News Category: Lumbar Spine

Walking is good exercise. It is often the main part of an exercise program for people with low back pain (LBP). But if it hurts to walk, back pain sufferers are less likely to follow through with the program.

In this study, physical therapists examine how LBP affects walking. The goal is to find a way to help them successfully participate in a walking program. We know that people in pain walk more slowly and shorten their stride length. They may do this to decrease the forces on the spine.

To find out more about the effect of pain on force from the ground up to the spine (called vertical ground force or VGF), three groups of patients were studied. The first group had back pain only. The second group had back and leg pain. The third (control) group were healthy adults of the same age and sex as the other two groups. The control group did not have any back or leg pain.

VGF was measured in all three groups at two different walking speeds. The first was their preferred walking speed. The second was their fastest pace. The researchers expected that if speed were kept the same, vertical ground force would be the same for the back pain only and control groups. They also thought the leg pain group would have less vertical ground force when walking at both speeds.

What did they find out? When given the choice, people with back pain walk slower to decrease the vertical ground force. But they can walk faster. When they do, the vertical ground force isn’t any higher than for people without back pain.

They also found that people with back and leg pain walk slower but use other ways to reduce vertical ground force through the painful side. They limp and walk in a protective manner. These two factors reduce the loading rate on the leg even when the loading force is the same as the other groups.

The most important finding of this study was the fact that walking decreased pain for the back pain only group. More research is needed to find a way to help patients with back and leg pain. This current study will continue in a second part. Other factors to consider include walking greater distances, shoe type, and walking outdoors.

Disc replacements are now available for the low back (lumbar spine) and the neck (cervical spine). The patient most likely to qualify for this surgery is someone with a herniated disc putting pressure on the spinal cord. Only one level is replaced. This is due to concerns that other levels will start to break down.

This is the first study published comparing the results of single-level cervical disc replacement with multiple (two or three) level replacements. Pain levels, function, and motion were used as measures of the results. X-rays and MRIs were also used to show the position of the implant. The same studies also showed the biomechanical motion in each spine.

The same surgeon treated everyone. An FDA-approved porous coated motion (PCM) implant was used. This type of implant allows bone to grow in and around the surface. Patients in the single-level group were very similar to patients in the multiple-level group. They were the same age and sex. They had the same severity of condition.

Patients were followed for up to three years. The results showed greater overall improvement for the multilevel group. Although the multilevel group had a longer hospital stay, their neck disability improved more. The reoperation rate and the number of problems after the operation were the same between the two groups.

The authors comment that this study shows that either operation does not burn any bridges. Anyone needing further surgery only required a minor operation. No one had to have the implant removed and a spinal fusion done.

Further study is needed before multiple disc replacements can be used for everyone. In fact, insurance companies won’t pay for improved technology. They want some proof that the results are superior not just not inferior. Two to five-year results are needed before a change can occur in the standard single-level only policy.

A painful, inflammatory disorder mostly affecting the spine is called ankylosing spondylitis (AS). New research shows that early diagnosis is important to prevent permanent deformities. If offered early enough, patient education and physical therapy can make a difference.

Early diagnosis can be difficult. In this report, rheumatologists offer some helpful advice to doctors about making an early diagnosis of AS. Early disease can be recognized by spinal pain and stiffness. The patient also reports fatigue. All of these symptoms are present in early adulthood. Some patients recall similar symptoms in childhood.

Standard methods of diagnosis may miss early AS. Early changes are seen on special MRIs. The radiologist will see cartilage changes, intra-articular inflammation, and bone marrow edema.

X-rays are still taken first. X-ray findings along with signs of inflammatory back pain guide the physician in ordering the more expensive MRIs. Signs of inflammatory back pain include:

There is a lot of research being done in the area of lower back pain, including searching for key factors in back disability prevention. Participants in this Delphi panel comprising 14 researchers, eight occupational health managers or consultants, seven clinical practitioners, two insurance organization employees and two worker advocates, undertook to find what influenced the choices for back disability prevention interventions.

The panel members were given summaries of 32 modifiable factors that were associated with pain-related disability. Increased fitness, expectation of recovery, access to alternative care, decreased physical workload and lifting devices were some of the 32 that were listed. The panel chose the factors that they each felt were most important and they were asked to rank them in order of their relative impact on the patients, in their opinion. The impacts were, for example, quality-of-life and ability to work. After ranking the factors, the panel was asked to explain what influenced their choices.

The researchers found that the panel members made their choices based largely on their own personal experiences and their views on the nature of back disability, expectations of how interventions would be implemented, as well as they typical patients or workers and their own values. Another factor was whether the injury was work-related.

Other findings indicated that educational background and current affiliation did not play a large role in choosing priorities.

The researchers concluded that there were two main clusters in choice of priorities for interventions to prevent back injuries: personal experience and issues that separated the impact from modifiable behaviors.

Gabapentin (Neurontin) has been used quite successfully for patients with neuropathic (nerve) pain in the hands and feet. In this study, patients with neurologic intermittent claudication (NIC) from lumbar spinal stenosis were given gabapentin.

Spinal stenosis is a narrowing of the spinal or nerve canal where the spinal cord or nerve roots are located. Pressure on these nerve tissues and possible lack of blood supply to the area can cause NIC. NIC is described as pain, numbness, or discomfort in the legs when standing or walking. The affected patient must stop, rest, or bend or stoop forward to get relief from the symptoms.

Gabapentin is a pain reliever and an anti-seizure medication. It seems to work well with patients who have nerve pain from diabetes. In this pilot study, it also helped patients with spinal stenosis.

Patients with spinal stenosis were divided into two groups. Everyone was treated with exercises, a corset, and an antiinflammatory drug. Only one group got the neurontin as well. Results were measured by walking distance, pain level, and neurologic symptoms.

Everyone was able to walk better after four months. But the gabapentin group could walk much farther at the end of each month. Pain levels were significantly improved in the gabapentin group. Twice as many people in the gabapentin group (compared to the control group) had less numbness in their legs and feet.

The authors conclude gabapentin may be a good drug to use with patients who have spinal stenosis. Further study is needed before this recommendation is made for everyone. Patients older than 65 (the age group affected most often by stenosis) must be studied carefully.

Management, not treatment, is the new byword for patients with low back pain. Bed rest is no longer advised even for a day or two. Staying active is the number one piece of advice doctors now give their back pain patients.

The goal is to avoid becoming a chronic pain patient. Treatment such as acupuncture, medications, and chiropractic care may have a place in reducing the painful symptoms. But most patients get better without anything but movement and activity.

Patient education goes hand in hand with staying active. Doctors, chiropractors, and physical therapists are helping patients understand and manage their own symptoms. Knowing what to expect takes a big load off the patient’s mind. And easing anxieties and worries can actually help reduce back pain.

Some patients who don’t get better following this management advice may need physical therapy. The therapist can help patients correct posture and gait. The physical therapist can help patients regain normal motion and joint dynamics.

If patients do not get better with a management approach, then further medical evaluation may be needed. The doctor may need to order lab tests or imaging exams such as X-ray or MRI.

The bottom-line with a management approach is that patients must become responsible for themselves. Poor posture, obesity, and low levels of fitness are all within our individual control. These factors are an important part of good health, including having a healthy spine.

The American Academy of Neurology (AAN) has just released new guidelines about the use of epidural steroid injections (ESIs) for low back pain.

ESI is used to control back and leg pain caused by pressure on the spinal nerve. This is called lumbosacral radicular pain. The injections work by reducing inflammation and swelling around the nerve.

When doing an ESI, the doctor inserts a needle through the skin so that the tip of the needle is in the epidural space. This space is the area between the bony ring of the spine and the covering of the spine called the dura. The dura is the sac that encloses the spinal fluid and nerves of the spine.

The results of recent studies confirm that ESIs do give some relief of lumbosacral radicular pain. Patients can get relief of painful symptoms for up to three months. ESIs do not cure any of the diseases they are commonly used for. They don’t change the patient’s level of function or need for surgery.

The AAN does not advise using ESIs on a regular basis. The use of ESIs for neck pain from cervical radiculopathy hasn’t been studied fully yet. Better studies with larger numbers of patients are needed in this area.

Disc protrusion in the lumbar spine can cause low back pain (LBP) that goes down the leg. The leg pain is often referred to as sciatica. Epidural steroid injection (ESI) is one treatment option for sciatica. The steroid along with a numbing agent is injected into the space around the spinal nerve. The goal is to reduce inflammation and swelling. The result is pain relief.

But does it really work? How long does the effect last? Many doctors debate the use of ESI for sciatica. Many studies have been done but most are not quality studies. Some studies with a good design have too few patients to be considered valid. Other studies with large numbers of patients have a poor design or the researchers turned the data around to prove their point of view.

A review of many studies show agreement on one thing. ESI give patients short-term pain relief from sciatica caused by disc problems. The pain goes away faster. Patients report reduced pain in days with the injection instead of weeks without the ESI. With or without the injection, there isn’t much difference in function. It’s just a matter of comfort. And the injection doesn’t keep patients from having surgery.

Doctors who use ESI should just be aware that it has the benefit of quick pain relief but there are still possible side effects. There is the risk of infection and abscess. There is concern about osteoporosis and bone fractures with repeated injections. This is especially true for older adults who are already taking steroids for other health problems.

One study showed that patients with disc protrusion do better with ESI than patients with disc extrusion. In protrusion, the disc bulges but stays inside its own protective covering. With extrusion, the disc material breaks through the outer layer.

All in all, the experts say that the best solution would be a drug that could give similar pain relief without an injection. The effect should last up to three months in order to compare to ESI.

People in modern society have a high incidence of chronic lower back pain. The increasing number of patients who suffer from this pain is causing problems socially and economically because of its effect on ability to work and cost on the healthcare system. This is leading researchers to work to find the best methods for diagnosing back pain and the most effective treatments.

One treatment for chronic lower back pain is spinal fusion, or surgery to fuse the discs that are causing the pain. In this cohort study, researchers looked at patients who were undergoing lumbar fusion for chronic lower back pain to find if evaluating the discs adjacent to those to be fused would make a difference in the outcome of fusion surgery.

Discovering if discs are causing pain isn’t simple. X-rays and imaging (magnetic resonance imaging and computed tomography imaging) may show if there has been degeneration, but can’t show if the discs are causing pain. A test called the provocative lumbar discography uses an injection into the spine to trigger pain if there is a problem with the disc.

According to the study authors, use of provocative lumbar discography is controversial and has not yet been consistently established as valid. The pain response from the injection is very subjective and the authors say, “discography is not a test at the level of a gold standard to identify whether a disc is truly a clinically significant pain generator in a chronic LBP patient.”

In this study, the patients first underwent the discography and then a temporary transpedicular fixation, a test that could provide temporary relief from back pain. The results of this test determined whether the patients would receive fusion surgery or continue with conservative management.

Eight-two patients had surgery. Following the surgery, the patients rated their pain from 0 (no pain) to 100 (excruciating pain); this was compared to their ratings prior to surgery. The researchers found that the patients who were identified as having degenerating discs adjacent to the fused discs had no different outcome from surgery than did those patients who had normal adjacent discs.

The authors point out that the study was small and there were some weaknesses in the study design, including the discography, because of the many variables in the procedure. As well, the authors state that there may have been possible bias in the selection of the patient groups. However, despite the drawbacks to the study, the findings did indicate that the pre-operative status of the adjacent discs did not appear to be relevant to patient outcome following fusion surgery.

Doctors know that psychosocial factors can play a role in the duration and outcome of lower back pain but, until now, few studies have focused on workers with lower back pain and when – and if – they can return to work. Also, the studies that have been done have used populations drawn from those who were able to make claims from workman’s compensation, perhaps affecting the study outcome.

This prospective cohort study of 140 male military personnel investigated the psychosocial variables, including job satisfaction, life stress, social support, and coping and their effects on pain, mood, and overall function. The study participants were assessed at baseline, six months and one year. The men were between 18 and 50 years of age and were experiencing their first episode of lower back pain. Their back pain had begun between six and 10 weeks earlier. Men who were taking or had taken medications to alter their moods, such as for depression or anxiety, weren’t eligible to take part.

The study participants were all examined by a physician and answered the same questionnaires at all three time points of the study. The questionnaires were: the Descriptor Differential Scale (DDS) for pain, the Pain and Impairment Relationship Scale (PAIRS) for everyday function, an interview regarding life adversity, the Social Support Questionnaire for support networks, the Ways of Coping Scale (WOC) for dealing with stressful situations, the Hamilton Rating Scale for Depression, and a return-to-work evaluation. During the study period, all participants received the usual orthopedic care.

At the end of the study, the researchers found that most of the participants continued to complain of pain but most, 63 percent, were able to return to work full time, without any restrictions. At the start of the study, only 37 percent of the participants were able to work full time.

When comparing participants who returned to work full time or with adaptations or restrictions, the researchers noted that at six months, 58.6 percent of the participants had returned to work with no restrictions, 10 percent were working with some modifications, 18.6 percent were doing alternate work, and 5.7 percent were going to be receiving discharges from the military shortly. Of the remaining participants, 1.4 percent had already left the military and the rest were lost to follow up. At 12 months, only 4.3 percent required modifications at work, 5.7 percent had completed their enlistment, and the remaining were lost to follow up.

The researchers analyzed the results and found that pain was the only significant indication as to whether a participant’s work status would change throughout the year. Other factors, such as social support and coping didn’t appear to play a similar role.

Although the findings in this study didn’t find a connection between emotional distress and return to work, the researchers did find that almost half of the participants, 49 percent, did report significant depression symptoms at two months. They point out that if the depressive symptoms were present before the back injury occurred, recovery may be affected.

Although the study was limited to males and the sample size was small, the researchers concluded that early intervention to improve function may improve rates of return to work, and reduce or prevent work disability.

Low back pain is a common injury among many people in Western society, regardless of age. Low back pain during adulthood can result in lost work time and diminished quality of life, but among the elderly, it can reduce their ability to participate in daily activities and to care adequately for themselves, resulting in a drastically reduced quality of life.

Previous studies in France and Britain used the Back Book as an educational tool for working-age adults who had lower back pain. The study findings showed that adding the book to education programs appeared to affect the patients in a positive manner when compared with those who did not receive the book. A third study using the book took place in the Netherlands but the researchers there found that the Back Book, combined with a 20-minute discussion regarding back care, did not show a higher level of improvement over those who didn’t receive the book.

In this clustered, randomized, controlled trial, researchers recruited 661 patients who were residents from 10 nursing homes in Spain. The patients were randomized per nursing home: four nursing homes to active education program, receiving Back Manual, a culturally adapted Spanish version of the Back Book; three to postural intervention with a Back Guide that discussed how to promote healthy posture; and three to the control group, receiving a book discussing general cardiovascular health. All participants received a talk from a physician how discussed the information available in the booklet.

The average age of the patients was 80 years old and the majority of the patients (64 percent) were women. Sixty five percent of the patients complained of lower back pain at the start of the study and the pain was chronic in 35 percent of the cases. More than half the patients were taking medications for chronic illnesses and around 55 percent were taking medications for lower back pain.

Before the study, the patients were assessed for their pain levels, functional disability and fear avoidance beliefs. Using a point system, the researchers found that after six months, all patients experienced some improvement, including those in the control group. Patients in the postural education group improved more than those in the control group, but not as much as the patients in the active education program. Also, patients who had lower back pain at the start of the study improved if they were in the active education group, but not if they were in either of the two others.

Although some improvements may not be considered statistically significant, the authors point out that there are relatively few low-cost treatments available for the prevention of lower back pain, so this type of intervention may still be useful.

The authors concluded that the addition of the Back Book to patient education does have merit and can improve the quality of life among elderly patients, particularly those who have lower back pain already.

There’s an ongoing trend in medicine for evidence-based care. Instead of a feel-good-for-the-moment approach, there must be some proof that the treatment actually works.

In the case of low back pain (LBP), some evidence-based guidelines are available. Patient education is the first and most important element. Patients must be informed about the causes and treatment of back pain. Many people with back pain are fearful and anxious about their symptoms but also about what will happen to them.

Listening to the patient and offering explanations and reassurance are the first two steps in the evidence-based approach. Doctors must be able to explain the concepts of back pain management in such a way that patients are convinced to follow the plan.

The doctor must be able to help patients see how and why their beliefs are wrong, and why a different method is best. They can do this by being informed themselves. Keeping up on the latest studies published in medical journals is a key factor. Letting their patients know what is valid, reliable, and effective is the goal.

And according to several large studies, this approach works well. The cost of treatment is much lower. Patients report a greater reduction in their pain. The results last six months to a year or more. A large number of patients were fully recovered. Only six per cent had another episode of back pain.

According to the results of two surveys done 10 years apart, chronic back pain is more common now than ever before. Eighteen per cent (18%) of U.S. workers report chronic pain while on the job.

There is concern because companies suffer productivity loss from presenteeism instead of absenteeism. In other words, workers go to their jobs rather than use sick leave. But their work suffers for it.

With the aging of America and people being more likely to report chronic pain now compared to 10 years ago, this trend may be important. Experts in the field of pain control have said many times that pain is untreated or under-treated in the U.S.

But editors at the BackLetter took a closer look at the survey. They discovered the Ortho McNeil drug company paid for both studies. This is a company that just happens to have a drug (ULTRAM-ER) for chronic pain. BackLetter editors point out that neither survey has been published in a peer-reviewed journal.

Until other studies can be done to confirm these findings, readers should be wary of press releases that give study results and suggest a medication at the same time. There may be a fine line between survey science and marketing, but there is a difference. As always, the warning Buyer Beware is a good one.

Better imaging technology has shown us that the brain changes in response to chronic pain. Scientists suspect changes in the structure of both the spinal cord and the brain occur. In fact, there may even be changes in the immune system. The result is an ongoing series of pain messages.

This new information has lead to proposed changes in how we treat chronic low back pain patients. Scientists are looking for ways to reverse some of these changes. A new method called deep learning therapy (DLT) is being tried.

With DLT the patient is told the problem is not psychologic. It’s neurologic. Then an exercise program is started. The goal is to gradually increase the use of the back. Patients are guided to increase function despite the pain.

A behavioral program is included. Patients are trained to break the hold that fear and anxiety have on them. They are taught how to reduce the attention they put on their pain.

The hope is that with DLT, retraining the painful parts of the body will reorganize the neural anatomy. The results in small studies have been positive. But so far patients have been improved but not cured.

Larger studies are needed to find rehab methods that work for everyone. For now, it’s assumed that some things only work for some people. It’s always a matter of finding out what works best for each individual. There may be genetic and environmental factors we still aren’t aware of that could make a difference. Future studies may bring these to light.

They say if you see six doctors for low back pain that you’ll get six different opinions about what to do. That may be true because research hasn’t been able to identify one best treatment plan for everyone.

One thing that may help us plan treatment for patients is to identify prognostic and predictive factors. Prognostic factors are those things, which if present, are linked with a good or bad outcome. Predictive factors can be used to tell which kind of treatment works best for the patient.

Researchers tried to rank factors most important in preventing disability from back pain. They got a group of people together to sort this all out. The group included researchers, doctors, therapists, and other interested parties.

Everyone was given a list of 35 possible factors to put in order of importance. When the top eight items were listed, each participant was asked to rank them according to which ones could be changed or modified.

The group had a wide range of opinions on these two lists of rankings. Only two factors had strong consensus (agreement). They were: 1) that care provider reassurance has a high impact on getting people back to work, and 2) that back supports have little influence on whether people get back to work.

The researchers concluded that getting everyone to agree may not be the goal. Agreement doesn’t necessarily mean a program is successful. In fact, consensus may result in a middle-of-the road approach to prevention. This may not be in the best interest of individual patients.

Wide spread disagreement about back pain and what to do to treat it is a fact. More research is needed to show what works and what doesn’t work. It may be that one program won’t work for everyone. Predictive and prognostic factors may help direct each back pain sufferer to just the right program.

Studies are ongoing trying to find the best treatment for disc herniation. The current standard of practice is to use nonoperative care for at least six weeks before considering surgery. Nonoperative care includes patient education, physical therapy, and antiinflammatory drugs.

One group involved in spine research is the Spine Patient Outcomes Research Trial (SPORT). Doctors and surgeons in 13 spine practices in 11 different states of the United States were part of this SPORT study.

In this study two groups of 250 patients were compared. All were 18 years old or older with a diagnosed disc herniation. Group 1 had surgery to remove the disc fragment. Group 2 had nonoperative care.

Follow-up was for two years. Patient results were measured based on pain, symptom severity, function, and patient-reported improvement. Overall, there was no difference in outcomes between the two groups. In general, the operative group had less sciatic pain after surgery. The surgery group also rated their progress as greater.

The authors point out that a large number of patients in each group switched to the other group. Some patients in the surgery group got better and no longer needed an operation. And some patients in the conservative care group got worse and needed surgery. This is called cross over.

The reasons for the high rate of cross over remain unknown. It may be the result of change in symptoms, which is common with disc herniation. The results of this comparison study point out the need to determine predictive factors. In other words, scientists hope to figure out which patients would do best having surgery and which would do better with an exercise program.

Lumbar spinal stenosis, a common condition among older people, can cause significant deterioration in quality of life. Currently there is no gold standard for treatment to relieve the pain caused by the stenosis. Some patients are treated surgically, especially if their symptoms are severe; others are managed conservatively with physiotherapy, medication, and education.

Earlier studies done to investigate the best treatment for spinal stenosis have not been conclusive. For example, one small study of 22 patients found that surgery was better at relieving pain and symptoms than was non-surgical treatment, and yet another study of 47 patients found only fair results in both surgery and non-surgery groups, with a small advantage to those who didn’t have surgery.

The authors of this prospective, non-randomized study said that previous studies didn’t address two important questions: “Is surgery or non-surgical treatment a better option for patients with…lumbar stenosis?” and “What proportion of these patients get better, worse, or remain the same with time?”

One hundred twenty five patients with persistent back pain that radiated down one or both legs participated in this study. One hundred twelve completed all requirements and were included in the results. The patients chose to either undergo surgery or to receive non-surgical treatment. Those who underwent surgery had one of two procedures: decompression or decompression with fusion. The non-surgical interventions included back bracing; epidural steroids (medication injected directly into the spinal cord); medications such as analgesics (pain medications), anti-inflammatory drugs, and muscle relaxants; spinal manipulation; and weight loss, if necessary.

Before receiving treatment, the patients were evaluated by the researchers who were using a questionnaire called the Roland-Morris questionnaire. The patients were followed for two years and the patients who didn’t undergo surgery were treated by their family doctors, although they were still followed by a spinal surgeon.

At the two-year follow-up, and using the same questionnaire to evaluate the patients, the researchers found that the patients who had decompression surgery or decompression surgery and fusion improved more (63.3 percent and 61.5 percent, respectively) than did the non-surgical group (25 percent). Four percent of the patients in the decompression-only group got worse, as did 12.5 percent of patients who had the other surgery. The majority of the patients who did not have surgery appeared to remain at the same level as prior to the surgery (62.5 percent). In the two surgical groups, 32.7 percent of the patients who had decompression only and 35.9 percent of the other group remained about the same as before the surgery.

Findings also showed that the patients who had surgery may experience residual symptoms and that they should be prepared for this to occur.

The authors did point out that there are some weaknesses in the study, including the group choices. They said that it could be that those patients who had the most to improve, the ones with the most symptoms, appear to be the ones who chose surgery.

The authors concluded that, although surgery can improve the quality of life in patients with spinal stenosis, they could still have residual symptoms that they should be aware of in order to prepare effectively.

Lower back pain afflicts many people. Some statistics claim that people have a 65 percent to 85 percent chance of developing lower back pain at some point in their life. In addition, among those who do have back pain, anywhere from 28 percent to 75 percent experience relapses, often more than one. Since back pain can affect someone’s ability to work and perform daily activities, and it is costly for the healthcare system, many researchers have tried to find ways to prevent back pain from occurring and how to relieve it once it’s started.

Many studies have investigated the effectiveness of exercise in helping relieve back pain, but none have been conclusive.

In this prospective, randomized trial, researchers assigned 50 patients with diskogenic low back pain to either an exercise group or a control group, in which the patients did not receive treatment. The patients were young, average age about 31 years, and most had sedentary jobs. None had any history of trauma to the back.

The exercise consisted of a new program, the Back Rx program that involves a series of exercises. The first, series A, had the patients doing isometric muscle work through physical therapy. The patients did this for six months. Series B built up on what was learned in series A with another six months of more dynamic muscle movements and yoga-based exercise that focused on the core muscles of the back. In this series as well, the patients targeted muscles in the chest, shoulders, abdomen, thighs, and hips. The patients in both the control group and the treatment group were allowed to take an anti-inflammatory (celecoxib) every day and a pain reliever consisting of hydrocodone and acetameniphen as needed.

Forty-four patients were available for follow-up after one year. Seventy percent of the patients in the treatment group reported a successful outcome while only 33 percent of the control group did. Over the course of the year, only 17 percent of the treated patients reported returning pain that lasted for more than three days while 48 percent of the control group had such pain. Finally, the treated group reported less frequent use of the pain reliever than did the control group.

The authors pointed out that the study did have a few weaknesses, the main one being the lack of testing to verify the diagnosis of diskogenic lower back pain. The researchers used patient history and symptoms to make the diagnosis. The authors also pointed out that the patients in the treatment group did report increased pain during the first three weeks of the exercise program and recommended that patients participating in such programs be warned about this possible occurrence.

The authors concluded that although the use of a back brace and oral medications may still be needed during treatment, a well-designed exercise program may be effective for patients with this type of back pain. They suggest that a larger scale, multicenter, controlled trial be undertaken to confirm their findings.

The cause or causes of lower back pain can be identified only, with certainty and based on clinical examination alone, in about 15 percent of patients. Back pain caused by facet (zygapophyseal) joints can occur in between 15 percent to 45 percent of patients who experience back pain. In this prospective, nonrandomized, consecutive study, researchers evaluated how common facet joint pain was among patients with chronic lower back pain that occurred after surgery of the lumbar spine.

One hundred seventeen patients took part in this study. They had to have had their surgery at least one year before surgery and had to have experienced pain for at least six months after the procedure. Almost half of the patients (45 percent) had undergone more than one surgery. All of the patients had tried other treatments to relieve the pain, including medications, physical therapy, and bedrest, but hadn’t been successful.

The researchers tested for facet joint pain by injecting an anesthetic block (lidocaine) into to each facet joint nerve of each patient. If the patient showed an 80 percent or more improvement in pain after the injection, this was a positive result. All of the patients were given the lidocaine block and if their results were positive after the lidocaine, the patients were given a second block of bupivacaine three or four weeks later. Sixty-seven patients had positive results from the lidocaine block and of those 67, 19 had positive results from the bupivacaine block.

From the study findings, the researchers reported that 16 percent of the patients with lower back pain and suspected facet joint pain did, indeed, have facet joint pain, and that the prevalence was 8 percent in the overall population. The researchers noted that although more studies are needed in order to better understand patient response and to improve clinical practice guidelines, using diagnostic facet joint nerve blocks to diagnose facet joint pain was relevant and useful.

Many studies have been done regarding prevention and management of disabilities following back injuries. Despite these studies, there’s still little agreement as to what factors are the most important and how to tackle the problem of back injury disability. Many of the studies and recommendations have differing opinions.

In order to reach a consensus on the topic, the authors of this study, a modified Delphi panel, recruited 33 researchers and occupational stakeholders (those who cared for patients, workers, employers, and insurance representatives) to review evidence summaries of 32 factors that contribute to back injury disability. The study participants were asked to rank the factors in order of priority in their opinion, taking into account the factors’ relative impact on patients and their modifiability. Factors included those such as fitness, workplace stress, back supports, provider reassurance, pain and depressive symptoms.

After the ranking was evaluated, the researchers found that there were significant differences in opinion regarding the effect of the factors on a patient’s ability to return to work, the foremost indicator of recovery from back injury in most studies. That being said, there were two areas that did indicate a strong consensus among the participants. One was regarding the impact of care provider reassurance; this was considered important. This has also been a factor documented in several earlier studies. The second factor was regarding the use of back support and its low impact on occupational participation.

Other factors were agreed upon, although not overwhelmingly, such as expectation of recovery, decreased fears, and increased knowledge.

The authors concluded that there were many discrepancies among the panel members and that this led to an inability to agree on the relative impact and modifiability of different factors that contribute to back injury recovery. Because of the great variety in ranking, programs for back disability prevention intervention should try to include multiple factors simultaneously, allowing the patient to benefit from each. More research does need to be done on the interventions and the authors point out that results need to include other aspects of patients’ lives, including functioning in the home and non-occupational activities.