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Background
Leg pain frequently accompanies low back pain and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back- related leg pain (LBLP) is important for clinical management and research applications.
The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP.
Methods
The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were quality appraised independently by two reviewers using a standardised scoring tool.
Purpose
To measure the prevalence, type and instigator of verbal interruptions during initial consultations between clinicians and patients with low back pain.
Background
During initial consultations, patients take on average, 92 seconds to outline their problem, if given the chance. Few achieve this, with clinicians interrupting (25–69% of cases) in as little as 12 seconds, either with an ‘overlap’, (a projection error of when a turn ends), or an ‘interruption’ (a start-up before the speaker's talk is complete). The prevalence and impact of these in back pain consultations is unknown.
Background
Implementation fidelity is the extent to which an intervention is delivered as intended by intervention developers, and is extremely important in increasing confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. Growing demands on healthcare services mean that multiple condition interventions involving highly prevalent musculoskeletal pain conditions such as chronic low back pain (CLBP) and/or osteoarthritis (OA) are of increasing clinical interest. This is the first in-depth review of implementation fidelity within self-management interventions for any musculoskeletal pain condition.
Methods
Structured self-management interventions delivered by health-care professionals (including at least one physiotherapist) in a group format involving adults with OA of the lumbar spine, hip or knee and/or CLBP were eligible for inclusion. The National Institutes of Health Behaviour Change Consortium Treatment Fidelity checklist was used by two independent reviewers to assess fidelity.
Aim
The primary aim of this pilot study was to assess and evaluate the SpineCor Pain Relief Brace as a method of reducing the pain experienced by patients diagnosed with degenerative scoliosis
Method
Participants (n=24) with an average age of 67 (+/− 8) old that fulfilled the study inclusion criteria were randomly allocated into either a treatment or control group. Both sets of participants received questionnaires (ODI, SF 36v2 and EQ5D-5L) at 1,3,6,9 and 18 months. In addition to the questionnaires the treatment group also received the SpineCor Pain Relief Brace and took part in a semi structured interview.
Background
Osteoarthritis (OA) and chronic low back pain (CLBP > 12 weeks duration) are two of the most common and costly chronic musculoskeletal conditions globally. Healthcare service demands mean that group-based multiple condition interventions are of increasing clinical interest and a priority for research, but no reviews have evaluated the effectiveness of group-based physiotherapy-led self-management interventions (GPSMI) for both conditions concurrently. Rapid review methodologies are an increasingly valid means of expediting knowledge dissemination and are particularly useful for addressing focused research questions.
Methods
The electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Register of Controlled Trials were searched from the earliest date possible to August 26th 2013. Structured group-based interventions that aimed to promote self-management and that were delivered by health-care professionals (including at least one physiotherapist) involving adults with OA and/or CLBP were eligible for inclusion. The screening and selection of studies, data extraction and risk of bias assessment were conducted independently by two reviewers.
Background
60% of back pain patients report pain radiation in the leg(s), which is associated with worse symptoms and poorer recovery. The majority are treated in primary care, but detailed information about them is scarce. The objective of this study is to describe the characteristics of patients with back and leg pain-seeking treatment in primary care.
Methods
Adult patients consulting their GP with back and leg pain were invited to the study. Participants completed questionnaires including sociodemographic, physical and psychosocial measures. They also underwent standardised clinical assessments by physiotherapists, and received an MRI scan.
Introduction
Research has suggested baby wearing results in happier healthier babies [1]. Various designs of carrier are available, is there one which has less impact on the biomechanics of the cervical spine?
Methods
18 volunteers (9 male and female) performed a warm up procedure on the neck (movement through each range of motion), repeated thrice. Measurement of the active cervical range of motion (ACROM) in flexion and extension using a Cervical Range of Motion device, described in previous studies [2]. Volunteers were then allocated a baby carrier to wear including a specially designed “baby” mannequin (dimensions based on population average statistics for a 1yro). Volunteers continued with ADLs, returning after 2 hours. With the carrier removed, measurements were repeated (without warm-up). Volunteers were assessed at the same time of day, thrice (control, single carrier, double carrier) with at least 1 day between carrying.
Aim
To assess the safety of day case lumbar decompressive surgery
Method
Retrospective study of 233 consecutive patients undergoing DCLDS who were identified from a prospective electronic database.
Background
Low back pain (LBP) is widespread in all populations and is a worldwide health problem, which poses substantial challenges for clinical management. Individuals with LBP may reduce their symptoms by implementing self-managed at-home interventions. The theoretical design of the LumbaCurve™ promotes the principles of a passive gravity-assisted traction (PGAT) stretch of the lumbar and sacral region in order to reduce LBP. This study aimed to assess the clinical effectiveness of the LumbaCurve™ in the management of LBP when compared to a control group of standardised care.
Methods
Following a screening form using Red Flags and STarT Back tools, 60 individuals with LBP were recruited to the 4-week intervention. Eligible participants completed a pre-intervention questionnaire and were randomly allocated to either ‘standardised care’ or ‘standardised care PLUS LumbaCurve™’ group. Intervention material was trialled for 4 weeks consecutively, followed by a post-intervention questionnaire. Pre and post assessments applied the Roland Morris Disability Questionnaire (RMDQ), Patient Reported Outcome Measures (PROMS).
Aim
To use Patient Reported Outcome Measures (PROMs) to determine the effectiveness of lumbar spinal surgery at a single UK institution.
Methods
Consecutive patients who underwent lumbar spinal surgery (discectomies or decompressions) from 1 January 2011 to 13 March 2013 at a UK District General Hospital were assessed. The procedures were performed or supervised by a senior Consultant Orthopaedic spinal surgeon. All patients completed PROM questionnaires before and three months following surgery. These included Visual Analogue Scores (VAS), SF-12, Oswestry Disability Index (ODI) and Roland Morris Low Back Pain Questionnaire (RMQ).
Purpose of the study and background
Patients' beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to study the relationship between diagnostic uncertainty and recall bias in two groups of chronic LBP patients, those who were certain about their diagnosis, and those who believed that their pain was due to an undiagnosed problem.
Summary of the methods used and the results
Patients (N=68) endorsed and subsequently recalled pain, illness, depression and neutral stimuli. They also provided measures of pain, diagnostic status, mood and disability. Both groups exhibited a recall bias for pain stimuli, but only the group with diagnostic uncertainty additionally displayed a recall bias for illness-related stimuli. This bias remained after controlling for depression and disability. Sensitivity analyses using grouping by diagnosis/explanation received supported these findings. Higher levels of depression and disability were found in the group with diagnostic uncertainty, but levels of pain intensity did not differ between the groups.
Purpose and background
Over two-thirds of pregnant women experience low back pain (LBP) that interferes with everyday activities, work and sleep. Acupuncture appears a safe, promising intervention but there are no high quality trial data, regarding its clinical or cost-effectiveness in comparison to standard care.
Methods
EASE Back was a feasibility and pilot RCT designed to inform a full trial evaluating the addition of acupuncture to standard care for pregnancy-related LBP. In preparation for the pilot trial, phase 1 of EASE Back consisted of semi-structured interviews exploring the views of pregnant women, midwives and physiotherapists about pregnancy-related LBP, use of acupuncture, and participation in clinical trials. Transcript data were anonymised and analysed using thematic analysis. Three members of the team independently coded a sample of transcripts to develop the coding framework.
Objectives
This paper describes the outcomes obtained from a 12 hour group based multidisciplinary functional restoration programme for patients with persistent low back pain who presented with psychosocial obstacles to recovery. The programme was designed to address modifiable psychosocial obstacles to recovery over a four week period, reduce pain related disability, improve pain self-efficacy and reduce patients' reliance on analgesic medication.
Design
A single group retrospective analysis.
Aim
To assess the safety of Zero Profile Interbody fusion (Zero P) device in Anterior Cervical Decompression and fusion (ACDF) for degenerative cervical stenosis.
Method
89 consecutive patients treated with Zero P interbody device from September 2009 to September 2012 were included in this retrospective study.
Inclusion criterion: degenerative cervical stenosis with myelopathy, persistent radiculopathy after at least 3 months of failed conservative management.
Exclusion criterion: Paediatric population; patients with infection, metastatic disease and trauma.
There were 39 females, 50 males with mean age of 55 (ranging from 24 to 84 years)
56 (64%) had surgery at 1 level, 31 (35%) at 2 levels, 1 (1%) at 3 levels. Total number of levels operated were 121. Common levels operated were C56 (62%) and C67 (47%)
Majority were operated due to radicular symptoms, 56 (64%) had radicular symptoms, 28(31%) had myelopathy and 5 (5%) Myeloradiculopathy
Introduction
The authors recognised that patients presenting to the Orthopaedic Spinal Rapid Access Service with symptoms and or signs of cauda equina syndrome may not have the diagnosis confirmed radiologically. Altered sensation in the ‘saddle area’, bilateral sciatica, urinary incontinence or retention, altered bowel habit, and sexual dysfunction are well recognised symptoms of cauda equina syndrome. Recognised side-effects of neuropathic medications commonly prescribed for radicular pain include: altered sensation, urinary incontinence or retention, and sexual dysfunction. We have undertaken a retrospective cohort analysis in order to identify the relationship between prescribed medications and presenting symptoms and signs.
Method
151 patients were referred to the service within a 6 month period. Case notes of 34 patients presenting with symptoms and or objective signs of CES in absence of positive radiological findings were reviewed. Data collected included the patient's age, sex, prescribed medications and presenting symptoms.
Background and purpose
To identify methods used to measure free living sedentary behaviour in people with back pain and review the validity and reliability of identified measures.
Methods
Databases including CINAHL, EMBASE, MEDLINE, AMED, PsycINFO, SPORTDiscus and the Sedentary Behaviour and Research Network website (
Background and Purpose of Study:
Differences in regional lumbar angles in sitting have been observed between subgroups of NSCLBP patients exhibiting motor control impairments (MCI) (O'Sullivan, 2005; Dankaerts et al, 2006). However, differences in standing posture and other spinal regions are unknown. This study aimed to compare regional spinal angles in healthy and MCI subgroups in sitting and standing.
Methods:
An observational, cross-sectional study investigated spinal kinematics of 28 Flexion Pattern (FP), 23 Active Extension Pattern (AEP) (O'Sullivan, 2005) and 28 healthy controls using 3D motion analysis (Vicon) during usual sitting and standing. Mean sagittal angle for Total Lumbar (TotLx), Total Thoracic (TotTx), Upper Thoracic (UTx), Lower Thoracic (LTx), Upper Lumbar (ULx) and Lower Lumbar (LLx) regions between groups were compared using one-way ANOVA.
Introduction
Orthopaedic Spinal Rapid Access Service (OSRAS) was developed in our institute to provide a structured pathway for management of urgent spinal pathologies during working hours of Monday to Friday. It was delivered through a published rota by a multi displinary team of Extended Scope Practitioner carrying a bleep and a Spinal Surgeon.
Aim
To evaluate the efficacy of OSRAS through a prospective audit.
Background and Purpose
Chronic low back pain (CLBP) can be constant or episodic. Fluctuations are common. We present two different pictures of the CLBP experience; timelines illustrating back pain over time and ‘web diagrams’ showing a snapshot of a phase in time.
Methods
Semi structured interviews from 34 participants from the UK BeST trial included timelines drawn collaboratively by the researcher and participant. Symptoms, events, treatment and consultations were arranged chronologically along a timeline. Initial thematic analysis on 63 interviews gave bio-psychosocial themes that were spoken about in an integrated way. Further analysis explored these interactions between themes. Interactions were classified as; helpful to recovery, unhelpful or mixed. Web diagrams were drawn for each interview and classified as Dense- mostly unhelpful interactions, Open – a combination of helpful and unhelpful interactions and Sparse – mostly helpful interactions.
Background
Emerging research has indicated that ‘significant others’ (spouses/relatives) may have important influences on continued work participation for individuals with chronic non-specific musculoskeletal pain (CMP). In order to expand on this novel area of research, data from studies conducted in The Netherlands and the UK were assimilated.
Method
In both studies, worker and significant other perceptions of pain self-efficacy, perceived partner responses to pain, pain catastrophizing, and contribution to work participation were explored in relation to the worker's CMP. In the Netherlands, questionnaire data were collected from workers with CMP and their significant others (n=103), and in the UK, in-depth semi-structured interviews were conducted (n=10). Appropriate quantitative and qualitative analysis techniques were applied.
Background and Aim
Spinal stability is associated with low back pain and affects the spines ability to support loads. Stability can be achieved if the applied force follows the curvature of the spine, passing close to the vertebral centroids. Previously we showed that calculated muscle forces required for stability in an idealised model increased with increasing and more evenly distributed lumbar curvatures. The purpose of this study was to calculate the muscle forces required for stability in standing in a group of healthy adults.
Methods
Positional MRI was used to acquire sagittal images of the lumbar spine in a standing posture in 30 healthy adults. Sacral inclination was measured and active shape modelling used to characterise lumbar spine shape. A two-dimensional model of the lumbar spine was constructed using vertebral centroid positions and a simplified representation of the lumbar extensor muscles. The muscle forces required at each level to produce a follower load were calculated using a force polygon.
Purposes of the study and background
Characteristics of muscle activity, represented by surface electromyography (EMG), have shown differences between patients with low back pain and healthy adults; how they relate to functional/clinical scales remains unclear. The purpose of the current study was to examine the correlation between frequency characteristics of EMG and patients' self-rated score of disability using continuous wavelet transform (CWT) analysis.
Methods and Results
Fifteen patients with chronic mechanical low back pain (LBP) and 10 healthy adults were recruited. Patients completed the Roland-Morris Disability Questionnaire (RMDQ) and bilateral EMG activity was obtained from erector spinae at vertebral level L4 and T12. Subjects performed 3 brief maximal voluntary contractions (MVCs) of the back extensors and the torque was measured using a dynamometer. CWT was applied to the EMG signals of each muscle in a 200ms window centred around the peak torque obtained during the MVCs. The ratio (low/high frequencies) of the energy, the peak energy, and the frequency of the peak energy were calculated for each muscle and then averaged and correlated with the individual's RMDQ score.
Patients had significantly lower peak power than the controls (p=0.04). Additionally, RMDQ positively correlated to the average ratio of energy (rho=0.71; p=0.01), meaning higher disability corresponded to a dominant distribution of energy in the lower-frequencies; but negatively correlated to the average frequency of peak energy (rho=-0.61; p=0.035), meaning lower frequency of peak energy corresponded to higher levels of disability.
Purpose of study and background
The use of NRB (Nerve Root Block) in radicular pain caused by stenosis is considered controversial in some centres, whereas its indication in radiculitis caused by disc herniation is widely accepted. Most studies evaluating NRB have combined disc herniation and stenosis pathologies in their inclusion criteria. This study explores the efficacy of NRB in different categories of stenosis: lateral recess, foraminal and combined.
Methods and results
68 patients underwent NRB by an ESP (Extended Scope Physiotherapist). 37 females, 31 males, mean age 75 years (range 23–87). Their stenosis was categorized as either lateral recess (n=43), foraminal (n=18), or combined (n=7) on MRI scan evaluation by 2 reviewers. Roland Morris Disability Questionnaire and Visual Analogue Scores were recorded pre-injection and 6 weeks post injection. 2 year final outcome was recorded with an ‘in-house’ questionnaire.
2 year outcome: Lateral recess stenosis: 37% had surgery, 40% required no further treatment. In foraminal stenosis: 17% had surgery, 50% required no further treatment. Combined pathology: 43% had surgery, 57% required no further treatment. Patients requiring no further treatment rated their 2 year outcome as satisfactory symptom control. Of the whole group 15% required a repeat injection, 7% were referred to pain clinic and one patient had died.
Purpose
To study the relationship between Zygoapophysial Joint Tropism and pathologic fractures affecting lumbar and thoracic vertebrae in elderly patients.
Methods
The sagittal plane orientation of the Zygoapophysial joints (facets or ZAJ) of 324 vertebrae of 63 patients were measured on MRI scans, stratified into lumbar and thoracic, fractured and non-fractured, and then classified according to the presence of tropism. The correlation between tropism and fractures, demographics pertaining to age, spinal level, and morbidity were studied.
Purpose and Background
Low birth weight is related to decreased lumbar spine vertebral canal size and bone mineral content later in life, suggesting that antenatal factors affect spine development. The purpose of this study was to explore associations between antenatal factors and lumbar spine morphology in childhood.
Methods
Antenatal data and supine MR images of the lumbar spine were available for 161 children. Shape modelling, using principle components analysis, was performed on mid-sagittal images to quantify different modes of variation in lumbar spine shape. Previously collected measures of spine canal dimensions were analysed.
Background
Stratifying patients with Low Back Pain (LBP) using the STarT Back Tool and delivering targeted treatment has demonstrated efficacy in individual physiotherapy settings. Physiotherapy interventions for LBP patients are often delivered in groups. This study aimed to explore the sustainability and cost effectiveness of a group stratified intervention in primary care.
Methods
This non-randomised controlled trial compared a novel group stratified intervention to a historical non-stratified group control. Patients from 30 GP practices in Waterford Primary Care were stratified and offered a matched targeted group intervention. The historical control received a generic group intervention. The primary outcome measure was disability (RMDQ) at 12 weeks. A cost effectiveness analysis was also undertaken. Analysis was by intention to treat. Ethical approval was obtained
Purpose and background
To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within patient risk subgroups (low, medium and high risk of persistent disabling pain determined by the STarT Back tool).
Methods
Adopting a cost-utility framework alongside a prospective, sequential comparison of separate patient cohorts (922 patients in total) with six-month follow-up, the base case analysis estimated the incremental LBP-related healthcare cost per additional quality-adjusted life year (QALY) by risk subgroup. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses examined alternative approaches (a complete case analysis, the incorporation of non-LBP-related healthcare use and estimation of societal costs relating to work absence).
Purpose of the study and background
In the majority of low back pain (LBP) patients a definitive cause for back pain cannot be established; consequently, many patients report feeling uncertain about their diagnosis. They also experience pain-related guilt, which can be divided into: social guilt, managing pain guilt and verification of pain guilt. This study aimed to test a theoretical (causal) model, which proposed that diagnostic uncertainty leads to pain-related guilt, which leads to depression, anxiety and finally to disability.
Summary of the methods used and the results
Structural equation modelling was employed to test this model on 438 participants with LBP. The model demonstrated an adequate to good fit with the data. Diagnostic uncertainty predicts all three types of guilt. Verification of pain guilt predicts disability, managing pain guilt predicts anxiety, while social guilt was the strongest predictor of negative outcomes, predicting depression, anxiety and disability.
Background
Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA.
Methods
A two phase search strategy of electronic databases was used to identify systematic reviews and studies relevant to this area. Articles were coded independently for their use of behaviour change theory, and the number of behaviour change techniques (BCTs) was identified using a 93 item taxonomy, Taxonomy (v1).
Background
The factors influencing normal spine curvature in midlife are unknown. We performed an MR and plain radiograph study on well characterised, unselected twin volunteers from the TwinsUK register (
Methods
T2 weighted MR scans and long spine standing radiographs were obtained at the same morning visit on twin pairs. Midline sagittal MR images were coded for 4 degenerative features. SpineviewTM software was applied plain films and calculated the angles of curvature. A classical twin study was performed. Multivariate regression analysis was used to determine the association between spine curves, LDD and confounders (age, body mass index).
Purpose and Background
Back pain impinges upon all aspects of life, has a reported UK lifetime prevalence as high as 84% and considering approximately a third of our lives are spent asleep the paucity of research into the effect a mattress has on back pain and sleep is surprising. Mood changes, effecting an increase in pain perception, due to sleep loss may also lead to a downward spiral of increasing back pain and greater sleep loss. A controllable factor in this spiral, affecting both aspects, is the mattress but to the authors' knowledge none currently available on the market have any robust, published research to objectively support any claims made and at best being ‘endorsed’ by experts. This may lead to possible misinterpretation of efficacy and leave professionals at a loss with what to advise when questioned.
Methods and Data collection
Method:
A three month, randomised, controlled, double blind crossover field study is proposed to take place in the participants own homes, ensuring the most natural sleep environment.
Data collection:
Three 28 day phases
1 - Baseline data, participants sleeping on their own mattress
2 - Random allocation of mattresses, half allocated test and half control
3 - Crossover of test and control mattress
Subjective measures of back pain and sleep quality will be collected utilising a daily sleep diary and visual analogue scales.
Objective measures of sleep quality using activity monitors during sleep.
Purpose of the study and background
This audit report outlines a physiotherapy lead spinal triage program for inpatients in a private hospital. The reason to trial this model was proposed as a way to expedite the assessment of inpatients presenting with back pain and implement an appropriate and prompt management plan.
Summary of the methods used and the results
An audit tool was developed to record the patient details and outcomes of referrals to the spinal triage program. Length of time between referral and triage was recorded as was the number of patients that went on to require a spinal surgeon consult and spinal intervention. A total of 75 patients were referred into Spinal Triage over a 7 month period.
The majority of in patients referred for spinal consult within this private hospital setting were triaged solely by physiotherapy (56%) and a management plan decided on in conjunction with the spinal surgeon on call who could access any imaging remotely. Six patients (8%) involved in the triage program went on to have spinal surgical intervention.
Background
Being involved in litigation is associated with poor outcomes, higher levels of pain, disability, catastrophising, fear-avoidance and other psychological factors. Poor access to treatments can contribute to chronicity of symptoms and poor outcomes, especially in patients involved in litigation with a longer time since the accident.
Purpose
To examine the relationship between time since the accident, access to treatments and current psychological variables.
Purposes of Study and Background
This study investigates the role of the patient and the therapeutic relationship with their medical practitioner in resolving CLBP (chronic low back pain). Many cases of chronic pain persist due to the stress response. The body is equipped with natural self-healing mechanisms that must be activated by the patient. This needs facilitation by someone trained to engage the patient in this process. Evidence shows that conventional medication; surgery and physical rehabilitation do not always resolve chronic pain. To ensure that the stress response doesn't sabotage biomedical intervention the patient may need to address any problems obstructing a healthy lifestyle. This means supporting healthy relationships, and good health in other areas such as: professional life, financial matters, beliefs and creativity.
Summary of Methods used and Results
Recent Case Studies are described where patients presented with severe CLBP. The Roland Morris Low Back Pain Disability Questionnaire was used to measure outcomes. Treatment included education about the ANS (autonomic nervous system); an active health plan in which the patient takes responsibility for their own healing; and movement guidelines to support the parasympathetic NS. The results show a significant pain reduction and increase in mobility.
