLP patients.Background
Methods
Low back pain (LBP) is the top leading global cause of years lived with disability. In order to examine LBP, researchers have typically viewed the spine in isolation. Clinically, it is imperative that the lower limbs are also considered. The aim of this study was to design a holistic and reliable multi-segmental kinematic model of the spine and lower limbs. The spine was modelled according to easily identifiable anatomical landmarks, including upper thoracic (T1-T6), lower thoracic (T7-T12) and lumbar (L1-L5) segments. Pelvis, thigh, shank and foot segments were included. A 10-camera 3D motion capture system was used to track retro-reflective markers, which were used to define each segment of 10 healthy participants as they walked 3 times at a comfortable speed over a 6km walkway. The relative peak angles between each segment were calculated using the Joint Coordinate System convention and Intraclass Correlation Coefficients (ICCs) were used to determine intra-rater and inter-rater reliability (between an experienced clinician and biomechanical scientist).Introduction
Method
The usefulness of markers of non-specific low back pain (NSLBP), including MRI derived measurements of cross-sectional area (CSA) and functional CSA (FCSA, fat free muscle area) of the lumbar musculature, is in doubt. To our knowledge, such markers remain unexplored in Lumbar Disc Degeneration (LDD), which is significantly associated with NSLBP, Modic change and symptom recurrence. This exploratory 3.0-T MRI study addresses this shortfall by comparing asymmetry and composition in asymptomatic older adults with and without Modic change. A sample of 21 healthy, asymptomatic subjects participated (mean age 56.9 years). T2-weighted axial lumbar images were obtained (L3/L4 to L5/S1), with slices oriented through the centre of each disc. Scans were examined by a Consultant MRI specialist and divided into 2 groups dependent on Modic presence (M) or absence (NM). Bilateral measurements of the CSA and FCSA of the erector spinae, multifidus, psoas major and quadratus lumborum were made using Image-J software. Muscle composition was determined using the equation [(FCSA/CSA)*100] and asymmetry using the equation [(Largest FCSA-smallest FCSA)/largest FCSA*100]. Data were analysed using Mann-Whitney U tests (p value set at). Intrarater reliability was examined using Intraclass Correlations (ICCs).Introduction
Methods
Current strategies to treat back pain address the symptoms but not the underlying cause. Here we are investigating a novel hydrogel material (NPgel) which can promote MSC differentiation to Nucleus pulposus cells. Current hMSCs were encapsulated in NPgel and cultured for 4 weeks under hypoxia (5%) with ± calcium (2.5mM and 5.0mM CaCl2), IL-1β and TNFα either individually or in combination to mimic the degenerate microenvironment. Cell viability was assessed by Alamar blue assay. Histological and immunohistochemical analysis investigated altered matrix and matrix degrading enzyme expression.Introduction
Methods
Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders. We included data from 4′940 patients documented in Eurospine's Spine Tango Registry from 2004 to 2015. Medical history and surgical details were documented on the Tango Surgery form, as were surgical and general medical complications arising between admission and discharge. Multiple logistic regression models were built to investigate the relationship between the number of any previous surgeries and the presence of a perioperative complication, controlling for other potential confounders (age, sex, smoking, BMI, comorbidity, number of vertebral levels affected).Background
Methods
The objective of this study was to assess the association between whole body sagittal balance and risk of falls in elderly patients who have sought treatment for back pain. Balanced spinal sagittal alignment is known to be important for the prevention of falls. However, spinal sagittal imbalance can be markedly compensated by the lower extremities, and whole body sagittal balance including the lower extremities should be assessed to evaluate actual imbalances related to falls. Patients over 70 years old who visited an outpatient clinic for back pain treatment and underwent a standing whole-body radiograph were enrolled. Falls were prospectively assessed for 12 months using a monthly fall diary, and patients were divided into fallers and non-fallers according to the history of falls. Radiological parameters from whole-body radiographs and clinical data were compared between the two groups.Objectives
Methods
Current policy and practice aimed at tackling work disability due to low back pain is largely aligned with the Psychosocial Flags Framework, which focuses on addressing individual beliefs and behaviours (yellow and blue flags). However, our understanding of the systemic and contextual factors (black flags) that are also proposed to act as obstacles within this Framework is under-represented, resulting in a disproportionate evidence base and suboptimal interventions. A ‘best-evidence’ synthesis was conducted to collate the evidence on those ‘black flags’ proposed to be the most important: compensatory systems (worker's compensation and disability benefits), healthcare provider systems and ‘significant others’ (spouse/partner/close family members). A systematic search of scientific and grey literature databases was performed, and the validity and merit of the available evidence was assessed using a system adapted from previous large-scale policy reviews conducted in this field.Background
Methods
The BACK To Health programme is part of the wider North of England back pain and radicular pain pathway. The purpose of this programme is to provide a CPPP approach based on the NICE guidelines CG88 for those with back pain that has not responded to early management and simpler therapies. The purpose of this study is to present preliminary results of this programme. Referral onto the programme occurred through triage and treat practitioners or consultant clinics. A total of 44 patients were referred, with 31 attending the programme. The programme was delivered as a 3 week residential programme, with patients present 9am-5pm Monday to Thursday. A MDT provided an intense programme consisting of education, physical exercise, practical coping strategies and group discussion. The work has received ethical approval from the School of Health and Social Care Research Ethics and Governance committee at Teesside University.Background
Method
Chronic musculoskeletal pain increases an individual's risk of developing many chronic diseases and the risk of all-cause early mortality. There is irrefutable evidence supporting the role of physical activity (PA) in reducing these risks. Sustaining changes to PA behaviours is challenging and efforts are needed to understand the barriers and facilitators of change. Understanding these factors is a vital step in developing behaviour change interventions.
Explore barriers and facilitators to engaging in PA in adults accessing pain services. Explore barriers and facilitators to promoting PA by healthcare professionals, exercise professionals and charity staff/expert patients.Background
Objectives
Auxetic materials have a negative poisons ratio, and a number of native biological tissues are proposed to possess auxetic properties. One such tissue is annulus fibrosus (AF), the fibrous outer layers of the intervertebral disc (IVD). However, few studies to date have investigated the potential of these materials as tissue engineering scaffolds. Here we describe the potential of manually converted polyurethane (PU) foams as three dimensional cellular scaffolds for AF repair. Rat MSCs were seeded onto fibronectin coated auxetic foams at a cell density of 6.4 × 103 cells/mm3, and cultured for up to 3 weeks. Cell viability was assessed throughout culture and following culture scanning electron microscopy (SEM) was used to assess morphological characteristics. Histological assessment was performed to assess production of matrix proteins.Background
Methods
A Qualitative study exploring patient's experience of Cauda Equina Syndrome (CES) was carried out. The aim of this study was to identify how Cauda Equina Syndrome symptoms may be more effectively identified by patients and their clinician. Patient's symptoms and experiences of their condition were explored, including issues associated with bladder, bowel and sexual function A summary of the methods used and the results. Via in-depth questions, participants were enabled to share their stories within a confidential setting. Narrative analysis of the patient's story allowed symptom progression and recognition to be explored and language used by participants themselves to describe symptoms identified. Seven themes emerged from the study. The findings were used to develop clinical tools to assist in the consultation process of potential CES patients. Finally the tools were validated by CES patients and clinicians prior to use within a clinical setting The findings of this research have been utilised, working with patients as partners, to establish clear, sensitive and understandable language to use during clinical questioning of potential CES patients. This patient choice of language for sensitive questions has been replicated on a clinical cue card to use during the consultation and on a credit card sized leaflet to give to patients. Working with patients, clear methods of communication have been developed surrounding potentially embarrassing but critical symptoms in order to assist ‘bringing the individual patient and the surgical team together at the earliest practical opportunity’ No conflicts of interest Source of funding; Physiotherapy Research Foundation (Part of the CSP Charitable Trust registered charity 279882)Purposes of the study and background
Conclusion
The MOCAM study is a major prospective questionnaire-based study investigating the relationship between low back pain (LBP) patient outcomes and non-specific treatment components, i.e., therapeutic relationship, healthcare environment, incidental treatment characteristics, patients' beliefs and practitioners' beliefs. Participating acupuncturists, osteopaths, and physiotherapists from the NHS and private sector have been asked to recruit at least 10 patients into the study. This paper aims to analyse current recruitment rates from MOCAM and identify barriers and facilitators to effective recruitment. Recruitment has taken place over 15 months. Invitation letters or emails were sent to individual practitioners identified using online search tools and professional networks. Recruitment rates were analysed descriptively. Within the private sector, response rates (number participating/number invited) are: acupuncturists 3% (49/1561), osteopaths 6% (53/912), physiotherapists 4% (40/1048). Private sector practitioners have each recruited on average 1, 4, and 2 patients into the study respectively. Within the NHS, the response rates are: acupuncturists 100% (2/2), osteopaths 8% (1/13), physiotherapists 63% (44/70). NHS practitioners have each recruited on average 4, 3, and 2 patients respectively.Purpose and Background
Methods and Results
Dropped Head Syndrome (DHS) is characterized by a chin on chest flexion neck deformity that is passively correctible. The condition is rare and literature on surgical and conservative management is focused on case studies and theoretical evidence. The purpose of this study was to investigate the value of physiotherapy in the treatment of DHS by case series analysis.Background and purpose of the study
Purpose of the study
Within the intervertebral disc (IVD), nucleus pulposus (NP) cells reside within a unique microenvironment. Factors such as hypoxia, osmolality, pH and the presence of cytokines all dictate the function of NP cells and as such the cells must adapt to their environment to survive. Previously we have identified the expression of aquaporins (AQP) within human IVD tissue. AQPs allow the movement of water across the cell membrane and are important in cellular homeostasis. Here we investigated how AQP gene expression was regulated by the microenvironment of the IVD. Human NP cells were cultured in alginate beads prior to cytokine, osmolality, pH and hypoxia treatments and subsequent RT-qPCR to assess regulation of AQP gene expression.Introduction
Methods
A single degenerate intervertebral disc is suggested to promote rapid degeneration in its adjacent discs. We validated this hypothesis using discordant co-twin case-control design. 185 pairs of twins were selected from the TwinsUK database having cervical MRI scans at baseline and at follow-up, after 10 years. Isolated disc degeneration (IDD) was diagnosed in subjects having severe loss in disc height (graded 3/3) in a single disc, whilst discs immediately adjacent manifested little or no degeneration (graded 0 or 1). The controls' ‘adjacent discs’ were considered at the same levels as their affected co-twins.Objectives
Methods