Back pain is a 20th century medical disaster. We sent people to the moon 30 years ago, we have cured polio and many other diseases thought to be incurable, yet we have no answer for simple backache. For all our resources and efforts, lower back pain disability is getting worse (from U.K Stats. Dept.) Why are we not delivering better and more effective health care for back pain? I believe there are many reasons for this. We do not seem to put our better understanding of back pain into practice. We are still poor at dealing with disability. Too often we ignore the disability and assume it will go away if we treat the pain. Gordon Waddell. The Back Pain Revolution. Churchill Livingstone 1998.
For 60 years since the formulation of the ruptured disc we have been able to injure our backs in the absence of trauma. It is time for a new common sense - in fact it is long overdue.
Nordin Hadler. Occupational Musculoskeletal Disorders. Lippincott Williams and Wilkins 1999.
Only 21% of patients stayed free of symptoms over a four-year period according to a study of 252 patients. If this study is typical, less than half of the patients seen in primary care can expect to be symptom free fours years later. Depression was the main factor associated with chronicity. Reference Burton et al. Presented at the Third International Forum for Primary Care Research into Lower Back Pain. Manchester England.
A new study finds little evidence that physical activity raises the risk of back pain among adolescents. Although adolescents may be more likely to have an acute injury due to physical activity, their overall risk of developing musculoskeletal back pain is not increased says co-author Ian Shrier, MD, in presenting the new study at the annual meeting of the American College of Sports Medicine. We can use this study to help allay fears of parents who say I don't want my child participating in sports because they will end up in pain.
Backletter Vol. 14, No. 8, August 1999.
The purpose of this study was to determine if posture and back pain changed from the first to the third trimester of pregnancy, and whether there is a relationship between the two. No significant relationships were found between magnitude of, or change in posture and back pain. These results suggest that in the standing position, the lumbar lordosis and saggital pelvic tilt increased and head position became more posterior as women progressed from their first trimester to their last. These were not related to lower back pain.
Franklin M, Conner-Kerr T. JSOPT. 28:3:133.1998
According to an increasing body of evidence, exercise in the elderly can increase functional abilities, stem muscle and bone loss and decrease the risk of falling. In conjunction with these benefits, another new study has shown that exercise improves the mood in the elderly.
The older the person, the less active the person, the more dramatic the results are from re-activation. In recent times, Physio South has carefully entered relatively inactive clients over 80 years old into the gym. The key we have found, is limiting exercise options until gradual improvement allows more exercise variations and progression.
Backletter Vol. 14, No. 8, August 1999.
A prospective nine year follow up study to evaluate the long term persistence of initially reported recurrent LBP, and to examine the significance of abnormalities found in MRI imaging in individuals between 15-18. The authors early findings already favoured the hypothesis of a causal relationship between the early evolution of a degenerative process of the lower lumbar discs and recurrent lower back pain in the near future. The current results further strengthen this hypothesis, indicating that individuals with disc degeneration soon after the phase of rapid growth, not only have an increased risk of recurrent lower back pain at this age, but are also at long-term risk of recurrent pain up to early adulthood.
In some previous studies up to 50% of children up to teenage years reported a history of lower back pain. The first episodes often start at 13-14 years of age and increase with age. The authors agree that lower back pain in the young is usually self-limiting. Normal disc degeneration begins in the early twenties. These changes are evident in nearly all middle aged persons and they are associated with age, but not lower back pain. A subset of young people with recurrent LBP (2-3% of target population), appear to have different characteristics from those found in later years. Are these the people who go on to suffer chronic and disabling LBP in later life?
In summary, the results indicate that patients with disc degeneration soon after the phase of rapid growth, not only have an increased risk of recurrent lower back pain at this age, but also a long term risk of recurrent LBP up to early adulthood.
Salminon et al. Spine 24:13:1316-1320, 1999
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Gaines W, and Hegmann K. Spine 24:4:1999.
Patients with acute, occupational lower back pain exhibiting Waddells non-organic signs, had a four times lengthier time for return to unrestricted work and a greater use of physical therapy and CT scans.
Volvo Award Winner in Clinical Studies
A Randomized Clinical Trial Of Three Active Therapies Mannion et al.
A randomized clinical trial of three active therapies involving 147 patients divided into one of three groups.
1) Specific Physiotherapy exercises including strengthening.
2) Muscle reconditioning on training devices.
3) Low impact aerobics.
Results
After all therapies, significant reductions were observed in pain intensity, frequency and disability and fear avoidance beliefs reduced. These results were maintained for 6 months with the exception of the physiotherapy group.
Conclusion
The general lack of treatment specifically suggests that the main effect was induced not through the reversal of specific physical weaknesses targeted by the treatment, but rather through some central effect, perhaps involving an adjustment of perception in relation to pain and disability.
Implications
This article has shown that general re-activation programmes may be as good as any specific intervention. Twenty years working in the gym has confirmed this to me clinically. Personally, a system, which includes screening for rapid responders to specific exercises (McKenzie and Stabilization), educates the patients and then starts a general exercise program with some specificity for lower back pain/function seems logical. PHYSIOSOUTH has been advocating this system for around a decade. It works, it's cost effective, it empowers patients and leaves them with on-going, self-monitoring exercise/rehab programmes.
Abdulwhab S & Sabbahi M. JSOPT 2000; 30(1): 4-12.
This two-group repeated measure study aimed to evaluate the change in the flexor carpi radialus reflex after reading (flexion) and neck retraction (extension lower cervical spine) and to correlate reflex changes with intensity of radicular pain. Neck retraction exercises are a standard part of the assessment and most exercises prescribed by the McKenzie system of treatment of lower cervical spine problems.
Results
Statistical analysis showed a significant decrease in the H reflex and increase in radicular pain after reading. The opposite occurred with neck retraction showing an increased reflex and decrease in pain.
Conclusion
Neck retractions appeared to alter the H reflex amplitude. These exercises might promote cervical root decompression and reduce radicular pain in patients with C7 radiculopathy. The opposite was true of the reading posture.
Implications
The McKenzie system has advocated repeated neck retraction as an exercise when associated with reduction in distal symptoms and decrease or abolishment of more local symptoms. This study gives the theory some evidence and reinforces this exercise as one of the most useful in the treatment of lower cervical dysfunction.
Fritz J, Delitto A et al.
This study aimed to determine the interrater reliability of the McKenzie assessment for acute lower back pain, including the centralization phenomenon. A videotape was made of a McKenzie assessment, 40 physical therapists were to provide operational definitions and asked to judge the patients status change in response to the tests.
Results
The interrater reliability was excellent for the total number of examiners. Judgments were not dependant upon experience but appropriate operational definitions.
Implications
This study partially validates the McKenzie assessment in regards to interrater reliability.
Vroomem et al. Spine 25:1, pp 91-97.
This was a cross sectional study of interobserver variability in primary care patients aiming to measure the consistency of signs and symptoms of nerve root compression in patients with sciatica. The literature is vague on the clinical tests for nerve root compression. Ninety one patients were randomly selected and investigated by a neurologist-resident couple.
Results
The straight leg raising test, crossed straight leg raising test, Bradgards sign, and Haffzigers sign were the most consistent nerve root signs.
Conclusion
For a more consistent overall diagnosis, the physician probably should put more emphasis on the history of the pain, on coughing, sneezing, straining, a feeling of coldness in the legs and urinary incontinence. The investigation of paresis, sensory loss, reflex changes, SLR, and Bradgards sign provide the most consistent results.
Fritz and George. Spine 1:25, pp106-114.
A prospective, consecutive, cohort study of patients with acute lower back pain was classified into subgroups of immobilisation (for instability), mobilisation (for sacroiliac and lumbar problems), or specific exercises (for McKenzie extension, flexion, lateral shift of traction). The patients were measured after treatment for outcome success and reliability of sub-classification was assessed.
Results
Similar outcomes were found for the patients in the mobilisation and specific exercise groups. Reliability was acceptable.
Conclusion
Further work is required to validate improvement in treatment using a sub-classification approach.
Carey et al. Spine 1:25, pp125-120.
This 22-month prospective cohort study aimed to describe the course of a group of 1246 patients with chronic lower back pain (over 3 months).
Results
Predictors of chronicity were poor baseline functional status and sciatica. A more powerful predictor was poor functional status at 4 weeks. 66% of the patients had functionally disabling symptoms at 22 months, and a majority of these were employed. 2.6% of the patients had surgery. Chronic lower back pain occurs in 7.7% of patients who seek care for acute low back pain, with unremitting pain for 22 months in 4.7%.
Conclusion
Once established, chronic lower back pain is persistent. Most patients with CLBP seek little care, and the majorities are employed.
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