News Category: General Spine

Eight out of every 10 adults will have back pain at some time in their lives. Only three of those pain sufferers will seek medical care. The goal of this study was to find out who asked for care for their back pain and why.

Workers in seven nursing homes and care facilities in the Netherlands were included in the study. There were nine kinds of workers, including nurses, kitchen help, physical therapists, office workers, drivers, and housekeepers. Questions were asked about health, work, and type of medical care used. Each worker filled out the survey twice, with a one-year gap between surveys.

The authors report how many workers had low back pain (LBP) during the one-year time period. More than half reported LBP at the time of the first survey. Of those workers, 75 percent had more than one bout of LBP during the year. Many of the workers with LBP also reported shoulder, neck, or knee pain. Overall general health was lower compared to workers without LBP.

Workers with pain lasting more than three months were more likely to seek care. Three types of doctors were consulted: general practitioner, occupational physician, and specialist. Chronic LBP patients were often sent by the doctor to a physical therapist.

Factors linked with seeking care included:

Homemakers. The invisible occupation. But it’s not invisible to the doctors who treat the many cases of back pain among homemakers. The results of this study show what happens to homemakers with low back pain (LBP) compared to women working outside the home who also have LBP.

Women covered under a large HMO (health maintenance organization) plan in Canada were the subjects of this study. Everyone was called by phone and asked questions about their pain and limits on function. Phone calls were made four to six weeks after the first doctor visit. The women were called again one and two years later.

By comparing employed workers to homemakers, researchers can look at the effect of formal employment has on LBP in women. In this study no difference was found between the two groups. The authors conclude that formal employment doesn’t affect later function in women with LBP.

Scientists in England are exploring ways to treat chronic back pain. The Back to Fitness (BTF) exercise program has been used and studied since 1980. The idea is to help patients overcome fear that keeps them from moving normally.

Who can get the most help from the BTF program? That’s the focus of this study. Patients were divided into two groups. Group one went to a one-hour exercise class twice a week for one month. Group two had general care as usual with the doctor.

Each patient was classified as a low- or high-fear avoider based on a test given before treatment. Change in this test score after the exercise or treatment program was used as a measure of success. Results were measured after six weeks and again one year later.

The authors report that high-fear avoiders did better with exercise than the group getting general care. The benefits only lasted a short time when the patient had a high level of distress or depression. Low-fear avoiders didn’t have any different results than the usual care group.

Different groups of patients may need different types of treatment. The BTF exercise program may be best for patients with high-fear avoidance beliefs.

A stable spine is important to good back health. Stabilization exercises are a part of back rehab. The muscles must be able to support the spine during different postures and movements. The muscles also help move the spine. But which muscles should be trained for spinal stability, and how should it be done? This is the focus of a study at the University of Waterloo in Ontario, Canada.

Forces on the spine were measured during eight stabilization exercises. The exercises were done while sitting, on hands and knees, and lying down. These three positions made sure the spine moved through all three planes of rotation: flexing forward, twisting (rotation), and bending sideways. The idea was to find out when and how the muscle fibers contracted. This is called a motor control strategy.

The electrical signals from seven muscles were recorded on both sides of the trunk and back. A computer program was used to calculate muscle length, force, and speed. Using this method, each muscle could be tested separately. The pattern of muscle action showed which muscles were active, when, and how they functioned.

The researchers found that no one muscle was the key to stability. Each muscle had its own job to do, and that job changed as the movement or activity changed. The abdominal muscles were involved in spinal stabilization no matter what activity was going on. The authors conclude that rehab must train as many muscles as possible. Limiting exercises to just a few muscles isn’t a good idea.

Avoid or confront? When it comes to conflict or pain, most people fall somewhere between those two extremes. Back pain patients are more likely to have chronic pain if they avoid movement that might cause them pain. This is called fear-avoidance behavior and is the topic of this case report.

A 42-year old sales manager with acute low back pain (LBP) showed signs of fear-avoidance behavior. He hurt himself when lifting a heavy suitcase into his car. An MRI showed a herniated disc at L4/5.

He was put seen by a physical therapist who gave him a special form called a Fear- Avoidance Beliefs Questionnaire. The results showed he was likely to be an avoider. This rating put him at increased risk for chronic LBP and disability. He was put on a program of exercises and given a special patient booklet called The Back Book.

After the patient read the booklet, the therapist discussed the idea of fear-avoidance with the patient. The patient went to physical therapy twice a week for three weeks. He did a home program of exercises and walking. The patient was tested for pain, disability, and fear-avoidance beliefs. These measures were taken before treatment, four weeks after treatment, and six months after starting therapy.

The results showed good improvement in all areas at the end of treatment. Six months later, fear-avoidance was still up but not as much as before therapy. It’s not clear why the patient slid back into fear-avoidance behaviors.

The authors conclude that physical therapists should screen low back patients for elevated fear-avoidance beliefs. If fear-avoidance beliefs are present, then the exercise program should be changed to address this problem. This case report is an example of how such a management program can be carried out.

Smoking has been linked with many health problems. It’s been shown to decrease healing after spinal surgery. But does it affect the results of rehab after surgery? This study looks at the effects of smoking in disabled people with a work-related spinal disorder.

A large group of patients (over 1,000) were divided into four groups. Nonsmokers were in one group. Smokers were put into one of three groups based on the number of cigarettes smoked each day. All patients were tested on physical, psychological, and social factors before and after treatment.

Treatment consisted of exercise, counseling, and stress management. Fitness and return to work were the goals of treatment. One year later, everyone was called by phone and asked a series of questions. The researchers report the following results:

Studies show that low back pain (LBP) patients often expect pain even before doing an activity. This anticipation of pain can negatively impact physical performance. In this study researchers looked at the effect of intense exercise on expected back pain. Previous studies show exercise reduces the intensity of back pain. It’s not clear how or why this happens. Maybe exercise alters anticipated pain. Or perhaps exercise just reduces the pain that comes with physical activity.

Seventy LBP patients were treated by physical therapists at three spine rehab programs. All three centers used the same exercise program. Patients attended therapy in groups of up to eight people. Sessions lasted two hours, three times a week for six weeks. At discharge patients were given a home exercise program.

The authors report that most of the patients in this study expected pain before doing the tests of back function. Then back pain occurred during the test. Patients who expected pain the most had the worst results on the test.

This response changed after spine rehab. Patients expected less pain and had less pain with testing. Therapists think anticipated pain can be altered by exercise that improves back function. Patients did better on tests with direct feedback, such as the number of pounds lifted or pressed. Future back rehab programs may want to keep this in mind when planning specific exercises.

This study gives proof that intense exercise may change pain that is expected before doing physical activities in people with chronic LBP. People in this study also had less pain as a result of doing activities.

Doctors need some way to measure impairment in back pain patients. Impairment is defined by the American Medical Association as “a loss of structure or function of part of the body.” Doctors need a tool to measure: 1) the severity of the disorder; 2) when patients get better or worse; and 3) when it’s safe to return to work.

In this study, researchers simplified a functional motion tool. The original model has five tests and takes too long (30 minutes). The new model measures the loss of function from a low back disorder using only one task (5 to 10 minutes).

The test was used first on healthy subjects. The subjects were adults of all ages and both sexes who did not have back pain. Then it was used on a group of 335 patients with low back pain. The results of each group were compared.

The authors report that the revised model has the same sensitivity as the original long test. Sensitivity of a test tells us how often the test shows a problem when, in fact, there is one. Specificity of the revised test went down slightly, from 94 to 92 percent. Specificity refers to how often a test shows no problem when there’s no problem. In other words, the revised model of impairment rating is slightly more likely to say a healthy patient is impaired than the original model.

Using results from both tests, they also found the time to recovery was predicted the same in 90 percent of the patients. This means the revised model gave the same results as the original model nine out of 10 times. They conclude that the revised model with fewer tasks is excellent. Doctors and therapists can use it to rate impairment.

One-third of all professional golfers have back pain at one time in their careers. It’s the most common musculoskeletal problem in both amateur and professional golfers. The golf swing is probably the cause of these troubles. Twisting at the top of the backswing, followed by the spine’s unwinding and extension during the downswing, put stress on the low back. Golfers with poor swing mechanics are at greatest risk for back pain.

The goal of this study was to find the exact biomechanical mechanism for low back pain in golfers. The authors thought it might be linked to decreased hip rotation in the lead hip. Decreased lumbar spine motion may be another possible cause.

Forty-two members of the Professional Golfers Association (PGA) were put into two groups. Group one had a history of low back pain lasting more than two weeks in the past year. Group two reported no back pain in the past year. At the time of this study, none of the players was having any back pain.

Range of motion (ROM) was measured for all players. Hip rotation of both hips and the lumbar spine was recorded. Other test measures included distance from fingertips-to-floor when bending forward and FABERE distance. FABERE is a test of hip outward rotation.

The authors report a positive link between loss of inward rotation in the lead hip with low back pain. Decreased lumbar extension is also positively linked. The other measures taken weren’t connected to back pain. Decreased ROM is often blamed for injuries in many sports. Golf just got added to the list.

What’s the general direction of back care these days? What changes or trends have been seen in the United States over the last 10 years? These are the questions answered by this report. Researchers compared the results of two surveys taken in 1987 and again in 1997. The surveys were used to find national estimates of use and cost of health services for back pain.

Patients were asked to keep a medical diary. Health care for nonspecific back pain was recorded. Nonspecific back pain means the exact cause is unknown. All visits to doctors, chiropractors, physical therapists, or other health care providers were listed. Tests, drugs, and visits to the emergency room were also recorded. Number of days in bed due to back pain was counted.

The authors found a 10 percent rise in visits to medical doctors between 1987 and 1997. At the same time, visits to physical therapists increased four percent. Visits to chiropractors went down by 10 percent. The use of drugs for pain control stayed about the same.

The number of patients seeking treatment for nonspecific back pain was 6.5 million in 1987 and 7.4 million in 1997. Patients in 1997 were older and better educated. They were also more likely to be injured while under worker’s compensation.

The authors suggest some reasons why there’s been a shift away from chiropractic treatment and toward doctor visits and physical therapy visits. Perhaps patients think these are better ways to treat nonspecific back pain. Maybe health insurance is a factor. If the insurance pays for a doctor visit but not chiropractic care, then the patient goes to a medical doctor. There’s also some question about how accurate the patients are in keeping their diaries. Patients may have forgotten to record some visits or the use of some drugs.

The authors conclude that rates of health care use for nonspecific back pain are actually rising. This is in spite of efforts to decrease the cost of care. Future studies to find ways to reduce painful symptoms and improve function at the same time is still the goal.

Much more is known about pain today than ever before. But our new knowledge isn’t helping pain sufferers much. Drugs, surgery, and even spinal cord implants just don’t cut it for most chronic pain patients. New research suggests that psychologic factors are key to pain. Thoughts, beliefs, and expectations may play a bigger role than we thought in long-term pain.

In this study, Dr. Turk, a well-known scientist on the topic of pain, reviews the latest pain-related research. He reports on the beliefs of pain sufferers, how to predict which patients will have chronic pain, and who will get better with treatment. Here are a few of his findings:

We know that back pain is very common among adults, but how often do children have it? Researchers in Israel surveyed 101 elementary schools to find out. Risk factors such as backpack usage, student weight, chair and desk height, and physical activity at recess were measured in 10,000 children. The children were in grades one through six.

The authors found that between one-third and one-half of all children carry more than 15 percent of their body weight in their backpacks or bags. Fifteen percent sit in chairs that are the wrong size or height. Even more common was the practice of sitting sideways to the teacher. A smaller number of students (six percent) had no physical activity at recess.

Recent studies including this one point out how common low back pain is in children and teenagers. The results show a link between having back pain early in life and experiencing it again in adulthood. Environmental risk factors are likely to blame. These risk factors include lifting and carrying too much, sitting too long, and daily smoking among teenagers with jobs requiring lifting.

The authors conclude there is an urgent need to reduce risks for back pain at school. Knowing the risk factors is the first step. The authors think that increased awareness is the next step. Reducing the risks is the final step.

The muscles along each side of the spine are called paraspinal muscles. The paraspinals have a major role in protecting the spine. Some studies have suggested that too much weakness and fatigue in the paraspinals can increase the risk for a first episode of low back pain (LBP). But just what happens to the muscles to cause this problem? And when does a muscle go from being normal and healthy to being dysfunctional?

Some think it’s possible that LBP occurs when the balance of fibers within the muscle is off. The muscle works a certain way depending on what kind of muscle fibers are present. There are two muscle fiber types: type I and type II. Type I fibers develop less tension and more slowly than type II. The more type I fibers are present, the easier it is for the muscle to resist fatigue. Type II fibers work hard and fast, but they aren’t designed for stamina.

Scientists at the Musculoskeletal Research Group in England put this theory to the test. They compared 35 men who had chronic LBP with 32 healthy men without LBP. Each man was tested with a series of muscle fatigue tests over two days. After the tests, a small piece of the paraspinal muscle was taken for a biopsy exam.

No differences were seen in muscle fiber types between the two groups. The healthy group had stronger muscle contractions and greater endurance (ability to hold the contraction over time). The authors conclude that even though patients with chronic LBP have less paraspinal muscle strength, it’s probably not because of fiber type.

Back and neck pain are common problems in adults of all ages, including adults over 70 years old. What we don’t know is what causes this pain in the older age group, or how back and neck pain develop over time. Do back and neck pain occur at the same time? How often? There haven’t been any studies in this area, until now.

This study comes from the Nordic Institute of Chiropractic and Clinical Biomechanics in Denmark. Danish twins between the ages of 70 and 102 were studied. The researchers used the Danish Twin Registry to collect data. The registry has information on Danish twins born from 1870 on. This allows for long-term studies to be performed. A total of 4,486 twins were included in this study.

Each person was asked a series of questions about back and neck pain, general health, and mental and physical function. Other questions about smoking history, years of school, and occupation were also included. Here’s what the authors found:

Lead poisoning is a major concern in America. Lead-based products such as paint, gasoline, and cans have been removed for the most part. Lead-based bullets are still in use because they break into pieces on impact, causing greater soft tissue damage. Anyone with bullet fragments still in the body is at risk for lead poisoning, a condition called plumbism.

In this study, doctors report on adults with bullet or bullet fragments in the intervertebral disc space. This is the space between the bones of the spine. Doctors found 238 patients with gunshot wounds to the spine at their hospital in Miami between 1969 and 1993. Only 12 of these patients still had a bullet fragment in their spines.

The researchers examined these 12 patients. They took X-rays and ran blood tests. There were no signs of lead poisoning from any of these tests for 11 patients. Only one patient had symptoms of plumbism. She reported fatigue and constipation. Both these symptoms went away when the bullet fragment was removed.

The authors say that with increasing urban violence, the number of gunshot wounds to the spine is also going up. They conclude that patients with gunshot fragments in the spine should be followed carefully on a long-term basis. Any signs of lead poisoning is a signal that the fragment should be taken out. The fragment could also move into the spinal canal, putting the spinal cord and spinal nerves at risk of injury.

Many people with damaged and aging discs have pain from lumbar instability. Fusion is one way to treat this problem. Doctors know that the stress on the disc above or below the fusion often leads to disc damage at those levels. In this study, doctors in Japan used a special method to measure stresses in the disc above the fusion.

The finite element method (FEM) was used. The FEM was first used in 1956 by the Boeing Company to test the strength of new airplane wings. In this study, the FEM was used to measure the load on adjacent discs after lumbar spinal fusion. Three loads were applied to the level above the fusion: 1) compression load; 2) flexion load; and 3) extension load.

Spines with two different types of fusion were tested. One group had a posterolateral fusion (PLF). The PLF takes pressure off the spinal nerve by removing the disc and using bone graft across the side and back of two or more vertebrae. The second type of fusion was the posterior lumbar interbody fusion (PLIF). In this type of fusion, the problem disc is removed from the back of the spine and replaced with bone graft.

Stress was measured in two places: the vertebral endplate and the annulus. The endplate is the thick cartilage between the disc and the next vertebra. The annulus is the ligament ring around the disc.

The authors report a large increase in stress on both areas for both types of fusion methods. They suggest that fusing a spinal segment when the next segment is already degenerating may not be in the best interest of the patient. It appears that in cases of adjacent disc degeneration, the risk of increasing instability of the spine is greater with a fusion than without.

Parents, teachers, and doctors around the world are increasingly concerned about children carrying heavy backpacks. Does this practice cause back pain? Is it damaging to the growing spine or soft tissues around the spine? This is the focus of a large study in Greece of 3,441 children and teens ages nine through 15.

Researchers looked at the effect of heavy backpacks on both back pain and increased spinal curves. Students’ gender, age, and height and weight were matched against spinal curves and back pain. The way they carried the backpacks (over one or both shoulders) was also recorded. Here’s what the researchers found:

Blood clots can be a deadly problem. About half a million cases of deep vein thrombosis (DVT) are reported in the United States every year. Surgeons know that DVT can occur after surgery. Operations involving the legs, such as a total hip or total knee replacement, have the greatest risk of DVT. DVT is a concern after spinal operations, too. As more and more spine operations are being done, DVT after spine surgery is a growing concern.

In this report, doctors from Italy offer some guidelines on preventing DVT after spine surgery. They point out who’s at risk. They also look at the risk of blood clots with different kinds of spine surgery. General risk factors for blood clots must be considered. Risk factors include obesity, age, prolonged bed rest, and diabetes or other diseases.

The doctor must look at the reason why each patient needs spine surgery. Is it the result of trauma? Tumor? Degenerative aging? And finally, the kind of operation must be considered. Attention is given to operating time, the part of the spine requiring surgery, and the position the patient will be in during the operation.

A single formula or way to prevent DVT in spine patients isn’t possible because of many differences between patients and operations. Each patient must be evaluated for risk individually. If blood thinners are used, surgeons must be aware if too much bleeding occurs during the operation. Some blood clotting is needed.

For patients at risk, these authors advise using drugs to prevent clots starting two hours before or up to six hours after the operation. They also advise using stockings and leg pumps after surgery.

Imagine suffering years and years of back pain with no relief. That’s what this group of 110 patients had in common. They’d had an average of 14 years of back pain. They were recruited to be part of a study using prolotherapy as a treatment.

Prolotherapy is the injection of a solution into ligaments. The injection may have glucose, glycerin, or phenol in it, along with a local anesthetic such as lidocaine. The idea behind the treatment is to increase the growth of collagen fibers in the weak ligaments.

The subjects were put into different groups. They either got a real injection into the spinal ligaments in the problem area, or they got a placebo injection. The placebo was a saline (salt) solution. The groups were also either given a special exercise program or just told to do normal activity.

Everyone was injected every two weeks for a total of six treatments. Injections were repeated at four and six months if the patients were still in pain. Anyone who relapsed could get another injection between six and 12 months. All patients were followed for two years.

Everyone got pain relief from the injections whether the injections were real or placebo. And the good results lasted up to two years. There wasn’t much difference between the exercise group and the normal activity group. Other measures such as mental health and use of drugs weren’t different either.

The authors conclude that ligament injections work no matter what solution was used or whether patients exercised or not. The researchers compared their study with the results from other similar studies. They don’t know why they got the results they did. They suggest the following theories:

Doctors at the Gifu University of Medicine in Japan report three cases of permanent paralysis. The cause in each case was a missed lesion putting pressure on the spinal cord in the middle of the spine. Symptoms of back and leg pain along with muscle weakness led doctors at first to think the problem was in the lumbar spine.

Imaging studies weren’t completely clear. An operation to take pressure off the spinal nerves in the lumbar spine wasn’t enough. All three patients got worse, with loss of bladder function, changed reflexes, and extreme muscle weakness.

More testing and an exam of the spine at a level above the lumbar spine showed a tumor in one case. The other two cases involved a cyst, herniated disc, and hardening of a spinal ligament. A second operation relieved the pressure on the spinal cord. However, the delay in diagnosis and treatment resulted in permanent damage to the spinal cord. All three patients had some ongoing neurological problems.

The doctors reporting these cases say the red flag in these cases was the mismatch of symptoms. The patients’ symptoms and the MRI of the lumbar area weren’t the same. More testing might have shown a loss of sensation higher up. For example, pinprick testing of the trunk would have been positive in at least one case.

Missing a compressive lesion in the thoracic spine doesn’t happen very often. The authors conclude that testing must be complete before doing surgery when the symptoms and the exam don’t match up.