Spine Backpain

Eur Spine J. 2009 Jun 27; Hampel P, Graef T, Krohn-Grimberghe B, Tlach LPsychological factors have been found to be of major importance for the transition from acute to chronic low back pain (CLBP). Although some evidence has been provided that depressive symptoms occur secondarily to CLBP, psychological treatment modules that specifically address depressive symptoms are not yet included in German inpatient rehabilitation programs. In this study, a standard rehabilitation program for patients with CLBP and depressive symptoms was compared to a standard rehabilitation, into which a cognitive-behavioral management training of depressive symptoms was integrated. Moreover, treatment effects of this multidisciplinary standard rehabilitation program delivered to patients with either no or only mild depressive symptoms were investigated. As a further aim of the present study, gender effects on rehabilitation outcomes were examined. Short-, mid-, and long-term effects on individual global improvement as well as pain-related, psychological, and work-related measures were evaluated among N = 199 consecutively admitted patients with CLBP, aged from 24 to 62 years. The standard rehabilitation program had no persisting effects on psychological outcomes among patients with no and mild depressive symptoms. Patients with moderate and severe depressive symptoms in the standard rehabilitation program did not benefit with clinical importance at the 6- and 12-month follow-up assessments, but did show clinically significant improvements in psychological outcome measures at the 6-month follow-up assessment when the supplemental psychological component was applied. Additionally, days of sick leave decreased in the intervention group in the mid-term when compared to the baseline. Females benefited more in mental health than males. However, due to regression effects at the 12-month follow-up assessment, booster sessions are highly recommended. The results presented here support the notion that a more adequately tailored rehabilitation program seems to improve rehabilitation success and prevent further development of CLBP among this high-risk subpopulation.

Int J Infect Dis. 2009 May 8; Gul HC, Erdem H, Bek SCentral nervous system involvement is a serious complication of brucellosis; data found in the literature are generally restricted to case reports and case series. In this study we pooled the data from Turkish medical practice in order to gain a thorough understanding of the subject. A search of Turkish publications on chronic neurobrucellosis was made using both Turkish and international databases. A total of 35 publications were analyzed and 187 neurobrucellosis cases were evaluated. Headache, fever, sweating, weight loss, and back pain were the predominant symptoms, while meningeal irritation, confusion, hepatomegaly, hypoesthesia, and splenomegaly were the most frequent findings. The major complications in patients were cranial nerve involvement, polyneuropathy/radiculopathy, depression, paraplegia, stroke, and abscess formation. Antibiotics were used in different combinations and over different intervals. The duration of antibiotic therapy reported ranged from 2 to 15 months (median 5 months). The mortality was 0.5% with suitable antibiotics. Neurobrucellosis may mimic various pathologies. For this reason, a thorough evaluation of the patient with probable disease is crucial for an accurate diagnosis and proper management of the disease.

Acta Neurochir (Wien). 2009 May 5; Jost G, Zimmerer S, Frank S, Cordier D, Merlo AMetastatic disease in the intradural compartment of the spine is a rare manifestation of cancer. We report the case of an 82-year-old patient with an intradural, extramedullary metastasis of renal cell carcinoma in the cervical spine. A literature search for intradural spinal metastases of renal cell carcinoma yielded a total of 26 further cases. 18 patients had sporadic renal cell carcinoma, and 9 patients had von Hippel-Lindau disease (VHL) in which the metastases of the renal cell carcinoma were embedded within spinal haemangioblastomas. Patients presented with paresis, back pain, altered sensation or, less frequently, bladder dysfunction. Intradural spinal metastases were diagnosed at an earlier age in VHL patients than in sporadic cases (mean 43 +/- 5 years vs. 60 +/- 14.5 years). The metastasis was surgically removed in 81% of patients. Pain improved in all patients, paresis in 90%, hypaesthesia in 38% and bladder dysfunction in 50%. Death occured as a result of systemic cancer progression. 93% of patients in the sporadic renal cell cancer group died within 1.5 years, whereas two thirds of the VHL patients were alive after 2 years.

Rev Neurol. 2009 Jun 16-30; 48(12): 636-8Coloma-Valverde G, Coloma-Rodriguez G, Camacho MCINTRODUCTION. Hemangiopericytomas are potentially malignant vascular tumours. They are usually located in the thighs, the buttocks and the retroperitoneum. Recurrence is very common and they produce metastases that are not usually intracranial within a period of not less than 24 months. Treatment involves surgery, accompanied by radiotherapy. CASE REPORT. A 32-year-old female who had been suffering from back pain for two months. The clinical examination was normal; however, the neuroimaging studies showed a lumbar tumour that involved the L1, and the patient was therefore submitted to a surgical intervention. The histopathological analysis showed the tumour to be a hemangiopericytoma. The patient received radiotherapy, and two months later presented recurrent vomiting and headaches. Computerised tomography and magnetic resonance imaging of the head enabled us to diagnose an intracranial tumour and she underwent a new operation. A new histopathological analysis of the lesion confirmed that it was a meningeal hemangiopericytoma. CONCLUSIONS. After reviewing the literature, this is the first case of a hemangiopericytoma in which the initial symptoms were caused by metastasis and not by the primary tumour.

Man Ther. 2009 May 12; Reeve A, Dilley AThe role of transversus abdominis (TrA) on spinal stability may be important in low back pain (LBP). To date, there have not been any investigations into the influence of lumbo-pelvic neutral posture on TrA activity. The present study therefore examines whether posture influences TrA thickness. A normative within-subjects single-group study was carried out. Twenty healthy adults were recruited and taught five postures: (1) supine lying; (2) erect sitting (lumbo-pelvic neutral); (3) slouched sitting; (4) erect standing (lumbo-pelvic neutral); (5) sway-back standing. In each position, TrA thickness was measured (as an indirect measure of muscle activity) using ultrasound. In erect standing, TrA (mean TrA thickness: 4.63+/-1.35mm) was significantly thicker than in sway-back standing (mean TrA thickness: 3.32+/-0.95mm) (p=00001). Similarly, in erect sitting TrA (mean thickness=4.30mm+/-1.58mm) was found to be significantly thicker than in slouched sitting (mean thickness=3.46mm+/-1.13mm) (p=0002). In conclusion, lumbo-pelvic neutral postures may have a positive influence on spinal stability compared to equivalent poor postures (slouched sitting and sway-back standing) through the recruitment of TrA. Therefore, posture may be important for rehabilitation in patients with LBP.

Hinyokika Kiyo. 2009 Apr; 55(4): 223-7Osaka K, Kobayashi M, Takano T, Tsuchiya F, Iwasaki A, Ishizuka E, Nagashima YWe report two cases of granulocyte-colony stimulating factor (G-CSF) producing infiltrating urothelial carcinoma of the kidney. Case 1: A 58-year-old woman was referred to our hospital for fever and right back pain. Blood test showed severe inflammation and computed tomographic (CT) scan demonstrated swelling and irregular enhancement of the right kidney. Under the diagnosis of pyonephrosis or renal tumor, we performed right radical nephrectomy. The patient died of lung and liver metastases 6 months postoperatively despite of adjuvant chemotherapy. Case 2: A 76-year-old woman was referred to our hospital for a chief complaint of gross hematuria. Retrograde pyelogram and CT scan demonstrated a right renal pelvic tumor and we performed right nephroureterectomy. The patient died of liver and lung metastases 4 months postoperatively. The pathological and histochemical findings of these two cases were G-CSF producing infiltrating transitional cell carcinoma of the kidney. They showed marked leukocytosis and elevation of serum G-CSF levels. To our knowledge, they are the first two cases of G-CSF producing infiltrating urothelial carcinoma of the kidney in Japanese literature.

Clin Drug Investig. 2009; 29(6): 359-79Frediani B, Cavalieri L, Cremonesi GClodronic acid (Cl(2)-MBP [dichloromethylene bisphosphonic acid], clodronate) is a halogenated non-nitrogen-containing bisphosphonate with antiresorptive efficacy in a variety of diseases associated with excessive bone resorption. The drug is believed to inhibit bone resorption through induction of osteoclast apoptosis, but appears also to possess anti-inflammatory and analgesic properties that contrast with the acute-phase and inflammatory effects seen with nitrogen-containing bisphosphonates. Clodronic acid has been shown to be effective in the maintenance or improvement of bone mineral density when given orally, intramuscularly or intravenously in patients with osteoporosis. Use of the drug is also associated with reductions in fracture risk. The intramuscular formulation, which is given at a dose of 100 mg weekly or biweekly, is at least as effective as daily oral therapy and appears more effective than intermittent intravenous treatment. Intramuscular clodronic acid in particular has also been associated with improvements in back pain. The drug is well tolerated, with no deleterious effects on bone mineralization, and use of parenteral therapy eliminates the risk of gastrointestinal adverse effects that may be seen in patients receiving bisphosphonate therapy.

Curr Pain Headache Rep. 2009 Jun; 13(3): 185-90Freynhagen R, Baron RChronic low back pain is highly prevalent in Western societies. Large epidemiological studies show that 20% to 35% of patients with back pain suffer from a neuropathic pain component. Presently, chronic lumbar radicular pain is the most common neuropathic pain syndrome. The pathophysiology of back pain is complex and nociceptive, and neuropathic pain-generating mechanisms are thought to be involved, which established the term mixed pain syndrome. Neuropathic pain may be caused by lesions of nociceptive sprouts within the degenerated disc (local neuropathic), mechanical compression of the nerve root (mechanical neuropathic root pain), or by action of inflammatory mediators (inflammatory neuropathic root pain) originating from the degenerative disc even without any mechanical compression. Its diagnosis and management remain an enigma, mainly because there is no gold standard for either. Accuracy of diagnostic tests used to identify the source of back pain and their usefulness in clinical practice, particularly for guiding treatment selection, is unclear. In connection with the specific instance of back pain (one of the single most costly disorders in many industrialized nations), neuropathic pain components are a significant cost factor.

Behav Res Ther. 2009 May 20; Flink IK, Nicholas MK, Boersma K, Linton SJThis paper describes a preliminary experimental evaluation of a technique intended to help people suffering from chronic back pain and low pain acceptance to alter the aversiveness or threat value of their persisting pain. Using a multiple baseline cross-over design six individuals with chronic back pain were taught to use a form of interoceptive exposure as well as a relaxation/distraction breathing-based technique in the presence of their pain. Half the participants used one method for three weeks, and then crossed over to the other method for a further three weeks. The other half did the reverse. Assessments were conducted at pre/post treatment and at a three month follow-up. Daily monitoring of pain-related distress was also completed. The results indicated moderately high improvements in pain acceptance across most participants and corresponding declines in pain-related distress. No clear differences occurred between conditions, but the changes on disability and catastrophising scales for most cases were consistent with those reported after more substantial interventions. The study raises some important clinical and methodological issues that could inform future research in this area.

Percept Mot Skills. 2009 Feb; 108(1): 196-208Hallegraeff HJ, de Greef M, Winters JC, Lucas CManipulative therapy as part of a multidimensional approach may be more effective than standard physical therapy in treating Acute Nonspecific Low Back Pain. 64 participants, 29 women and 35 men, with Acute Nonspecific Low Back Pain and a mean age of 40 yr. (SD=9.6) were randomly assigned to two groups: an experimental group (manipulative therapy plus physical therapy) and a control group (only physical therapy). A multicentre, nonblinded, randomised clinical trial was conducted. Pain relief was the main performance criteria measured together with secondary criteria which included functional status and mobility of the lower back. Fritz, Childs, and Flynn's clinical prediction rule--a duration of symptoms less than 16 days, no pain distal of the knee--was used to analyse the results. In combination with an age >35 years, results showed a statistical significant effect for disability, but no statistically significant benefit of additional manipulative therapy over physical therapy found for pain and mobility within 4 treatments. Controlled for the applied clinical prediction rule, there were statistically significant interaction effects with low effect size for disability and sex, but no significant effects were found for pain of mobility.

JCCA J Can Chiropr Assoc. 2009 Jun; 53(2): 102-20Martel J, Dugas C, Lafond D, Descarreaux MSelf questionnaires are an important aspect of the management of neck pain patients. The Bournemouth Questionnaire (BQ), based on the biopsychosocial model, is designed to evaluate patients with neck pain. The validated English version of this questionnaire (BQc-English) has psychometric properties that range from moderate to excellent. The goal of this study is to translate and validate a French version of the Bournemouth Questionnaire for neck pain patients (BQc-f). Its translation and adaptation are performed using the translation back-translation method, generating a consensus among the translators. This validation study was performed on 68 subjects (mean age 41 years old) who participated in a randomized controlled trial regarding the efficiency of manual therapy for neck pain patients. This experimental protocol was designed to generate data in order to evaluate the construct validity, longitudinal validity, test-retest reliability and responsiveness. The BQc-f psychometric properties of construct validity (r = 0.67, 0.61, 0.42) for pre treatment, post treatment and longitudinal validity, respectively), test-retest reliability (r = 0.97) and responsiveness (effect size = 0.56 and mean standardized response = 0.61) are sufficient to suggest it could be used in the management of patients with neck pain.

Eur Spine J. 2009 May 10; Roussel N, Nijs J, Truijen S, Vervecken L, Mottram S, Stassijns GThe objective of the study was to evaluate the breathing pattern in patients with chronic non-specific low back pain (LBP) and in healthy subjects, both at rest and during motor control tests. Ten healthy subjects and ten patients with chronic LBP participated at this case-control study. The breathing pattern was evaluated at rest (standing and supine position during both relaxed breathing and deep breathing) and while performing clinical motor control tests, i.e. bent knee fall out and active straight leg raise. A blinded observer analyzed the breathing pattern of the participants using visual inspection and manual palpation. Costo-diaphragmatic breathing was considered as optimal breathing pattern. Subjects filled in visual analog scales for the assessment of pain intensity during the tests. At rest, no significant differences were found between the breathing pattern of patients and healthy subjects (P > 0.05). In contrast, significantly more altered breathing patterns were observed in chronic LBP-patients during motor control tests (P = 0.01). Changes in breathing pattern during motor control tests were not related to pain severity (P > 0.01), but were related to motor control dysfunction (P = 0.01).

Disabil Rehabil. 2009 May 19; 1-6Wilson IM, Kerr DP, Lennon SPurpose. To investigate whether low back pain (LBP) is a problem for people with a stoma. Method. Following ethical approval, a postal questionnaire was sent to the Ileostomy Association of Northern Ireland (n = 402). Results. The response rate was 81.6%. Two hundred ninety three (72.8%) were included in the analysis. The participants fell into three groups: those who never had LBP (n = 102, 34.8%), those who had LBP but not within the last 6 months (n = 26, 8.9%) and those who had LBP within the last 6 months (n = 165, 56.3%). Participants with LBP (n = 165) compared the ease with which they could carry out everyday tasks: 'before' and 'since' surgery. There was a mean increased difficulty of between 1.75 and 2.26 points across all tasks. The Roland Morris Disability Questionnaire scores ranged from 0 to 24 with 50% having a score of 8/24 or higher. Some participants (n = 76, 46.1%) believed that the stoma surgery was the reason for their back pain, followed by 27.9% (n = 46) blaming weak muscles. Others (53.3%) thought their back pain was worsening. There was a significant rise in the incidence of first episode back pain within a year of surgery. Conclusions. These results suggest that LBP is a problem for people with a stoma.

Int J Cardiol. 2009 May 7; Wilson J, Reda H, Gurley JCThe anomalous origin of the right coronary artery (RCA) as a branch of the left anterior descending (LAD) artery is a very rare variation of single coronary artery. At least 36 cases have been described previously in the literature. The vast majority of previous reports have described a single anomalous vessel with its origin after the first septal perforator of the LAD, which courses anterior to the right ventricular outflow tract to reach territory normally served by the right coronary artery. Of 35 cases in structurally normal hearts, 19 (54%) patients had > 50% narrowing in one or more epicardial coronary arteries (54%), at least 14 (40%) of whom required revascularization. Thirteen cases (37%) did not have significant coronary artery disease, while the remaining 3 cases were unclear. The current report reviews previous reports of this anomaly and describes a patient with an anomalous RCA from the mid-LAD, in whom heart block, back pain and dyspnea was the initial manifestation of ischemia. On heart catheterization, there was significant coronary artery disease in the LAD proximal to the origin of the anomalous artery. The patient was successfully revascularized with a unique sequential left internal mammary artery bypass to the anomalous vessel and LAD.

Spine. 2009 Apr 20; 34(9): E333-6Tsai J, Huang TJ, Huang CC, Li YY, Hsu RWSTUDY DESIGN: Case report. OBJECTIVE: To describe the case of a patient who habitually chewed betel quid and presented with intractable lower back pain owing to L4-L5 discitis caused by Eikenella corrodens. SUMMARY OF BACKGROUND DATA: E. corrodens is a normal inhabitant of mucosal surfaces in humans, particularly the oral cavity. Vertebral discitis due to E. corrodens is extremely rare. Discitis caused by E. corrodens in a habitual betel quid chewer has not been reported thus far. METHODS: A 52-year-old man had suffered from lower back pain for many years, and it worsened 3 months before admission. He had had severe periodontitis because of habitual betel quid chewing for over 10 years. RESULTS: The patient underwent staged spine surgeries because of the coexistence of L4-L5 discitis and isthmic spondylolisthesis. Tissue culture revealed the presence of E. corrodens. One and half years after the operation, the patient was fully ambulatory but demonstrated mild atrophy in the right thigh compared with the left thigh. CONCLUSION: E. corrodens discitis is extremely rare. We hypothesize that E. corrodens is a potential causative organism of discitis in patients who habitually chew betel quid.

Curr Rev Musculoskelet Med. 2009 Mar; 2(1): 15-24Binder DS, Nampiaparampil DELow back pain is the most common pain symptom experienced by American adults and is the second most common reason for primary care physician visits. There are many structures in the lumbar spine that can serve as pain generators and often the etiology of low back pain is multifactorial. However, the facet joint has been increasingly recognized as an important cause of low back pain. Facet joint pain can be diagnosed with local anesthetic blocks of the medial branches or of the facet joints themselves. Subsequent radiofrequency lesioning of the medial branches can provide more long-term pain relief. Despite some of the pitfalls associated with facet joint blocks, they have been shown to be valid, safe, and reliable as a diagnostic tool. Medial branch denervation has shown some promise for the sustained control of lumbar facet joint-mediated pain, but at this time, there is insufficient evidence that it is a wholly efficacious treatment option. Developing a universal algorithm for evaluating facet joint-mediated pain and standard procedural techniques may facilitate the performance of larger outcome studies. This review article provides an overview of the anatomy, pathophysiology, diagnosis, and treatment of facet joint-mediated pain.

Am J Respir Crit Care Med. 2009 Jun 25; Romieu I, Riojas-Rodríguez H, Marrón-Mares AT, Schilmann A, Perez-Padilla R, Masera ORATIONALE: Exposure to biomass smoke has been related to adverse health effects. In Mexico, one household in four still cooks with biomass fuel, but there has been no evaluation of the health impact of reducing indoor air pollution. OBJECTIVE: To evaluate the health impact of the introduction of an improved biomass stove (Patsari) in Mexican women. METHODS: A randomized controlled trial was conducted in the Central Mexican state of Michoacán. Households were randomized to receive the Patsari stove or keep their traditional open fire. A total of 552 women were followed with monthly visits over 10 months to assess stove use, inquire about respiratory and other symptoms and obtain lung function measurements. Statistical analysis was conducted using longitudinal models. RESULTS: Adherence to the intervention was low (50%). Women who reported using the Patsari stove most of the time compared to those using the open fire had significantly lower risk of respiratory symptoms (RR 0.77, 95% CI 0.62-0.95 for cough and RR 0.29, 95% CI 0.11-0.77 for wheezing) adjusted for confounders. Similar results were found for other respiratory symptoms as well as for eye discomfort, headache and back pain. Actual use of the Patsari stove was associated with a lower FEV1 decline (31 mL) compared to the open fire use (62 mL) over 1 year of follow up (p=0.012) for women 20 years and older, adjusting for confounders. CONCLUSION: Use of the Patsari stove was significantly associated with a reduction of symptoms and of lung function decline comparable to smoking cessation.

Pain Physician. 2009 May-Jun; 12(3): 685-8Ho KY, Jones L, Gan TJBACKGROUND: Chronic pain is a debilitating problem with significant impact on healthcare utilization in the US. Many chronic pain patients use complementary or alternative medicine (CAM) in addition to standard pharmacologic therapy. OBJECTIVE: The aim of our study was to identify differences in the characteristics of usage of CAM for chronic pain control among several ethnic groups. DESIGN: We recruited 92 consecutive patients seeking treatment at the pain clinic and interviewed them using a questionnaire. RESULTS: The most common pain complaint was back pain (55.4%) and the mean pain duration for all chronic pain problems was 9.8 years. Approximately 81% of respondents were using or have used CAM before. The commonest CAM used by patients in our study included massage therapy, spiritual healing as well as the consumption of mineral and vitamin supplements. Sixty-three percent of them were satisfied with CAM treatment compared to 56% of patients who were satisfied with prescription therapy. However, there was no difference in the use of CAM among the different ethnic groups (P > 0.05). CONCLUSION: Our study demonstrates that CAM is used very frequently in patients with chronic pain. However, it did not show any ethnic or racial differences in CAM utilization.

Eur J Pediatr. 2009 May 28; Fabry GThe spine in children can be affected by different bone pathologies such as trauma, infection, and tumoral processes. Most typical however are postural deformities, of which the evolution is mainly influenced by growth. An overview will be given of the most frequent problems encountered in children. Back pain is not infrequent and should always be taken seriously. In recent years, however, there has been an increase in functional complaints, mainly due to stress-related problems. Improving imaging techniques allows more and more accurate diagnoses and should be used judiciously. Postural deformities should be divided into functional and structural entities. Functional hyperkyphosis, hyperlordosis, and scoliosis should be identified by a thorough clinical evaluation and certainly not be overtreated. A structural scoliosis has the most potential of creating cardiovascular or pain problems in later life. Not all curves however have a bad prognosis. It is the task of the clinician to identify the children needing special attention, based on their knowledge of the underlying pathology as in congenital scoliosis and of the physiological age or maturity of the child, especially in the adolescent idiopathic scoliosis. Treatment should be initiated according to the prognosis regardless of the age of the child.

Eur J Neurol. 2009 May 12; Skljarevski V, Ossanna M, Liu-Seifert H, Zhang Q, Chappell A, Iyengar S, Detke M, Backonja MBackground: Duloxetine has demonstrated analgesic effect in chronic pain states. This study assesses the efficacy of duloxetine in chronic low back pain (CLBP). Methods: Adult patients with non-radicular CLBP entered this 13-week, double-blind, randomized study comparing duloxetine 20, 60 or 120 mg once daily with placebo. The primary measure was comparison of duloxetine 60 mg with placebo on weekly mean 24-h average pain. Secondary measures included Roland-Morris Disability Questionnaire (RMDQ-24), Patient's Global Impressions of Improvement (PGI-I), Brief Pain Inventory (BPI), safety and tolerability. Results: Four hundred four patients were enrolled, 267 completed. No significant differences existed between any dose of duloxetine and placebo on reduction in weekly mean 24-h average pain at end-point. Duloxetine 60 mg was superior to placebo from weeks 3-11 in relieving pain, but not at weeks 12-13. Duloxetine 60 mg demonstrated significant improvement on PGI-I, RMDQ-24, BPI-average pain and BPI-average interference. Significantly more patients taking duloxetine 120 mg (24.1%) discontinued because of adverse events, versus placebo (8.5%). Conclusions: Duloxetine was superior to placebo on the primary objective from weeks 3-11, but superiority was not maintained at end-point. Duloxetine was superior to placebo on many secondary measures, and was well-tolerated.

Int J Toxicol. 2009 May-Jun; 28(3): 219-29Dagenais S, Wooley J, Hite M, Green R, Mayer JProlotherapy is one of the many treatments available for chronic musculoskeletal disorders. A commonly used drug contains dextrose 12.5%, glycerin 12.5%, phenol 1.0%, and lidocaine hydrochloride 0.25% in aqueous solution (recently termed Proliferol). For chronic low back pain, this is injected into lumbosacral ligaments to stimulate connective tissue repair. Despite generally positive clinical results, the toxicity of this drug is not well characterized and was assessed in 48 (24 male, 24 female) Yucatan miniature swine randomly assigned to low (1x), medium (5x), or high (10x) dose or saline placebo. Outcomes included clinical observations, clinical chemistry, hematology, coagulation, urinalysis, toxicokinetics, and full gross and microscopic histopathology after 24 hours or 14 days. Findings attributable to Proliferol after 24 hours included dose-response elevations in alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, and creatine kinase, which returned to normal after 14 days. There were no remarkable findings in hematology, coagulation, or urinalysis. Urine concentrations of lidocaine and phenol both peaked after 8 hours. Histopathology findings after 24 hours included hemorrhage, inflammation, necrosis, and vascular changes in the ligaments and adjacent soft tissues at the sites of injection. After 14 days, there was evidence of repair under way, with fibrosis and skeletal muscle regeneration at the injection sites.

Chin J Traumatol. 2009 Jun; 12(3): 138-41He QY, Xu JZObjective: To evaluate the short-term outcomes of short segmental pedicle screw fixation combined with percutaneous vertebroplasty in treatment of nonadjacent thoracolumbar fractures. Methods: Twenty patients who suffered from nonadjacent thoracolumbar fractures were treated by short segmental pedicle screw fixation for burst fracture and by percutaneous vertebroplasty for compression fracture. X-rays, CT and MRI scans were conducted using the same protocol before and after surgery and during follow-up. Pre-and post-operative American Spinal Injury Association (ASIA) grades, fusion of fracture sites, visual analog scale (VAS) of back pain, and Oswestry disability index (ODI) were accessed. Results: All patients were followed up for an average period of 12 months. The sagittal profile of the thoracolumbar spine was restored satisfactorily. No patient had neurologic deterioration after surgery, and 9 patients with incomplete lesions improved postoperatively by at least one ASIA grade. The fusion rate was 100%. The average VAS of back pain was 7.6 preoperatively and 3.2 postoperatively. The average ODI was 72.5 preoperatively and 35.5 postoperatively. Conclusions: Short segmental pedicle screw fixation combined with percutaneous vertebroplasty in treatment of nonadjacent thoracolumbar fractures exhibits such advantages as preserving functional segment units, reliable fixation, good neurologic recovery and early mobilization and, therefore, is suitable for treating nonadjacent thoracolumbar fractures.

Spine J. 2009 May 30; Dupeyron A, Lecocq J, Vautravers P, Pélissier J, Perrey SBACKGROUND CONTEXT: There is little information about the simultaneous changes of intramuscular pressure (IMP) and oxygen saturation (StO(2)) of the paraspinal muscle under various conditions of posture and load. PURPOSE: To measure simultaneously and compare IMP and StO(2) across a range of static trunk postures commonly observed during normal work tasks. STUDY DESIGN: A prospective study using a repeated-measure design in clinical setting. PATIENT SAMPLE: Sixteen healthy young men with no history of back pain. OUTCOME MEASURES: Simultaneous measurements of IMP by a flexible slit catheter and StO(2) by near infrared spectroscopy of the multifidus muscle were performed. METHODS: The two measures were taken in six static posture tasks: standing upright and bending forward with and without load (20kg), bending backward and during a sustained isometric contraction (ie, Sorensen test). To compare the influence of the tasks on IMP and StO(2) variables, a one-way variance analysis with repeated measures was used. Spearman's rank correlation coefficient (rho) was determined between the two variables for each posture task. RESULTS: We observed only a moderate but significant correlation between IMP and StO(2) values in upright standing and a trend in bending forward positions with load (p

Gesundheitswesen. 2009 Jun 23; Flothow A, Zeh A, Nienhaus AINTRODUCTION: Back pain is one of the most common and expensive health problems in Germany. Apart from somatic parameters, psychological factors are thought to influence the aetiology and, especially, the chronification of back pain. A literature search has been performed to establish which psychological procedures are used in the diagnosis, prevention and therapy for back pain, and how effective they are. METHOD: The connection between back pain and psychological factors was investigated in English and German technical articles identified in a literature search in Medline (2000-2006) and in psyndex (2000-2006). 714 hits were identified for the key words "back pain and preven-tion", 61 hits for "back pain and psychological factors", 732 hits for "back pain and risk factors" and 4 hits for "back pain and chronification of pain". 75 technical articles or studies were selected from these hits and used as a basis for the evaluation of the above questions. The search was completed by a manual search in the literature lists of published articles, perusing monographs, searching the internet and evaluating congress and meeting reports (2000-2008). RESULTS: The results of various studies show that cognitive, emotional and behavioural aspects and the processes of respondent and operant learning are of great importance in processing and overcoming pain. Biopsychosocial procedures appear to be superior to biomedical procedures. There has been good research on the (psychological) risk factors which contribute to the chronification of pain. It seems to be sensible to use screening procedures, such as the "Orebro Musculoskeletal Pain Questionnaire (OMPQ)" for the identification of patients at increased risk of chronification. For patients with chronic symptoms, there are evidence-based psychological programme components; these are usually successful, especially as part of multimodal programmes. As yet, there have only been initial studies on the use of psychological intervention for prevention, particularly in occupational settings. DISCUSSION: In the high risk group of patients already suffering from back pain, relapses and chronification can best be prevented by multimodal programmes. A decisive condition for the success of these physiotherapeutic, ergotherapeutic, sports therapeutic and psychotherapeutic interventions is apparently that there should be a standardised procedure in accordance with the theoretical principles of behavioural therapy, complied with by all those involved in the process. However, the principle objective of all measures should be the avoidance of the transition from acute to chronic back pain and the protracted and expensive clinical course this can lead to. Psychological intervention appears to work here as well. Further studies are needed to clarify whether the psychological program components are effective in isolation or whether they must be embedded in a multimodal (preventive) concept. It must also be investigated which target groups benefit most from which type of preventive (psychological) intervention. Provision of specific information is an alternative preventive approach. This health psychological or educative procedure corresponds to demedicalisation of this condition. Although media campaigns have been successfully performed in Australia, it is as yet unclear whether these can be transferred to Germany and which structural changes these would require in our health care system.

J Rehabil Med. 2009 Jun; 41(7): 550-6Skillgate E, Vingård E, Josephson M, Holm LW, Alfredsson LOBJECTIVE: To investigate the associations between smoking and alcohol consumption, and long-term sick leave due to unspecific back or neck pain among employees in the public sector. DESIGN: A 3-year prospective cohort study. SUBJECTS: Approximately 9000 persons in the public sector in Sweden were invited to participate. Of these, 7533 answered a questionnaire and 6532 were included in the study, classified as having "good health for working". METHODS: New periods of sick leave >or= 28 days were consecutively reported from the employers or the occupational health service during a period of 3 years. Rate ratios were estimated by means of Cox proportional hazard regression model. RESULTS: Smoking was associated with an increased risk of long-term sick leave due to unspecific back or neck pain. Compared with people who have never smoked, "ever smokers" had a higher risk (rate ratio = 1.8, 95% confidence interval: 1.3-2.4). Alcohol consumption tended to be associated with a decreased risk, but the results were not statistically significant. CONCLUSION: Our results suggest that smoking is a risk factor for long-term sick leave due to unspecific back or neck pain. Moderate alcohol consumption tends to have a protective effect, at least among women in the public sector.

J Electromyogr Kinesiol. 2009 May 23; Nelson-Wong E, Callaghan JPPURPOSE AND SCOPE: Low back pain development has been associated with static standing postures in occupational settings. Previous work has demonstrated gluteus muscle co-activation as a predominant pattern in previously asymptomatic individuals who develop low back pain when exposed to 2-h of standing. The purpose of this work was to investigate muscle co-activation as a predisposing factor in low back pain development while including a multifactorial approach of clinical assessment tools and psychosocial assessments to identify individuals who are at risk for pain development during standing. RESULTS: Forty percent of participants developed low back pain during the 2-h of standing. Pain developers demonstrated bilateral gluteus medius and trunk flexor-extensor muscle co-activation prior to reports of pain development. Pain developers and non-pain developers demonstrated markedly different patterns of muscle activation during the 2-h of standing. A novel screening test of active hip abduction was the only clinical assessment tool that predicted pain development. CONCLUSIONS: Gluteus medius and trunk muscle co-activation appears to be a predisposing rather than adaptive factor in low back pain development during standing. A combination of a positive active hip abduction test and presence of muscle co-activation during standing may be useful for early identification of at-risk individuals.

Pain Pract. 2009 May 15; Viggiano A, Zagaria N, Passavanti MB, Pace MC, Paladini A, Aurilio C, Tedesco MA, Natale F, Calabrò R, Monda M, De Luca EAbstract Objective: The aim of the present work was to measure the pain threshold in hypertensive patients with a new auto-algometry method. Design and Setting: Auto-algometry consists of asking the subjects to push their fingers against a fixed round-tip needle until they feel a pain sensation. An electronic force transducer permits the measurement of the force applied by the subjects and storage of the data on a personal computer. Eight tests are performed twice on each subject on the tip and back of four fingers. For each test, the maximal applied force (grams) is defined as pain threshold. The overall discomfort during the entire procedure is reported by the subjects on a 0 (no discomfort) to 10 (intolerable pain) scale. Patients and Interventions: A group of hypertensive patients (n = 22) and a group of normotensive subjects (n = 22) underwent the auto-algometry examination. Results: The pain threshold was higher in hypertensive patients compared with normotensive subjects. All discomfort scores referred by the subjects fell within the 4-6 range. Conclusion: The data obtained from this study indicate that the auto-algometer as described here can detect hypoalgesia associated with hypertension.

Fam Pract. 2009 Jun 21; Corbett M, Foster N, Ong BNBACKGROUND: The implementation of guideline recommendations in primary care has become widespread. The treatment of low back pain (LBP) has followed suite. Research shows that the use of LBP guidelines is influenced by the believability of the underlying evidence, the GPs consultation style and uncertainties surrounding diagnosis and treatment. OBJECTIVE: To qualitatively examine the attitudes and self-reported behaviour of GPs in relation to guideline adherence for patients with LBP. METHOD: A mixed-method design combining a national UK-based survey of GPs and physiotherapists with an embedded qualitative study. This report focuses only on the GP interviews. We explored GPs' experience of managing LBP patients and the rationale for treatment offered to a patient described in a written vignette. All interviews were digitally recorded, fully transcribed and analysed using the constant comparative method. RESULTS: GPs encountered difficulties adhering to guideline recommendations for LBP patients. They experienced particular tensions between recommendations to stay active versus the expectation of being prescribed rest. GPs expressed that chronic LBP often poses an intractable problem requiring specialist advice. The perception that guideline recommendations are 'imposed' may create resistance, and the evidence base is not always considered believable. CONCLUSIONS: GPs acknowledge guideline recommendations but divergence occurs in implementation. This is due to GPs focussing on the whole person-not just one condition-and the importance of maintaining the doctor-patient relationship, which relies on effective negotiation of mutual perceptions and expectations. Further exploration on how consultation processes can be constructed to effectively combine evidence with patient-centred care is needed.

Clin J Pain. 2009 Jul-Aug; 25(6): 495-9Koopman JS, Vrinten DH, van Wijck AJOBJECTIVES: Microcurrent therapy (MCT) is a novel treatment for pain syndromes. The MCT patch is hypothesized to produce stimuli that promote tissue healing by facilitating physiologic currents. Solid evidence from randomized clinical trials is lacking. To evaluate the efficacy of MCT in treating aspecific, chronic low-back pain, we conducted a double-blind, randomized, crossover, pilot trial. METHODS: Ten succeeding patients presenting with nonspecific, chronic low-back pain in our university hospital were included. Patients started with two, 9-day baseline period followed by a 5-day treatment periods. During the treatment periods, either a placebo or MCT (verum) patch was randomly assigned. Mean and worst pain scores were evaluated daily by a visual analog scale (VAS). Furthermore, analgesic use, side effects, and quality of life were assessed after each period. Differences between the last 4 days of a treatment period and the baseline period were calculated. Differences between verum and placebo periods per patient were compared using paired t tests. A 20-mm VAS score reduction was considered clinically relevant. RESULTS: The VAS score was lower during verum treatment, with a reduction [95% confidence interval (CI] of -0.43 (-1.74; 0.89) in mean and -1.07 (-2.85; 0.71) in worst pain. Analgesic use decreased during verum treatment, except for nonsteroid anti-inflammatory drug use, which increased. Quality of life improved during verum treatment. However, note of the findings were statistically significant. DISCUSSION: A positive trend in MCT use for aspecific, chronic low-back pain is reported. Further investigations are required to evaluate the significance and relevance of this.

Can J Neurol Sci. 2009 May; 36(3): 336-9Al-Said YA, Al-Rached HS, Al-Qahtani HA, Jan MMBACKGROUND: Osteomalacia is an uncommon cause of muscle weakness. Our objectives were to describe features of myopathy associated with Vitamin D deficiency and examine the contributing factors leading to osteomalacic myopathy in our region. METHODS: Patients identified retrospectively for the six year period ending in December 2006 with the diagnosis of osteomalacia and/or Vitamin D deficiency associated proximal muscle weakness were included. They were followed in three major centers in western Saudi Arabia. Clinical, biochemical, radiological, and electrophysiological findings were collected before and after Vitamin D treatment by chart review. RESULTS: Forty seven female patients aged 13-46 years (mean 23.5, SD 4.5) were included. All were veiled and covered heavily when outside the house for social and cultural reasons. Only eight (17%) had adequate varied diet with daily milk ingestion. All patients presented with progressive proximal muscle weakness lasting 6-24 months (mean 14) prior to our evaluation. The weakness was severe in six (13%) patients leading to wheel chair bound states. Associated musculoskeletal pain involving the back, hips, or lower limbs was common (66%). Osteomalcia was the referral diagnosis in only 11 patients and the remaining 36 (77%) patients were misdiagnosed. All patients had metabolic and radiological profiles suggestive of osteomalacia. Remarkable recovery was documented in all patients following oral cholecalciferol and calcium supplementation. CONCLUSIONS: Vitamin D deficiency is an important treatable cause of osteomalacic myopathy in Saudi Arabia. The diagnosis is frequently delayed or missed. Screening for Vitamin D deficiency in patients with acquired myopathy is needed to identify this treatable disorder.

J Brachial Plex Peripher Nerve Inj. 2009 Jun 19; 4(1): 8Amr SM, Essam AM, Abdel-Meguid AM, Kholeif AM, Moharram AN, El-Sadek REABSTRACT: BACKGROUND: The superiority of a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy in direct cord implantation was investigated as to providing adequate exposure to both the cervical cord and the brachial plexus, as to causing less tissue damage and as to being more extensible than current surgical approaches. Methods: The front and back of the neck, the front and back of the chest up to the midline and the whole affected upper limb were sterilized while the patient was in the lateral position; the patient was next turned into the supine position, the plexus explored anteriorly and the grafts were placed; after that he was turned again into the lateral position, a posterior cervical laminectomy was done, the grafts were retrieved posteriorly and side grafted to the anterior cord. Using that approach, 5 patients suffering from complete traumatic brachial plexus palsy, 4 adults and 1 obstetric case, were operated upon and followed up for 2 years. 2 were (C5,6 ruptures C7,8T1 avulsions), 3 were (C5,6,7,8T1 avulsions). C5,6 ruptures were grafted, all avulsions were cord implanted. Results: Surgery in complete avulsions led to Grade 4 improvement in shoulder abduction/flexion and elbow flexion . Cocontractions occurred between the lateral deltoid and biceps on active shoulder abduction. No cocontractions occurred after surgery in (C5,6 ruptures C7,8T1 avulsions), muscle power improvement extended into the forearm and hand; pain disappeared. Limitations include: spontaneous recovery despite MRI appearance of avulsions, fallacies in determining intraoperative avulsions (wrong diagnosis, wrong level); small sample size; no controls rule out superiority of this technique versus other direct cord reimplantation techniques or other neurotization procedures; intra- and interobserver variability in testing muscle power and cocontractions.Conclusion: Through providing proper exposure to the brachial plexus and to the cervical cord, the single stage combined anterior (first) posterior (second) approach approach might stimulate brachial plexus surgeons to go more for direct cord implantation. In this study, it allowed for placing side grafts along an extensive donor recipient area by end-to-side side-to-side grafting neurorrhaphy and thus improved results. Level of evidence: Level IV, prospective case series.

Clin J Pain. 2009 Jul-Aug; 25(6): 477-84Back SE, Payne RA, Waldrop AE, Smith A, Reeves S, Brady KTOBJECTIVES: Patients who are prescribed opioids often display 1 or more aberrant prescription use behaviors (eg, requesting early refills, borrowing medication from family), which raise concern among healthcare professionals. Little is known about the sex differences in specific types of aberrant behaviors or sex-specific predictors of such behaviors. The current study is aimed to begin addressing this gap in the literature. METHODS: A battery of anonymous, self-report assessments was administered to 121 (49 men, 72 women) chronic pain patients enrolled in an outpatient pain management clinic. Most of the participants were white women with an average age of 51.6 years (SD=13.2). RESULTS: Significantly more men than women were taking a prescribed opioid (91.7% vs. 77.8%, P=0.05). Women were significantly more likely than men to hoard unused medication (67.6% vs. 47.7%, P=0.04) and to use additional medications to enhance the effectiveness of pain medication (38.8% vs. 20.0%, P=0.04). A trend toward men using alternative routes of administration (eg, crushing and snorting pills) more often than women was observed (8.9% vs. 1.5%, P=0.08). Among men, high rates of aberrant prescription use behaviors were associated with current alcohol use and the use of oxycodone and morphine. Among women, use of hydrocodone was associated with high rates of aberrant prescription use behaviors. DISCUSSION: Some aberrant prescription use behaviors are common among chronic pain patients and may be sex-specific. Predictors of aberrant prescription use behaviors may also differ by sex. Additional research is needed to help identify aberrant prescription use behaviors that best predict sex-specific risk for developing opioid abuse or dependence.

Eur Spine J. 2009 Jun 23; Lauridsen HH, Manniche C, Korsholm L, Grunnet-Nilsson N, Hartvigsen JUnderstanding changes in patient-reported outcomes is indispensable for interpretation of results from clinical studies. As a consequence the term "minimal clinically important difference" (MCID) was coined in the late 1980s to ease classification of patients into improved, not changed or deteriorated. Several methodological categories have been developed determining the MCID, however, all are subject to weaknesses or biases reducing the validity of the reported MCID. The objective of this study was to determine the reproducibility and validity of a novel method for estimating low back pain (LBP) patients' view of an acceptable change (MCID(pre)) before treatment begins. One-hundred and forty-seven patients with chronic LBP were recruited from an out-patient hospital back pain unit and followed over an 8-week period. Original and modified versions of the Oswestry disability index (ODI), Bournemouth questionnaire (BQ) and numeric pain rating scale (NRS(pain)) were filled in at baseline. The modified questionnaires determined what the patient considered an acceptable post-treatment outcome which allowed us to calculate the MCID(pre). Concurrent comparisons between the MCID(pre), instrument measurement error and a retrospective approach of establishing the minimal clinically important difference (MCID(post)) were made. The results showed the prospective acceptable outcome method scores to have acceptable reproducibility outside measurement error. MCID(pre) was 4.5 larger for the ODI and 1.5 times larger for BQ and NRS(pain) compared to the MCID(post). Furthermore, MCID(pre) and patients post-treatment acceptable change was almost equal for the NRS(pain) but not for the ODI and BQ. In conclusion, chronic LBP patients have a reasonably realistic idea of an acceptable change in pain, but probably an overly optimistic view of changes in functional and psychological/affective domains before treatment begins.

Spine J. 2009 Jun 15; Wallace AS, Freburger JK, Darter JD, Jackman AM, Carey TSBACKGROUND CONTEXT: Chronic back pain is a condition characterized by high rates of disability, health-care service use, and costs. PURPOSE: The purpose of this study was to identify factors associated with patients' satisfaction with their last health-care provider visit for chronic low back pain (LBP). STUDY DESIGN/SETTING: A cross-sectional, state-level, telephone survey was administered to patients with chronic LBP. PATIENT SAMPLE: The sample consisted of 624 individuals with chronic LBP who reported seeing a health-care provider in the previous year. OUTCOME MEASURES: Dependent variables included satisfaction with last visit for LBP and intent to seek care from additional providers. Independent variables included the Roland-Morris Disability Questionnaire, 3-month pain ratings using a 0 to 10 Likert scale, the Medical Outcomes Survey Short Form 12, and self-reported health service utilization (provider type, number of visits to health-care providers, medication use during the previous month, and treatments and diagnostic tests during the previous year). METHODS: Bivariate and multivariate analyses were used to explore how demographic, insurance-related, and health-related characteristics were associated with patient satisfaction. RESULTS: Participants who were not satisfied with one or more aspects of their last clinic visit were younger (51.0 vs. 54.21 years), reported higher 3-month pain ratings (7.23 vs. 6.53), and were more commonly Hispanic (53.2% vs. 46.8% for other ethnicities) and uninsured (43.1% vs. 29.3% for other insurance groups). Those who intended to seek care from additional providers were younger (50.05 vs. 55.49 years), had higher 3-month pain ratings (7.20 vs. 6.46), had lower Short Form 12 mental health component scores (44.75 vs. 49.55) and physical component scores (30.07 vs. 31.55), and were more commonly black (54.6% vs. 45.4% for other racial groups) and uninsured (56.9% vs. 43.1% for other insurance groups). Narcotic use was associated with satisfaction (odds ratio=2.12, p=.01), whereas lack of insurance was associated with respondents' intent to seek care from additional providers (odds ratio=2.97, p

Chiropr Osteopat. 2009 Jun 17; 17(1): 5Moller LT, Hansen M, Leboeuf-Yde CABSTRACT: BACKGROUND: Although maintenance care appears to be relatively commonly used among chiropractors, the indications for its use are incompletely understood. A questionnaire survey was recently carried out among Swedish chiropractors in order to identify their choice of various management strategies, including maintenance care. That study revealed a common pattern of choice of strategies. However, it would be necessary to verify these findings in another study population. Objectives: The main aim of the present study was to attempt to reproduce the findings in the Swedish study and to obtain more information on the use of maintenance care. METHOD: A group of 11 chiropractors were selected because they used maintenance care. They were interviewed using the questionnaire from the previous Swedish survey. The questionnaire consisted of a simple description of a hypothetical patient with low back pain and nine possible ways in which the case could develop ("scenarios"). There was a choice of six different management strategies for each scenario. In addition, the chiropractors were encouraged to provide their own definition of maintenance care in an open-ended question. Interviews were taped, transcribed and analyzed. For the open-ended question, statements were identified relating to six pre hoc defined topics on the inclusion criteria/rationale for maintenance care, the frequency of treatments, and the duration of the maintenance care program. RESULTS: The response pattern for the nine scenarios was similar to that obtained in the Swedish survey. The open-ended question revealed that in patients with low back pain, maintenance care appears to be offered to prevent new events. The rationale was to obtain optimal spinal function. There appears to be no common convention on the frequency of treatments and duration of the treatment program was not mentioned by any of the interviewees. CONCLUSION: There seems to be relative agreement between chiropractors working in different countries and sampled through different methods in relation to their choice of management strategies in patients with low back pain. However, more precise information is needed on the indications for maintenance care and its treatment program, before proceeding to studying its clinical validity.

Aust J Physiother. 2009; 55(2): 138Smeets RJQUESTION: Does a graded exercise program emphasising lumbar stabilising exercises reduce pain and disability at 12 months, compared with a walking program, for patients with recurrent low back pain? DESIGN: Randomised controlled trial. SETTING: A single private physiotherapy clinic in Sweden. PARTICIPANTS: 71 patients with recurrent mechanical low back pain (>8 weeks duration, with at least 1 pain-free period during the past year) and without leg pain were allocated to one of two groups, using a concealed allocation process. The groups were comparable at baseline with respect to age, sex, proportion of participants who had sought care for back pain, and pain duration (approximately 10 years). INTERVENTIONS: The graded exercise program and the walking program were both 8 weeks' duration. The exercise program was individually supervised by a physiotherapist weekly for 45 minutes. In the walking program, patients met with a physiotherapist for 45 minutes in week 1 and again in week 8. The exercise program consisted primarily of stabilising exercises for the lumbar spine, commencing with re-learning activation of the transversus abdominis and multifidus muscles, with assistance of a pressure biofeedback cuff. Exercises were progressed according to clinical judgement, pain levels, and movement control and quality. Progression entailed incorporation of muscle activation in upright positions and during functional activities. Continued implementation of the exercises in daily life was encouraged. The reference group were instructed to walk for 30 minutes daily at the fastest pace that did not aggravate pain. Walking compliance was monitored with a self-completed daily diary. OUTCOMES: The primary outcomes were perceived pain and disability at 12 months, measured by self-completed questionnaires returned by post. Disability was measured with the Oswestry Disability Questionnaire (scale 0-100, where 100 = maximum disability). Pain was measured with 100-mm visual analogue scale (where 100 = worst pain imaginable). RESULTS: At 12 months 86% of patients were followed up. At this time there was no clinically-important difference between the groups with respect to median (IQR) change in pain: exercise group -12 (-34 to -3); walking group -12 (-22 to 0). For disability at 12 months, the between-group difference in median scores was 8 on the Oswestry score: exercise group -10 (-20 to -2); walking group -2 (-12 to 2). CONCLUSION: Lumbar stabilising exercises appear to have a similar effect on pain and disability for patients with recurrent low back pain as a daily walking program.

Ann Phys Rehabil Med. 2009 Jun 9; Phaner V, Fayolle-Minon I, Lequang B, Valayer-Chaleat E, Calmels POBJECTIVES: Mechanical low back pain (LBP) is a major public health problem. Today's standard care strategy involves a combination of drug-based and non-drug therapies. The use of conservative orthopaedic brace treatment is subject to debate. The lack of data and consensus in the literature on the value of this treatment in chronic LBP prompted to us to seek to estimate the modalities and indications for brace use in France. MATERIALS AND METHOD: We performed a questionnaire-based survey of physician members of the French Society of Physical Medicine and Rehabilitation (SOFMER). RESULTS: We received 55 completed questionnaires. Although the indications for this treatment were very heterogeneous (in both clinical and paraclinical terms), the prescribing behaviour was rather uniform. The brace is worn during the day for less than 3 months (with a progressive reduction in use over 1 to 2 months), together with physiotherapy before and after immobilization. The patient keeps the brace at the end of the treatment period. Orthopaedic treatment appears to be prescribed in many chronic LBP situations. Analysis of spinal posture and magnetic resonance imaging results (and Modic changes in particular) influence the therapeutic decisions. CONCLUSION: Clinical and paraclinical indications of this treatment must be precisely defined and evaluated in prospective, multicenter studies with homogeneous cohorts.

Ind Health. 2009 Jul; 47(3): 301-12Smith DR, Mihashi M, Adachi Y, Shouyama Y, Mouri F, Ishibashi N, Ishitake TAn increasing body of evidence now suggests that menstrual disorders may influence the development of Low Back Pain (LBP) among women of reproductive age. To investigate this issue in Japan, we conducted a large cross-sectional survey of female nurses from a university teaching hospital during 2008. Nurses reported a wide range of symptoms both prior to and during menstruation, including breast tenderness, stomach pain, light headedness and fatigue. Around three-quarters had experienced at least one episode of LBP in the previous 12-months, with most symptoms lasting one week or less. Increasing body weight was correlated with an increased risk of LBP affecting their daily activities (OR: 12.94, 95%CI: 1.54-116.56). Having three or more children was correlated with a reduced risk of experiencing LBP (OR: 0.13, 95%CI: 0.01-0.97). Nurses who reported breast tenderness prior to menstruation were twice as likely to suffer LBP (OR: 2.09, 95%CI: 1.20-3.73), while those who reported breast tenderness during menstruation were almost twice as likely to suffer LBP that interfered with their daily activities (OR: 1.85, 95%CI: 1.06-3.32). Overall, our study suggests that reproductive symptoms and menstrual disorders may influence the development of LBP among Japanese nurses, although the magnitude of this effect appears to be less than that reported in some previous research.

Spine. 2009 Apr 20; 34(9): E337-41Akeda K, Kasai Y, Kawakita E, Seto M, Kono T, Uchida ASTUDY DESIGN.: A case of primary Ewing sarcoma of the lumbar spine is presented. OBJECTIVE.: To present and review a rare case of primary Ewing sarcoma of the lumbar spine that required differentiation from spinal infection. SUMMARY OF BACKGROUND DATA.: Primary Ewing sarcoma originating from the spinal column is very rare. Because Ewing sarcoma is one of the most aggressive bone tumors with high proliferative and invasive potential, its clinical symptoms and variety of imaging manifestations can mimic the pathologic findings of other diseases, including infectious diseases. METHODS.: The clinical course, radiologic features, pathology and treatment outcome of a patient with primary Ewing sarcoma of the lumbar spine was documented. RESULTS.: The magnetic resonance imaging findings showed an abnormal marrow signal at the L2 vertebra and significant enlargement of the unilateral iliopsoas muscle. Immunologic and molecular analysis of the surgical specimen provided a diagnosis of Ewing sarcoma. Laminotomy followed by multidisciplinary therapy including chemotherapy and radiation therapy was effective for treating this case. CONCLUSION.: We report a case of Ewing sarcoma that mimicked a psoas abscess secondary to spinal infection. Abnormal magnetic resonance imaging images, as well as a confusing clinical course, made diagnosis difficult. When enlargement of the iliopsoas with a vertebral lesion is detected in a child with low back pain, Ewing sarcoma should be included in the differential diagnosis.

Spine. 2009 Apr 20; 34(9): 970-977Wasiak R, Young AE, Dunn KM, Côté P, Gross DP, Heymans MW, von Korff MSTUDY DESIGN.: Literature review. OBJECTIVE.: To present a framework for future analyses of back pain recurrence and explore the applicability and relevance of existing recurrence indicators. SUMMARY OF BACKGROUND DATA.: Empirical studies of back pain have included a variety of indicators of recurrence, resulting in a range of findings about recurrence rates and associated factors. Little is known about the relationships between existing indicators. METHODS.: Literature overview, expert panel, and workshop discussion at the IX International Forum on Primary Care Research on Low Back Pain. RESULTS.: Using the International Classification of Functioning, Disability, and Health (ICF), disabling back pain was conceptualized as a health condition, i.e., back pain disorder (BPD), and BPD recurrence was conceptualized as involving a return of atypical back pain and/or back-pain-related difficulty performing tasks and actions related to the initial episode. Using the ICF, 2 types of recurrence indicators were identified: those directly describing components of BPD and those indirectly doing so (e.g., recurrence of health care utilization). CONCLUSION.: In light of the difficulty in measuring BPD recurrence, transparent definitions and a clear understanding of the implications of using particular indicators is required. Future research should focus: on examining the capture BPD recurrence by various research instruments, improving understanding of the relationship between indicators, and gaining insight into how individuals experiencing BPD view recurrence.

Endoscopy. 2009 Jun; 41(6): 493-7Hookey LC, Bielawska B, Samis A, Jalink D, Ellis R, Khokhotva V, Hurlbut D, Mercer DBACKGROUND AND STUDY AIMS: The evolution of NOTES to clinical implementation has been hampered by lack of a reliable, safe, and easy-to-implement technique for closure of the opening created in accessing the peritoneum. The Queen's closure uses a combination of endoscopic clips and loop devices to seal such defects in the stomach wall. This study aimed to assess the Queen's closure in a porcine survival model. METHODS: Five 30-kg pigs underwent endoscopic transgastric surgery with exploration of the peritoneum. The endoscope was then withdrawn back into the stomach and the closure performed. The animals were recovered, monitored closely, and underwent endoscopy 1 week after surgery. They were then euthanized at 2 (n = 2) and 3 (n = 3) weeks after surgery with subsequent necropsy. RESULTS: The mean procedure time (from intubation of the esophagus to withdrawal of the endoscope) was 79 minutes (range 45-105 minutes) with a mean time of exploration of the peritoneum of 14 minutes (range 8-25 minutes). All animals recovered well with no apparent pain, distress, or signs of infection. Endoscopic examination 1 week after surgery revealed all the closures to be intact and only identifiable by a small ulcer. At necropsy, the gastrotomy site was identifiable only by minor serosal adhesions. Histological study demonstrated full-thickness closure with minimal inflammation. CONCLUSIONS: The Queen's closure is a reliable and safe technique that provides full-thickness gastrotomy closure without any observed complications. The technique has proven to be transferable knowledge that holds promise for clinical implementation.

Spine. 2009 Apr 20; 34(9): 917-23Cakir B, Schmidt R, Mattes T, Fraitzl CR, Reichel H, Käfer WSTUDY DESIGN.: Analysis of segmental and total lumbar range of motion (ROM) before and after total lumbar disc replacement. OBJECTIVE.: To examine the relationship between absolute segmental and total lumbar ROM and evolution of ROM on clinical outcome. SUMMARY OF BACKGROUND DATA.: At the moment, data are scarce with regard to the evolution of total lumbar ROM (t-ROM) and segmental ROM (s-ROM) after total lumbar disc replacement. Moreover, the influence of ROM on clinical outcome still is unclear and remains a matter of controversial debate. METHODS.: Forty patients operated on for mono- or bisegmental symptomatic degenerative disc disease with a total of 45 artificial discs (ProDisc-L, Synthes) were analyzed. Pre- and postoperative s-ROM and t-ROM were measured on flexion/extension radiographs. The Oswestry Low Back Pain Disability Questionnaire and the Short Form 36 Health Survey were obtained pre- and postoperatively with a minimum follow-up of 3 years (37-64 months). RESULTS.: Neither the s-ROM (pre-/postoperatively: 6.9 degrees /7.3 degrees ) nor the t-ROM (pre-/postoperatively: 34.9 degrees /35.8 degrees ) did change significantly after implantation of an artificial disc. Postoperatively, there was an increase of s-ROM (t-ROM) in 40% (40%), a decrease in 35% (30%), and no change in 25% (30%) of the patients. A significant inferior clinical outcome only was observed in patients with decreased t-ROM. The resulting postoperatively s-ROM had no significant impact on outcome. CONCLUSION.: Neither the absolute s-ROM nor the evolution of s-ROM (increase, decrease, unchanged) was positively correlated with better clinical outcome. Although a positive correlation was observed with regard to t-ROM.

Spine. 2009 Apr 20; 34(9): E316-22Stanton TR, Latimer J, Maher CG, Hancock MSTUDY DESIGN.: Systematic review. OBJECTIVE.: To identify the definitions of recurrence (and related recovery definitions) currently used in the literature. SUMMARY OF BACKGROUND DATA.: Recurrence of low back pain (LBP) is a common and costly problem and the goal of many treatments is to prevent future recurrences. However, it is unclear whether standardized recurrence definitions are being used in the research literature evaluating the risk of recurrence and the effectiveness of treatments to prevent recurrence. METHODS.: A literature search was performed of MEDLINE, EMBASE, CINAHL, AMED, and PEDro, and from chosen systematic reviews investigating treatments that could plausibly affect recurrence of LBP. Studies were considered eligible if they investigated recurrence of LBP in a cohort of patients with LBP. Inclusion was assessed by 2 reviewers and definitions of recurrence (and related recovery) were extracted. RESULTS.: Fifty-three studies were identified by the review. Only 32% of studies gave explicit definitions of recurrence and only 10% gave a definition for both recurrence and recovery. Less than 10% of studies shared a common definition of recurrence. CONCLUSION.: Because of a lack of an agreed terminology it is very difficult to compare results between studies reporting recurrence rates or evaluating strategies to prevent recurrence. Steps to achieve consensus on recurrence and recovery definitions are required. In the interim, it is recommended that a minimum pain duration of 24 hours with a minimum pain intensity equivalent to the appropriate minimal important change for the chosen scale, be used for defining a recurrence. If disability measures are used, it is also recommended that the appropriate minimal important change be used. For recovery, a minimum duration of 1 month pain-free should be used.

Spine. 2009 Apr 20; 34(9): 978-983Carragee EJ, Cohen SPSTUDY DESIGN.: A 5-year prospective observational study in US Army Reserve soldiers. OBJECTIVES.: The aims of this study were 2-fold: to evaluate the prevalence of soldiers reporting no previous back pain (BP) on 3 consecutive annual assessments, and to compare these findings to those obtained from a subsequent monthly detailed BP assessment. SUMMARY OF BACKGROUND DATA.: BP history is a risk factor for future BP and disability. Conversely, subjects reporting a negative history of back troubles are thought to be at low risk for future BP events. Reporting of previous BP is assumed to have high validity. Few studies have critically evaluated the validity of the self-reported "lifetime asymptomatic" status in civilian or military populations. METHODS.: Two hundred eighty-five special operations reserve soldiers were queried annually using standardized US Army Medical Questionnaires, among whom 154 (54%) reported no BP or history thereof over 3 consecutive years. Over the next 18 months these soldiers completed annual US Army Medical Questionnaires, as well as monthly numerical rating scale pain scores, Oswestry Disability Indexes, and questions regarding back injuries. At the study's conclusion, soldiers again completed the annual medical certificate, and the results of this final BP assessment were compared with those from monthly surveillance reports. RESULTS.: During monthly surveillance of purported "lifetime asymptomatic" soldiers, the 18-month cumulative percentages reporting BP scores >/=2, >/=4, and >/=6 were 84%, 64%, and 14%, respectively. For Oswestry Disability Index scores, these percentages were 25% for scores >/=10, and 12% for scores >/=20. Yet, at the conclusion of the 5-year study, 97% soldiers still described themselves as being "asymptomatic for BP problems." CONCLUSION.: In physically active soldiers self-identified as without back problems, the report of BP using frequent surveillance tools is extremely common. The overwhelming majority of these soldiers appeared to have high resilience to common BP episodes (i.e., returned to usual duties). Episodic BP should be considered a normative rather than exceptional occurrence. Similar to other conditions, long-interval surveys of BP history may underestimate the true prevalence of BP.

Med Hypotheses. 2009 Jun 12; Ishihara KAlthough there are numerous studies examining the relationship between spinal imaging abnormality and low back and leg pain, the majority are only concerned with the correlation between these two. If we were to attempt to use the results of these studies as the basis for a treatment plan, it would be necessary to investigate the presence (or absence) of a causal relationship between the two. However, upon examination of previous studies we consider that this causal relationship has in fact either not been proven or has been refuted. To this end, we have conducted this study based on the hypothesis that spinal imaging abnormality and low back and leg pain possess a spurious relationship wherein muscle tension is the lurking variable. Furthermore, we propose a five-phase hypothesis considering the generative sequence of and causal relationship between spinal imaging abnormality, low back and leg pain, and muscle tension. Specifically, Phase I represents the healthy condition; Phase II indicates the occurrence of muscle tension only; Phase III indicates the occurrence of pain resulting from muscle tension; Phase IV represents the occurrence of both pain and imaging abnormality as a result of muscle tension; and Phase V indicates residual imaging abnormality despite amelioration of muscle tension. We believe that this hypothesis has the potential to facilitate pathological understanding and resolve the current confusion surrounding the diagnosis and treatment of spinal disorders.

Spine. 2009 Jun 15; 34(14): 1436-40Dundar U, Solak O, Yigit I, Evcik D, Kavuncu VSTUDY DESIGN: This study was a prospective, randomized, controlled study. OBJECTIVE: To compare the effectiveness of aquatic exercise interventions with land-based exercises in the treatment of chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: Land-based exercise and physiotherapy are the main treatment tools used for CLBP. Clinical experience indicates that aquatic exercise may have advantages for patients with musculoskeletal disorders. METHODS: A total of 65 patients with CLBP were included in this study. Patients were randomly assigned to receive aquatic exercise or land-based exercise treatment protocol. Aquatic exercise program consisted of 20 sessions, 5 x per week for 4 weeks in a swimming pool at 33 degrees C. Land-based exercise (home-based exercise) program were demonstrated by a physiotherapist on one occasion and then they were given written advice The patients were assessed for spinal mobility, pain, disability, and quality of life. Evaluations were performed before treatment (week 0) and after treatment (week 4 and week 12). RESULTS: In both groups, statistically significant improvements were detected in all outcome measures (except modified Schober test) compared with baseline. However, improvement in modified Oswestry Low Back Pain Disability questionnaire and physical function and role limitations due to physical functioning subpart of Short-Form 36 Health Survey were better in aquatic exercise group (P < 0.05). CONCLUSION: It is concluded that a water-based exercises produced better improvement in disability and quality of life of the patients with CLBP than land-based exercise.

Spine. 2009 Jun 15; 34(14): E484-7Kramer JL, Dvorak M, Curt ASTUDY DESIGN.: Case report. OBJECTIVE.: To describe the diagnostic challenges in a patient suffering from thoracic disc herniation (TDH) and spina bifida complicated by multiple lumbar spinal cord abnormalities, i.e., tethered cord, lumbar syringomyelia, and diastematomyelia. SUMMARY OF BACKGROUND DATA.: Advances in neuroimaging, i.e., magnetic resonance imaging, increase the sensitivity to disclose both clinically relevant but also other spine and spinal cord abnormalities. TDH accounts for less than 1% of all surgically treated disc herniations. Syringomyelia and diastematomyelia are comparably rare and present with varying degrees of spinal cord dysfunction. METHODS.: A 54-year-old women presented with progressive pain and sensorimotor symptoms in the lower back and limbs. Neurologic examination revealed lower limb spastic motor deficits and spinal ataxia. Magnetic resonance imaging revealed a T6-T7 disc herniation, with spinal cord signal change in addition to a spina bifida with sacral tethered cord, lumbar syringomyelia, and diastematomyelia. Combined neurophysiological testing identified a neurologic lesion in the mid thoracic cord, with normal lower limb nerve conduction and reflex recordings, but pathologic somatosensory-evoked potential and T6 paravertebral electromyography. RESULTS.: The patient was diagnosed with a clinically relevant T6-T7 disc herniation and underwent successful surgical decompression resulting in electrophysiological improvements. CONCLUSION.: This unique case highlights the value of electrophysiology in the evaluation of a complex spinal disorder in a patient suffering from acquired TDH in the presence of extensive congenital spine and spinal cord abnormalities. Clinical symptoms and signs can be complemented by neurophysiological techniques to improve diagnostic accuracy and improve the basis for treatment recommendations. In cases involving multiple spinal abnormalities, a comprehensive neurophysiological assessment beyond paravertebral electromyography studies, including nerve conduction and somatosensory-evoked potential recordings, is recommended to assist in confirming the diagnosis.

Swed Dent J. 2009; 33(1): 27-39Lundström IMThe aim of this study was to discover possible connections between general diseases and oral mucosal disorders, and between different oral symptoms by studying the prevalence of various such conditions in oral medicine patients. For this study 2640 consecutive patients (841 men, 1799 women) were interviewed concerning orofacial and systemic symptoms and diseases. The report includes all patients and the main diagnostic groups were: oral lichen planus/lichenoid (OLP), oral dysfunction (OD), recurrent aphthous stomatitis (RAS), oral candidosis (CAN), hyposalivation (HSA), reactive lesions (REA), and leukoplakia (LEU). Results were compared to a reference group (REF) and the normal population (NOP) (when possible). Fifty-eight per cent of all patients experienced oral smarting and orofacial pain and 36% subjective dryness.Women were more often affected. The OD, OLP, RAS and HSA groups reported significantly more orofacial pain and headache than the REF group. Tobacco was used by 17%. LEU and CAN patients had the highest frequencies, 65% and 39%. In the total patient sample cardiovascular diseases were noted in 24%, gastrointestinal disorders in 48%, skin symptoms in 45%, diabetes in 6% and thyroid diseases in 10%. The HSA and OD patients had significantly more gastrointestinal and the HSA and CAN more endocrine disorders than the NOP and REF groups. Forty-seven per cent of the women were postmenopausal and 28% reported vaginal complaints. Vaginal symptoms were most common in HSA patients (45%), 58% of them also stating dry eyes. Prolonged general pain was frequent, especially in HSA, OD, and OLP patients where significant differences were noted to the references. Women were most often affected. Psychological problems were recorded for 53% and were correlated to oral smarting, orofacial and back pain. Orofacial and general pain, symptoms from other epithelial organs, and psychological problems as well as correlation between the different disorders were frequent in oral medicine patients.

Spine J. 2009 Jun 12; Peng CW, Bendo JA, Goldstein JA, Nalbandian MMBACKGROUND CONTEXT: Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion and disc replacement but the impact of obesity on this procedure has not been determined. PURPOSE: To assess the perioperative outcomes of anterior retroperitoneal lumbar surgery in obese versus non-obese patients. STUDY DESIGN/SETTING: Prospective review of patients with anterior retroperitoneal lumbar disc procedures PATIENT SAMPLE: Seventy-four patients with anterior retroperitoneal lumbar disc procedures performed were evaluated. OUTCOME MEASURES: Access-related parameters included tissue depth (skin-to-fascia and fascia-to-spine depths), length of incision, estimated blood loss during the anterior procedure, the duration of the anterior exposure, and the duration of the entire anterior procedure. Outcome measures included complications attributable to the anterior procedure, analgesic use, length of time to ambulation, and length of hospitalization. METHODS: Seventy-four anterior retroperitoneal lumbar disc procedures were prospectively analyzed. Patient age, sex, body mass index, comorbidities, diagnosis, and operative parameters were collected. Access-related parameters and outcome measures were compared between obese and non-obese patients. Obesity was defined as body mass index greater than or equal to 30. RESULTS: There were 35 males and 39 females. Mean age was 46.6 years. The main diagnosis (63.5%) was discogenic back pain. Forty-one (55%) patients were non-obese and 33 were obese. The two patient groups were comparable in terms of age, sex, diagnosis, mean number of anterior levels operated, and previous abdominal surgery (all p>.05). In obese patients, there were two iliac vein lacerations (major complication rate, 6.1%), one superficial infection, and one urinary tract infection (minor complication rate, 6.1%). In non-obese patients, there were two iliac vein lacerations, one intestinal serosal tear (major complication rate, 7.3%), and two urinary tract infections (minor complication rate, 4.9%). There was no significant difference in the complication rates between obese and non-obese patients (p=.6). Obese patients have significantly longer duration of anterior exposure, duration of entire anterior surgery, longer length of anterior incision, and more depth from skin to fascia and from fascia to spine compared with non-obese patients. However, obesity does not affect blood loss, analgesic use, length of time to ambulation, and length of hospitalization. CONCLUSION: Perioperative outcomes in obese and non-obese patients were comparable and obesity is not related to an increased risk of morbidity in anterior lumbar surgery.

Int J Biol Sci. 2009; 5(5): 388-96Wei A, Williams LA, Bhargav D, Shen B, Kishen T, Duffy N, Diwan ADChronic back pain is a global health problem affecting millions of people worldwide and carries significant economic and social morbidities. Intervertebral disc damage and degeneration is a major cause of back pain, characterised by histological and biochemical changes that have been well documented in animal models. Recently there has been intense interest in early intervention in disc degeneration using growth factors or stem cell transplantation, to replenish the diseased tissues. Bone Morphogenetic Proteins (BMPs) have been approved for clinical use in augmenting spinal fusions, and may represent candidate molecules for intervertebral disc regeneration.BMP13 has an important role in embryonic development and recent genetic evidence shows a role in the development of the human spine. This study explores the effect of BMP13 on a damaged intervertebral disc in an ovine model of discal degeneration. We found that, when injected at the time of injury, BMP13 reversed or arrested histological changes that occurred in the control discs such as loss of extracellular matrix proteins. In addition, BMP13 injected discs retained greater hydration after 4months, and possessed more cells in the NP.Taken together, BMP13 may be a potent clinical therapeutic agent when used early in the degeneration cascade to promote healthy disc tissue.

Clin Microbiol Infect. 2009 Jun 6; Uçkay I, Dinh A, Vauthey L, Asseray N, Passuti N, Rottman M, Biziragusenyuka J, Riché A, Rohner P, Wendling D, Mammou S, Stern R, Hoffmeyer P, Bernard LClin Microbiol InfectAbstract Propionibacterium acnes is the most frequent anaerobic pathogen found in spondylodiscitis. A documented case required microbiological proof of P. acnes with clinical and radiological confirmation of inflammation in a localized region of the spine. Microbiological samplings were obtained by surgery or aspiration under radiological control. Twelve males and 17 females (median age, 42 years) with spondylodiscitis due to P. acnes were diagnosed within the last 15 years. Three patients were immunosuppressed. All patients reported back pain as the main symptom, and most were afebrile. Three patients had a peripheral neurological deficit, one a motor deficit, and two a sensory deficit attributable to the infection; and six patients had an epidural abscess. The most frequent risk factor was surgery, which was present in the history 28 of 29 (97%) patients. The mean delay between spinal surgery and onset of disease was 34 months, with a wide range of 0-156 months. Osteosynthesis material was present in twenty-two cases (76%). In 24 (83%) patients, additional surgery, such as débridement or spondylodesis, was performed. Previous osteosynthesis material was removed in 17 of the 22 (77%) patients where it was present. Total cure was reported in all patients, except one, after a mean duration of antibiotic therapy of 10.5 weeks (range, 2-28 weeks). In conclusion, spondylodiscitis due to P. acnes is an acute infection closely related to previous surgery. The most prominent clinical feature is pain, whereas fever is rare, and the prognosis is very good.

Eur J Neurosci. 2009 Apr; 29(7): 1490-500Hodges PW, Galea MP, Holm S, Holm AKMorphological and behavioural changes in back muscles are common in back pain and injury. Recent data indicate a rapid reduction in the size of the multifidus, a deep back muscle, within 3 days of experimental intervertebral disc (IVD) injury in pigs. A reduced neural drive may contribute to this. We investigated changes in corticomotor excitability following IVD lesion by evaluation of the response of back muscles to electrical stimulation of the motor cortex. Motor evoked potentials (MEPs) were studied in 12 Swedish landrace pigs before injury, immediately after abdominal incision, immediately after L3-4 IVD lesion with a scalpel, and 15 min later. In two animals, responses were also evoked by descending volleys excited at the level of the mastoid processes (cervicomedullary evoked potentials) without motor cortex activation. In five animals, a sham procedure was followed without IVD lesion. MEPs were recorded in short (deep) and long (superficial) fibres of the multifidus at L3-5 on the lesioned side and at L4 contralaterally with intramuscular wire electrodes. Although the MEP amplitude increased in several muscles after incision, at 15 min after IVD lesion only the MEP amplitude of the deep L4 multifidus on the lesioned side was increased [36% (SD 15%), P < 0.05]. There were no changes in MEP amplitude after 15 min at adjacent or contralateral levels. The response to cervicomedullary stimulation reduced slightly. This suggests that the increased MEP amplitude was due to changes in cortical excitability. These data indicate that IVD lesion induces localized increases, and not decreases, in the excitability of cortical inputs to the deep paraspinal muscles that cross a lesioned disc.

Phys Ther. 2009 Jun 11; Costa LO, Maher CG, Latimer J, Smeets RJBackground Rehabilitative ultrasound imaging (RUSI) measures of abdominal wall muscles are used to indirectly measure muscle activity. These measures are used to identify suitable patients and to monitor progress of motor control exercise treatment of people with low back pain. PURPOSE: /b> The purpose of this study was to systematically review reproducibility studies of RUSI for measuring thickness of abdominal wall muscles. Data Sources Eligible studies were identified via searches of MEDLINE, EMBASE, and CINAHL. The authors also searched personal files and tracked references of the retrieved studies via the Web of Science Index. Study Selection Studies involving any type of reliability and or agreement of any type of ultrasound measurements (B or M mode) for any of the abdominal wall muscles were selected. Data Extraction Two independent reviewers extracted data and assessed methodological quality. Data Synthesis Due to heterogeneity of the studies' designs, pooling the data for a meta-analysis was not possible. Twenty-one studies were included, and these studies were typically of low quality and studied subjects who were healthy rather than people seeking care for low back pain. The studies reported good to excellent reliability for single measures of thickness and poor to good reliability for measures of thickness change (reflecting the muscle activity). Interestingly, no studies checked reliability of measures of the difference in thickness changes over time (representing improvement or deterioration in muscle activity). CONCLUSIONS:/b> The current evidence of the reproducibility of RUSI for measuring abdominal muscle activity is based mainly on studies with suboptimal designs and the study of people who were healthy. The critical question of whether RUSI provides reliable measures of improvement in abdominal muscle activity remains to be evaluated.

Spine. 2009 Jun 10; Mannion AF, Junge A, Elfering A, Dvorak J, Porchet F, Grob DSTUDY DESIGN.: Prospective study. OBJECTIVE.: The present study compared different theories on the role of expectations in a group of patients undergoing lumbar decompression surgery. SUMMARY OF BACKGROUND DATA.: Patients' expectations of treatment are a potentially important predictor of self-rated outcome after surgery. Some studies suggest that high baseline expectations per se yield better outcomes, others maintain that the fulfillment of prior expectations is paramount, and still others assert that it is the actual improvement in symptom status that governs outcome, regardless of prior expectations. METHODS.: Hundred patients took part (33 F, 67 M; mean [SD] age, 65 [11] yrs). Before surgery, they completed a booklet containing the Roland-Morris (RM) disability questionnaire, 0-10 pain graphic rating scales (back and leg separately), and Likert-scales about the degree of improvement expected in various domains. Two and 12 months after surgery, questions were answered regarding the perceived improvement for each of these domains, the RM and pain scales were completed again, and the patients rated the global outcome on a 5-point Likert-scale. RESULTS.: Compared with the actual improvement recorded at 12 months, prior expectations had been overly optimistic in about 40% patients for the domains leg pain, back pain, walking capacity, social life, mental well-being, and independence, and in 50% patients for everyday activities and sport. There was no significant relationship between baseline expectations and follow-up scores for back pain, leg pain, RM-disability (corrected for baseline values), or global outcome. Hierarchical multiple regression analysis revealed that "expectations being fulfilled" was the most significant predictor of global outcome. CONCLUSION.: In this patient group, expectations of surgery were overly optimistic. Having one's expectations fulfilled was most important for a good outcome. The results emphasize the importance of assessing patient-orientated outcome in routine practice, and the factors that might influence it, such that realistic expectations can be established for patients before surgery.

Rheumatol Int. 2009 Jun 6; Vereckei E, Mester A, Hodinka L, Temesvári P, Kiss E, Poór GThere have been only scattered reports suggesting that musculoskeletal manifestations including back pain and sacroiliac joint involvement may be associated with celiac disease. In order to confirm this issue in a larger cohort, rheumatic manifestations were analyzed in 21 adult celiac patients using a comprehensive clinical, laboratory and radiological analysis. The diagnosis of celiac disease was based on the histopathology of jejunal biopsy specimens. The mean duration of celiac disease was 15 (0-31) years. All patients were currently on gluten-free diet and none of the patients had gastrointestinal symptoms at the time of the study. Using various imaging techniques, involvement of the sacroiliac joints was confirmed in 70% of celiac patients. Imaging revealed different morphological changes in the sacroiliac joint, e.g. accumulation of synovial fluid, synovitis, erosion with concomitant sclerosis, sacroiliitis or calcification of the ligament. These changes probably represent different clinical stages and/or manifestations of the same process. In a follow-up study of eight patients, after 11 years on a gluten-free diet, the great majority of patients had no clinical symptoms; yet, a subclinical progression of the sacroiliac joint involvement could be verified. Our results suggest the importance of regular rheumatologic follow-up of patients with celiac disease.

Rheumatology (Oxford). 2009 May 15; Hermann J, Giessauf H, Schaffler G, Ofner P, Graninger WObjectives. To evaluate the usefulness of clinical parameters in screening for early SpA in patients meeting Calin's criteria for inflammatory back pain (IBP). Methods. General practitioners used Calin's criteria for IBP to refer patients younger than 45 years to our early SpA clinic. We obtained the patients' medical history and performed a clinical examination including plain X-rays and magnetic resonance images of all affected areas. Laboratory tests for acute-phase reactants and HLA-B27 were also obtained. Two rheumatologists made a diagnosis of SpA according to the existing criteria. Results. Of the 92 patients referred, 30 (33%) were diagnosed with SpA and 62 (67%) with a non-inflammatory disorder. Spontaneous awakening night pain, the presence of Calin's criteria for IBP and tenderness of the SI joints (SIJs) were independently associated with SpA. Neck pain and reduced cervical spine sagittal movement occurred mostly with non-inflammatory disease. A history of night pain and improvement of pain with exercise but not with rest, as well as expression of HLA-B27 and abnormal CRP levels were significantly more common in patients with SpA. Conclusions. Specific clinical symptoms such as spontaneous awakening night pain, cervical pain and tenderness of the SIJs on clinical examination appear useful in screening younger patients with back pain for early SpA.

Curr Rev Musculoskelet Med. 2009 Mar 25; Middleton K, Fish DELow back pain (LBP) affects approximately 60-85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15-45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as "an illness in search of a disease." Indeed, once "red flag" diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

Drug Chem Toxicol. 2009; 32(2): 114-9Koushesh HR, Afshari R, Reza Opioid abuse is common in Iran. In 2005, a new version of locally produced illicit opioid vials, so called Norgesic, appeared in the illicit market, which gained popularity rapidly and led to an improvement of stigmatizing the general appearance of dependent cases. Later, some cases suffered Cushing's-like problems. A prospective case series was designed to evaluate 18 Norgesic-dependent subjects who volunteered for abstinence therapy in a rehabilitation clinic from November 1, 2005, to December 30, 2005. In this study, we aimed to describe the clinical and paraclinical findings in detail and define the potential determinants of this Cushing's syndrome outbreak. History, physical examination, plasma cortisol level, and urine screen tests were used to describe the patients. All subjects were male with a mean (SEM) age of 29.8 +/- 1.6 years. The opioid-dependence period was 8.4 +/-0.9 years. In an average of 4.7 +/- 0.3 months, subjects increased their usage to 5.5 +/- 0.5 vials a day. Patients claimed to gain weight. Striae were seen in 38.9%, previously documented psychological problems in 33.3%, weakness in 27.8%, high systolic blood pressure in 22.2%, moon face in 16.7%, hirsutism in 11.1%, extensive dermal infection in 11.1%, gynecomastia in 5.6%, back pain in 5.6%, insomnia in 5.6%, and lack of potency in 5.6%. Their cortisol level, on average, was 4.8 +/- 1.1 mug/dL. Hepatitis C virus was positive in 22.2%. Urine-screening tests were positive for morphine and negative for buprenorphine. In conclusion, these new vials contain steroids as well as opioids. This combination could be more dangerous than opioids themselves.

Med Sci Sports Exerc. 2009 Jun; 41(6): 1182-1187Gusi N, Prieto J, Madruga M, Garcia JM, Gonzalez-Guerrero JLPURPOSE:: The aim was to assess the health-related quality of life and physical fitness of women who care for a relative with dementia compared with an age-matched group of noncaregiver women, for the purpose of designing adequate physical exercise programs. METHODS:: A cross-sectional study was conducted in Extremadura, Spain, with 54 caregivers and 56 noncaregivers who were assessed by the SF-36 questionnaire and a battery of fitness tests. RESULTS:: The reported mental health (mental, emotional role, and social categories of SF-36) of the carers was 22% lower than that of the noncaregivers, but both groups were similar in physical health. On the whole, the reported general health of the carers was 11% lower than that of the noncarers. In fitness outcomes, caregivers had better scores in body composition, bimanual strength, and leg strength but lower scores in the endurance capacity of the trunk extensor muscles. CONCLUSION:: Relative to the standard exercise programs of the general population, exercise programs for female caregivers should be more focused on preventing back pain by developing the endurance strength of the trunk extensors. A supervised exercise program including the interaction between caregiver and health professional could also help to minimize the psychosocial components that affect the health-related quality of life.