Spine Backpain

PM R. 2009 Feb; 1(2): 117-26Harris-Hayes M, Van Dillen LROBJECTIVE: The classification of patients with low back pain (LBP) may be important for improving clinical outcomes and research efficiency. The purpose of this study was to examine the inter-tester reliability of 2 trained physical therapists to classify patients with LBP by using the standardized Movement System Impairment (MSI) classification system. The 5 proposed MSI classifications are based on the most consistent patterns of movement and alignment observed throughout the examination that correlate with the patient's symptom behavior. DESIGN: Test-retest to assess reliability SETTING: Academic healthcare center outpatient facility PARTICIPANTS: Thirty subjects (21 women and 9 men) with chronic, recurrent LBP (mean age 31.1 +/- 12.9 years) were examined independently by 2 experienced physical therapists. METHODS: Training consisted of self-study of a procedure manual, a supervised practice of examination procedures and classification rules, and discussion. Subjects were examined independently by each therapist using a test-retest design. Each therapist assigned a LBP classification upon completion of the examination. Both therapists were blinded to the other therapist's findings. MAIN OUTCOME MEASURES: Inter-tester reliability of therapists classifying the LBP problems was indexed by the percent agreement and kappa coefficient. RESULTS: Overall percent agreement on the classification assigned was 83% with kappa = 0.75 (95% confidence interval = 0.51-0.99; P < .0001). CONCLUSION: Inter-tester reliability of classification of patients with LBP when therapists use a standardized clinical examination based on the MSI classification system is substantial.

Int Dent J. 2009 Jun; 59(3): 141-7Jordan RA, Markovic L, Holzner AL, Richter B, Gaengler POBJECTIVES: Atraumatic Restorative Treatment (ART) was a major step forward in community dentistry but treatment options for deep carious lesions or pulp involvement still focus on tooth extraction in under-served areas worldwide. To bridge the gap between ART and extraction this pilot study aimed to develop and follow-up a basic root canal treatment for rural dental health facilities in the Republic of The Gambia (West Africa), faced with an environment lacking technical equipment and developing primary oral health care. METHODS: 25 single rooted teeth with acute irreversible pulpitis were root canal treated with a standardised endodontic instrument kit and a specific procedure. A step-back technique was used with intermittent chlorhexidine 0.2% and saline irrigation. Root canal obturation was performed using a single-cone technique with gutta-percha using Grossman's root canal cement. Coronal filling was carried out by using ART. Clinical examinations were documented before treatment, one day, five days, six months and twelve months postoperatively. RESULTS: None of the root canal fillings had to be revised due to postoperative complications. In 9 out of 25 teeth, transitory apical pain disappeared after a few days. After six months, all ART fillings appeared clinically acceptable, two fillings had to be corrected. Four class II restorations and three class IV restorations needed replacement after 12 months. Patients' assessment of health related quality of life improved significantly, especially concerning dental pain, chewing ability and fitness for work. CONCLUSIONS: Preliminary clinical follow-ups showed encouraging results for the basic root canal treatment approach. Longitudinal clinical studies with greater populations are required to substantiate these results. Modifications in the coronal filling technique are preferable to improve the clinical performance of extended ART cavity restorations.

Pain Med. 2009 May-Jun; 10(4): 639-53Celestin J, Edwards RR, Jamison RNBACKGROUND: In the multimodal treatment approach to chronic back pain, interventional back procedures are often reserved for those who do not improve after more conservative management. Psychological screening prior to lumbar surgery or spinal cord stimulation (SCS) has been widely recommended to help identify suitable candidates and to predict possible complications or poor outcome from treatment. However, it remains unclear which, if any, variables are most predictive of pain-related treatment outcomes. OBJECTIVE: The intent of this article is to perform a systematic review to examine the relationship between presurgical predictor variables and treatment outcomes, to review the existing evidence for the benefit of psychological screening prior to lumbar surgery or SCS, and to make treatment recommendations for the use of psychological screening. RESULTS: Out of 753 study titles, 25 studies were identified, of which none were randomized controlled trials and only four SCS studies met inclusion criteria. The methodological quality of the studies varied and some important shortcomings were identified. A positive relationship was found between one or more psychological factors and poor treatment outcome in 92.0% of the studies reviewed. In particular, presurgical somatization, depression, anxiety, and poor coping were most useful in helping to predict poor response (i.e., less treatment-related benefit) to lumbar surgery and SCS. Older age and longer pain duration were also predictive of poorer outcome in some studies, while pretreatment physical findings, activity interference, and presurgical pain intensity were minimally predictive. CONCLUSIONS: At present, while there is insufficient empirical evidence that psychological screening before surgery or device implantation helps to improve treatment outcomes, the current literature suggests that psychological factors such as somatization, depression, anxiety, and poor coping, are important predictors of poor outcome. More research is needed to show if early identification and treatment of these factors through psychological screening will enhance treatment outcome.

Int J Behav Med. 2009 Jul 25; Demmelmaier I, Asenlöf P, Lindberg P, Denison EBACKGROUND: Long-term outcome in back pain is related mainly to cognitive factors such as pain-related beliefs and expectations. Most research has been performed on patient samples. PURPOSE: This study aimed at investigating changes over time in reported back pain, pain intensity, disability, health care consumption, and sick leave as well as biopsychosocial factors over a 12-month period. A second aim was to identify predictors of reported pain, pain intensity, disability, health care consumption, and sick leave. METHOD: As parts of a large back pain sample from a general population (n = 1,024), two groups-one with first-episode pain (n = 77) and one with long-term pain (n = 302)-responded twice to a self-administered questionnaire. Among participants reporting pain at both assessments, changes over time were analyzed and predictive models were tested. RESULTS: Generally, the results demonstrated overall stability in the self-reports over time. However, reported pain decreased in both groups, while pain catastrophizing and pain expectations increased in the first-episode group. Pain intensity and disability were predicted in regression models including four cognitive factors and initially reported levels of pain intensity and disability. CONCLUSION: The significance of pain-related beliefs and expectations both in early and later stages of a back pain condition is pointed out. The results in this study based on a sample from the general population are in line with previous research on patient samples.

Orthopedics. 2009 Jul; 32(7): Yoshioka K, Kawallara N, Murakami H, Demura S, Kawaguchi M, Oda M, Matsumoto I, Tomita KThis article describes a case of cervicothoracic giant cell tumor expanding into the superior mediastinum treated by total spondylectomy. A 42-year-old-man presented with back pain and paraparesis. Magnetic resonance imaging revealed the collapse of the T2 vertebral body. The spinal cord was severely compressed by the tumor mass. The tumor had spread from T2 to the mediastinum, so that the tumor was in contact with many vital structures. To resect the tumor completely, total spondylectomy from T1 to T3 was performed through a combined anterior-posterior approach. The tumor was dissected from the vital structures using an anterior low cervical approach and splitting one-third of the sternum. En bloc vertebral resection from Th1 to Th3, including the tumor pseudocapsule, was possible through a posterior approach. The tumor around the nerve roots or dura was resected piece by piece since it was possible to separate the capsulated tumor from the dura. Splitting one-third of the sternum allowed separation of the tumor from the anterior vital structures, under direct vision. This allowed en bloc vertebral resection of the tumor that had spread to the mediastinum from T2 and in the craniocaudal direction from T1 to T3. Although giant cell tumor is benign, it can be locally aggressive. Complete excision of a giant cell tumor is the best treatment option even for the cervicothoracic spine, to protect the vital structures or neural function.

J Occup Rehabil. 2009 Jul 28; Carleton RN, Abrams MP, Kachur SS, Asmundson GJIntroduction Fear-anxiety-avoidance models of chronic pain emphasize psychological constructs as key vulnerabilities for the development and maintenance of disabling chronic pain. Complementarily, Waddell described physical signs and symptoms thought inconsistent with anatomic and pathologic disease patterns that might function as indications of pain-related psychological distress. Research has not supported using Waddell's signs due to low inter-rater reliability and limited associations with psychological distress; however, these findings are equivocal. Similarly, theorists have suggested that endorsement of Waddell's symptoms may indicate psychological distress; however, the precedent research has not included the psychological constructs described in fear-anxiety-avoidance models as vulnerability factors for the development and maintenance of chronic pain. Methods Participants for the current study were patients (n = 68; 35% women) with chronic low back pain involved in a multi-disciplinary work-hardening program provided by a third-party insurer. Patients endorsing more than two of Waddell's symptoms were compared with those who did not on demographic variables as well as established self-report psychological measures, measures of perceived disability, functional capacity, and treatment outcome. Results Patients endorsing more than two of Waddell's symptoms reported higher levels of depressive symptoms, pain-related anxiety, fear, catastrophizing, and pain intensity. Unexpectedly, there were no significant differences in functional capacity. Similar differences were found between those who did and did not return to work. Conclusions While Waddell's symptoms must still be interpreted judiciously, they may provide much needed cross-disciplinary utility as indicators that more detailed psychological assessment is warranted. Comprehensive implications and directions for future research are discussed.

Acta Vet Hung. 2009 Sep; 57(3): 417-26Kovács K, Jakab C, Szász AMRecently, an increase in the occurrence of oral diseases in cats has been observed. Symptoms vary from case to case, but loss of appetite or fastidiousness can almost always be noted. Proliferative inflammatory eosinophilic granulomatosis is a common disease in cats, which may be localised to the skin, the mucocutaneous junctions or the oral cavity. The disease has three different manifestations: indolent cellular ulcer, eosinophilic plaque, and eosinophilic granuloma. The last mentioned form predominantly affects the medial surface of the thigh, the cheek, the tongue and the palate. Pain is not common, the lesion is nonpruritic if localised to the skin, but the nodular form in the oral cavity may make deglutition difficult. In this case, a 10.5-year-old cat was presented in poor condition due to feeding problems. Examination revealed a mass of unknown origin with macroscopically tumorous appearance, localised to the pharyngeal part of the tongue, which made swallowing and voluntary feeding difficult. The granuloma was removed by laser-assisted surgery. After adequate preparation, a LASER diode with 6-10 W output power was used, set to continuous constant-amplitude output (CW) running in a 0.6 mm optic fibre to the site of interest. The removed tissue was examined for pathomorphological features: haematoxylin and eosin, Giemsa, Azan and PAS stainings were performed to aid diagnosis. After surgery the cat recovered fast on steroids, and its condition and quality of life improved greatly. The traditional surgical technique was inapplicable due to the heavy vasculature and corresponding bleeding of the tongue.

PM R. 2009 Jun; 1(6): 541-6Lee SU, Lee JI, Butts K, Carragee E, Fredericson MOBJECTIVE: To determine whether posterior lumbar disk contour dimensions differ in the flexed seated, upright seated, and extended seated positions. DESIGN: Two subgroups of subjects with degenerative disk disease were compared: those with central posterior disk bulge (at L4-5 or L5-S1 levels) and those with a dark nucleus pulposus without posterior disk bulge (L3-4, L4-5, and/or L5-S1 levels). SETTING: Academic medical center. PARTICIPANTS: Eight subjects with a central disk bulge and 9 subjects with a dark nucleus pulposus on magnetic resonance imaging. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Quantitative comparisons of posterior disk contour between neutral, flexed, and extended sitting positions. RESULTS: Of 8 subjects with central disk bulge, spinal flexion (from the neutral position) produced a decreased disk contour in all subjects, whereas spinal extension (from the neutral position) produced an increased disk contour in 6 subjects, a decreased disk contour in 1 subject, and no measurable change in 1 subject. Changes in posterior disk contour in subjects with a dark nucleus pulposus were variable. Approximately half increased and half decreased, but no relation to position was determined. CONCLUSIONS: The results of this pilot study suggest a consistent pattern of decreased posterior disk contour with spinal flexion and increased posterior disk contour with spinal extension in subjects with central disk bulge, but not in those with a dark nucleus pulposus.

J Orthop Trauma. 2009 Aug; 23(7): 525-30Taghipour H, Moharamzad Y, Mafi AR, Amini A, Naghizadeh MM, Soroush MR, Namavari AOBJECTIVE: To determine the factors that have an adverse effect on the long-term health-related quality of life (HRQOL) of veterans who have lost their extremities on the battlefield. DESIGN: Cross-sectional study. SETTING: Tertiary prosthesis center. PARTICIPANTS: One hundred forty-one male Iranian veterans who have sustained unilateral lower extremity amputation during the Iran-Iraq War (1980-1988) were evaluated after an average of 21.6 years (range, 20-27 years) after amputation. INTERVENTION: No intervention. MAIN OUTCOME MEASUREMENTS: Physical and mental HRQOL according to the Short Form-36 (SF-36) Health Survey. A cutoff point to define poor versus good HRQOL was calculated using the first quartile of SF-36 physical and mental component scores. RESULTS: Poor physical HRQOL was positively associated with transfemoral amputation, phantom movement, low back pain, and a lower Barthel Index [odds ratios (ORs): 4.1, 7.8, 9.1, and 0.9, respectively). Poor mental HRQOL was associated with education level lower than high school diploma and the articular pain of the sound leg (OR = 2.9 and 6.5, respectively). Being employed or receiving disability was a factor that had a lower OR to associate with poor mental HRQOL (OR = 0.2). CONCLUSIONS: Alleviation of complaints such as low back pain and articular pain of the sound leg through appropriate medical management, granting facilities for continuing education, and employment are issues that should be considered by authorities and rehabilitative centers to increase HRQOL in amputee veterans.

PM R. 2009 Feb; 1(2): 127-36Haig AJ, Yamakawa KS, Parres C, Chiodo A, Tong HOBJECTIVES: To describe neurophysiologic changes over time in persons with and without spinal complaints and to assess whether paraspinal denervation predicts change in stenosis on magnetic resonance imaging (MRI) and clinical course. DESIGN: Prospective, controlled, masked trial. SETTING: University spine program. PARTICIPANTS: Persons aged 55 to 80 years, screened for polyneuropathy and determined on clinical examination to have spinal stenosis, mechanical low back pain, or no spinal symptoms. INTERVENTIONS: A comprehensive codified history was obtained and subjects underwent physical examination, ambulation testing, masked electrodiagnostic testing including paraspinal mapping, and MRI, repeated at greater than 18 months. This study presents detailed technical information and additional analyses not reported previously. MAIN OUTCOME MEASUREMENTS: Change in electrodiagnostic findings. Among persons with clinical stenosis, relationship of change in paraspinal mapping scores to MRI findings and clinical changes. RESULTS: Of 149 initial subjects, 83 (79.3% of eligible subjects) repeated testing at 20 (+/-2 SDs) months. No significant change in limb muscle spontaneous activity or motor unit pathology was noted in any group. In 23 persons with initial diagnosis of stenosis, paraspinal mapping electromyography related to change in diagnosis over time (analysis of variance F = 3.77, P = .037), but not to most initial magnetic resonance imaging measurements or to change in spinal canal diameter. CONCLUSIONS: Clinical spinal stenosis is neurophysiologically stable in most persons. Paraspinal electromyographic changes reflect large changes in clinical course, but neither neurophysiologic nor clinical changes relate to change in spinal geometry over 20 months.

J Pain. 2009 Jul 21; Krebs EE, Lurie JD, Fanciullo G, Tosteson TD, Blood EA, Carey TS, Weinstein JNOur objective was to assess predictors of self-reported opioid use among patients with back pain due to lumbar disc herniation or spinal stenosis. Data were from the Spine Patient Outcomes Research Trial (SPORT), a multi-site observational study and randomized trial. We examined characteristics shown or hypothesized to be associated with opioid use. Using generalized estimating equations, we modeled associations of each potential predictor with opioid use at 12 and 24 months. At baseline, 42% of participants reported opioid use. Of these participants, 25% reported continued use at 12 months and 21% reported use at 24 months. In adjusted models, smoking (RR = 1.9, P < .001 at 12 months; RR = 1.5, P = .043 at 24 months) and nonsurgical treatment (RR = 1.7, P < .001 at 12 months; RR = 1.8, P = .003 at 24 months) predicted long-term opioid continuation. Among participants not using opioids at baseline, incident use was reported by 8% at 12 months and 7% at 24 months. We found no significant predictors of incident use at 12 or 24 months in the main models. In conclusion, nonsurgical treatment and smoking independently predicted long-term continued opioid use. To our knowledge, this is the first longitudinal study to assess predictors of long-term and incident opioid use among patients with lumbar spine conditions. PERSPECTIVE: This longitudinal study of patients with disc herniation or spinal stenosis found that nonsurgical treatment and smoking predicted long-term self-reported opioid use. The greater risk of opioid continuation with nonsurgical therapy may be helpful in decision-making about treatment. The relationship between opioid use, smoking, and other substance use deserves further study.

Acta Orthop. 2009 Jan 1; 445-450Andersen T, Christensen FB, Niedermann B, Helmig P, Høy K, Hansen ES, Bunger CBackground and purpose An increasing number of lumbar fusions are performed using allograft to avoid donor-site pain. In elderly patients, fusion potential is reduced and the patient may need supplementary stability to achieve a solid fusion if allograft is used. We investigated the effect of instrumentation in lumbar spinal fusion performed with fresh frozen allograft in elderly patients. Methods 94 patients, mean age 70 (60-88) years, who underwent posterolateral spinal fusion either non-instrumented (51 patients) or instrumented (43 patients) were followed for 2-7 years. Functional outcome was assessed with the Dallas pain questionnaire (DPQ), the low back pain rating scale pain index (LBPRS), and SF-36. Fusion was assessed using plain radiographs. Results Instrumented patients had statistically significantly better outcome scores in 6 of 7 parameters. Fusion rate was higher in the instrumented group (81% vs. 68%, p = 0.1). Solid fusion was associated with a better functional outcome at follow-up (significant in 2 of 7 parameters). 15 patients (6 in the non-instrumented group and 9 in the instrumented group) had repeated lumbar surgery after their initial fusion procedure. Functional outcome was poorer in the group with additional spine surgeries (significant in 4 of 7 parameters). Interpretation Superior outcomes after lumbar spinal fusion in elderly patients can be achieved by use of instrumentation in selected patients. Outcome was better in patients in which a solid fusion was obtained. Instrumentation was associated with a larger number of additional surgeries, which resulted in a lesser degree of improvement. Instrumentation should not be discarded just because of the age of the patient.

Pain. 2009 Jul 22; McClish DK, Smith WR, Dahman BA, Levenson JL, Roberts JD, Penberthy LT, Aisiku IP, Roseff SD, Bovbjerg VETreatment options for sickle cell disease (SCD) pain could be tailored to pain locations. But few epidemiologic descriptions of SCD pain location exist; these are based on few subjects over short time periods. We examined whether SCD pain locations vary by disease genotype, gender, age, frequency of pain, depression, pain crisis or healthcare utilization. We enrolled 308 adults with SCD in 2002-2004. Subjects kept daily pain diaries for up to 6months, including a body chart. Mixed model and generalized estimating equations were employed for analyses. Two hundred and sixty subjects completed at least one body chart. An average of 3.3/16 sites (25%) were painful. The number of pain sites varied by age, depression, frequent pain days, crisis and unplanned hospital/ED utilization. Lower back, knee/shin and hip, hurt on average more than a third of pain days, while jaw and pelvis hurt on fewer than 10% of days. Odds of a crisis were increased substantially when pain was in the arm, shoulder, upper back, sternum, clavicle, chest or pelvis (OR>1.5) while the odds of unplanned utilization were substantially increased for the sternum, clavicle and chest (OR>2.0). Pain in SCD varies considerably both within and between subjects, although it occurs most commonly in the lower back and lower extremities. The number and location of pain sites vary significantly by age, frequent pain, crisis and utilization. Identification and understanding of combinations of pain location and intensity may help to understand the etiology of SCD and improve SCD management.

Spine J. 2009 Jul 22; Wai EK, Roffey DM, Bishop P, Kwon BK, Dagenais SBACKGROUND CONTEXT: Low back pain (LBP) is a common musculoskeletal disorder that often occurs in the working-age population. Although numerous physical activities have been implicated in its etiology, determining causation remains challenging and requires a methodologically rigorous approach. PURPOSE: To conduct a systematic review focused on establishing a causal relationship between occupational bending or twisting and LBP. STUDY DESIGN: A systematic review of the literature using Medline, Embase, CINAHL, Cochrane Library, and Occupational Safety and Health database, gray literature, hand-searching occupational health journals, reference lists of included studies, and experts. Evaluation of methodological quality using a modified Newcastle-Ottawa Scale for observational studies. Summary levels of evidence for each of the Bradford-Hill criteria for causality for each category of bending or twisting and type of LBP. SAMPLE: Studies reporting an association between occupational bending or twisting and LBP. OUTCOME MEASURES: Numerical association between different levels of exposure to bending or twisting and the presence or severity of LBP. METHODS: A systematic review was performed to identify, evaluate, and summarize the literature related to establishing a causal relationship, according to Bradford-Hill criteria, between occupational bending or twisting and LBP. RESULTS: This search yielded 2,766 citations. Ten high-quality studies reported on bending and LBP. Five were case-control studies and five were prospective cohort studies. There was conflicting evidence for association, with five studies demonstrating significant associations in the majority of their risk estimates, but no evidence for consistency. Seven studies assessed dose response, with four studies demonstrating a nonsignificant dose-response trend. Four studies were able to assess temporality, but only one demonstrated significant risk estimates. Biological plausibility was discussed by two studies. There was no available evidence for experiment. Seven high-quality studies reported on twisting and LBP. Two were case-control studies and five were prospective cohort studies. Three studies reported significant associations in the majority of their risk estimates, with no evidence for consistency. Three studies demonstrated a nonsignificant dose-response trend. Two studies were able to assess temporality, but only one study was able to demonstrate significant risk estimates. Two studies discussed biological plausibility. There was no available evidence for experiment. CONCLUSIONS: A summary of existing studies was not able to find high-quality studies that satisfied more than three of the Bradford-Hill criteria for causation for either occupational bending or twisting and LBP. Conflicting evidence in multiple criteria was identified. This suggests that specific subcategories could contribute to LBP. However, the evidence suggests that occupational bending or twisting in general is unlikely to be independently causative of LBP.

Physiotherapy. 2009 Mar; 95(1): 29-35Miller JS, Litva A, Gabbay MOBJECTIVES: The National Health Service is developing an ethos of self-care. Patients are being encouraged to become proficient in helping themselves. This has long been a philosophy of the physiotherapy profession, where self-care between consultations has been an integral part of the treatment process through encouraging the uptake of self-care skills training. This study explored how patients with shoulder and back pain perceived videotaped exercises and instructions to support their routine physiotherapy, and how the videotape was used. DESIGN: A videotape, developed by physiotherapists for patients with musculoskeletal problems, of exercises to view at home was given to patients by their physiotherapists to support their routine physiotherapy consultations. A qualitative methodology was used to examine how patients responded to being given a videotape of exercises and instructions between consultations. Data were collected through semi-structured interviews. SETTING: The study was based in 26 general practices that had access to practice-based physiotherapists in two primary care trusts in the north-west of England. PARTICIPANTS: Thirty-three patients with shoulder and back pain who received a videotape of exercises and advice were interviewed. RESULTS: Three themes emerged from the data: finding space for exercise; remembering and doing exercises; and supporting the physiotherapy-patient relationship. Patients discussed aspects of motivation, and described how a videotape of exercises might support or inhibit the performance of exercises prescribed by physiotherapists. Patients identified a range of different ways in which they derived support from the videotape. CONCLUSIONS: The videotape supported patients with a variety of different needs as it enhanced their ability to complete exercises correctly. Videotapes (or DVDs) are useful for patients and could be adopted as a tool to support treatment.

Physiotherapy. 2009 Mar; 95(1): 8-14von Garnier K, Köveker K, Rackwitz B, Kober U, Wilke S, Ewert T, Stucki GBACKGROUND: There are indications that segmental stabilising exercises (SSEs) are effective in the treatment of low back pain. The evaluation of successful training in SSE performance in patients requires a reliable outcome measure. The PRONE test gives an indication of the activity of the transversus abdominis muscle. Performed in prone lying using a pressure biofeedback unit, it has been used as an aid to training and to assess the subject's ability to perform SSEs correctly. OBJECTIVES: To evaluate inter-observer and test-retest reliability of the PRONE test. DESIGN: Repeated measures by three observers on 2 days. SETTING: Department of Physical Medicine and Rehabilitation, Ludwig-Maximilian University, Munich, Germany. PARTICIPANTS: Forty nurses (39 females and one male), aged between 24 and 62 years, with at least one episode of low back pain. MAIN OUTCOME MEASURES: During the test, movement of the abdominal wall was monitored by measuring a change in pressure during muscle contraction termed 'abdominal hollowing'. Defined observation and palpation criteria were verified by the observers to ensure correct execution of the test. METHODS: Participants were tested on two separate days. On the first day, Observer A performed two similar test sets, each with four exercises. On the second test day, Observers B and C conducted one test set each. RESULTS: This study found an intra-class correlation coefficient (ICC) of 0.47 [95% confidence interval (CI) 0.20 to 0.67] for inter-observer reliability, and an ICC of 0.81 (95% CI 0.67 to 0.90) for test-retest reliability. Kappa values and the limits of agreement were also calculated with similar results. CONCLUSIONS: For this subject group, the PRONE test had relatively low inter-observer reliability but, as may be expected, higher test-retest reliability. It is suggested that by providing visual feedback, the PRONE test may enhance patients' insight into their deep abdominal muscle recruitment and thereby increase their motivation to exercise.

PM R. 2009 Feb; 1(2): 137-46Schenkman ML, Jordan S, Akuthota V, Roman M, Kohrt WM, Hearty T, Cleary C, Backstrom KMOBJECTIVE: Despite considerable effort to reduce low back pain (LBP), approximately 60% of patients have recurrence after their first episode. The high rate of recurrence suggests that more effective intervention approaches are needed. This randomized, controlled feasibility trial was designed to compare disability, physical functional capacity, and pain outcomes at 2, 6, and 12 months for 2 conventional and 1 novel physical therapy (functional movement training) intervention for recurrent LBP. DESIGN: Randomized, controlled feasibility trial. SETTING: University hospital outpatient physical therapy clinic. PARTICIPANTS: Sixty-one participants (60% female) with recurrent LBP. INTERVENTIONS: Subjects were randomized to 1 of 3 intervention groups: group 1 had a single session consisting of standard back pain education; group 2 had 6 sessions in 8 weeks of conventional physical therapy; and group 3 had 6 sessions in 8 weeks of a novel method of functional movement training. Change from baseline was used to determine within-group changes and between-group differences for participants who finished each time point (2, 6, and 12 months). Changes were evaluated using analysis of variance and Newman-Keuls post hoc analysis. MAIN OUTCOME MEASURES: The primary outcome measure was the novel Continuous Scale Physical Functional Performance test (CS-PFP), a measure of actual physical functional capacity. Secondary measures included the revised Oswestry Disability Index, a measure of pain-related disability, the Roland Morris Disability Questionnaire, and a standard visual analogue pain scale. RESULTS: Of the participants, 67% provided data at 2 months and 44% provided information at 12 months. Raw change scores were evaluated at 2, 6, and 12 months. While no statistical significance was reached with any outcome measure, the trends suggested little change for group 1 (education) and suggested that greatest improvement in function may occur in group 3 (functional movement training). In particular, at 2 months, the CS-PFP change scores revealed a trend (P=.072) toward greater improvement in groups 2 (conventional physical therapy) and 3 (functional movement training) compared with group 1. At 12 months, Oswestry Disability Index and CS-PFP scores also trended toward significance for groups 2 and 3 (P=.7 and .9, respectively). Mean change scores were also calculated and revealed groups 2 and 3 had improved by 2 months and this improvement remained stable at the 1-year mark. Trends in the direction of best improvement occurred for those in the functional movement training group. CONCLUSION: A large-scale randomized, controlled trial is warranted to determine whether an intervention based on functional movement training is superior to conventional, impairment-based intervention for individuals with recurrent LBP.

G Ital Med Lav Ergon. 2009 Jan-Mar; 31(1 Suppl A): A24-9Magnavita NBACKGROUND: This study explored the relationship between individual characteristics, physical and psychosocial work-related risk factors and the musculoskeletal pain among non-specialized personnel working in different kinds of social care. METHODS: The study population consists of 342 employees of a cooperative for in-house, outpatient and scholar social care. The study was conducted using a cross-sectional survey design. Data were collected by means of questionnaires, including questions about having or having had musculoskeletal symptoms (12 months prevalence), the perception of social support from co-workers and superiors, the perception of job strain according to the Karasek's demand/control model, and anxiety and depression according to the Goldberg's 9-items scales. RESULTS: In all groups prevalence rates of musculoskeletal complaints were high. A forward stepwise binary logistic regression analysis showed that symptoms from the low back were significantly related to psychological demands, and depression score; symptoms from the upper back were related to age, anxiety and depression; symptoms from the neck were related to psychological demands, authority over decisions, gender and anxiety. CONCLUSIONS: The results of the present study indicate that both low and upper back complaints and neck complaints are major health problems in social care workers. Musculoskeletal disorders seemed to be related both to job strain and to individual and emotional factors. The professional groups under study all are target for preventive interventions; these interventions need to be specified for each of the professional groups, and to include educational, organizational, and ergonomic measures.

Mymensingh Med J. 2008 Jul; 17(2 Suppl): S32-8Shakoor MA, Rahman MS, Moyeenuzzaman MA randomized clinical trial was conducted in the Department of Physical Medicine & Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from 1st April 2006 to 31st March 2007. A total of 102 patients of Chronic LBP were included in the study. Out of them, 42 (41.2%) were male and 60 (58.8%) were female and male: female ratio was 1:1.43. The mean age of the patients was 42.22+/-8.07 years. They were divided randomly into two groups by the way of lottery for the clinical trial. Group A was treated with short wave diathermy (SWD) and non steroidal anti inflammatory drugs (NSAID) and Group B was treated with placebo SWD and NSAID. After treatment the result was compared and student's 't' test was done to see the level of significance. There was significant improvement after treatment in both the group (P=0). In comparison between two groups, it was found that there was no significant improvement in pre-treatment, after 1st week and after 2nd week. Improvement was found in Group A than Group B after 3rd week (P=0.05). And the improvement was gradually increased in Group A in comparison to Group B. Finally, it was found that there was significant improvement in Group A than Group B after 6th week (P=0). From the present study, it may be concluded that both the treatment (NSAID and SWD) is effective for the treatment of Chronic LBP. But the patient may be more benefited if SWD is used as an adjunct to NSAID.

Pharmacol Ther. 2009 Jul 17; Maurice T, Su TPOriginally considered an enigmatic protein, the sigma-1 receptor has recently been identified as a unique ligand-regulated molecular chaperone in the endoplasmic reticulum of cells. This discovery causes us to look back at the many proposed roles of this receptor, even before its molecular function was identified, in many diseases such as methamphetamine or cocaine addiction, amnesia, pain, depression, Alzheimer's disease, stroke, retinal neuroprotection, HIV infection, and cancer. In this review, we examine the reports that have clearly shown an agonist-antagonist relationship regarding sigma-1 receptors in models of those diseases and also review the relatively known mechanisms of action of sigma-1 receptors in an attempt to spur the speculation of readers on how the sigma-1 receptor at the endoplasmic reticulum might relate to so many diseases. We found that the most prominent action of sigma-1 receptors in biological systems including cell lines, primary cultures, and animals is the regulation and modulation of voltage-regulated and ligand-gated ion channels, including Ca(2+)-, K(+)-, Na(+), Cl(-), and SK channels, and NMDA and IP3 receptors. We found that the final output of the action of sigma-1 receptor agonists is to inhibit all above-mentioned voltage-gated ion channels, while they potentiate ligand-gated channels. The inhibition or potentiation induced by agonists is blocked by sigma-1 receptor antagonists. Other mechanisms of action of sigma-1 receptors, and to some extent those of sigma-2 receptors, were also considered. We conclude that the sigma-1 and sigma-2 receptors represent potential fruitful targets for therapeutic developments in combating many human diseases.

Zhonghua Wai Ke Za Zhi. 2009 May 1; 47(9): 689-92Wang ZX, Hu YGOBJECTIVE: To explore the prevalence, distribution and clinical significance of high-intensity zone (HIZ) in anterior annulus fibrosus (AF) in comparison with HIZ in posterior AF of lumbar disc. METHODS: According to the diagnosis and location of HIZ, 610 lumbar magnetic resonance images with entire clinical materials were divided into control group (without HIZ), anterior AF group (HIZ), posterior AF group (HIZ) and anterior & posterior (AP) AF group (HIZ). The incidence of HIZ was summarized. The clinical data, such as male/female ratio, age, and body weight, prevalence of low back pain (LBP) and distribution of HIZ, were compared and analyzed between the groups. RESULTS: Three hundred and fifteen cases shown no HIZ (51.6%), 95 cases presented HIZ in anterior AF (15.6%, 119 discs), 159 cases presented HIZ in posterior AF (26.1%, 189 discs) and 41 cases presented HIZs in both anterior and posterior AF (6.7%, 96 discs). There was significant difference between the prevalence of HIZ in anterior AF and that in posterior AF (P < 0.01). The male/female ratio and body weight of each groups showed no difference (P > 0.05), and the age was proved to be statistically different between four groups (P < 0.01, control group < posterior AF group < AP AF group < anterior AF group). HIZs in anterior AF often occurred at L(1,2)-L(4,5), whereas, they usually developed at L(3,4)-L(5)S(1) in posterior AF. The incidence of LBP in control group, anterior AF group, posterior AF group, AP AF group were 40.0%, 52.6%, 55.4% and 65.8%, respectively. The LBP prevalence of control group was lower than that of other three groups (P < 0.05), and the prevalence of last three groups showed no difference (P > 0.05). CONCLUSIONS: Compared with HIZ in posterior AF, the HIZ in anterior AF of lumbar disc has a lower prevalence, often develops in elder patients and in upper motion segments. It also indicates an obvious relation to LBP as the former.

Palliat Support Care. 2009 Mar; 7(1): 97-108Magill LOBJECTIVE: The aim of this study was to learn how music therapy sessions, held prior to the death of a loved one, impact spirituality in surviving caregivers of advanced cancer patients. METHOD: The method of naturalistic inquiry was used to investigate the spiritual meaning of pre-loss music therapy sessions. Bereaved caregivers of seven different patients, who had been receiving music therapy through a home-based hospice program, participated in individual open-ended interviews. Interviews were recorded, transcribed, and coded. Themes were organized as they emerged. RESULTS: As caregivers reflected on their experiences in music therapy, they reported autonomous joy (music therapy affected the caregiver directly) and empathic joy (caregivers' joy was based in remembering seeing the patient happy in music therapy). They also noted feelings of empowerment due to the ways they felt they had contributed in the care of the patients through music therapy. The caregivers were found to engage in processes of reflection that inspired these spiritual themes: reflection on the present (connectedness), reflection on the past (remembrance), and reflection on the future (hope). They referred to the ways that the music therapy sessions helped them find connection with self, others (through bringing their loved ones "back to life" and have a "renewal of self"), and the "beyond"; and that times in music therapy brought them happy memories and sentiments of hope. Meaning through transcendence was found to be the overarching trend in this study, as caregivers were lifted from remorse into heightened sense of meaning and gained "airplane views" of their lives. SIGNIFICANCE OF RESULTS: Pre-loss music therapy can potentially assist caregivers during times of bereavement, as they retain memories of joy and empowerment, rather than memories of pain and distress, and find meaning through transcendence.

J Clin Nurs. 2009 Jul 8; Ho SS, Yu WW, Lao TT, Chow DH, Chung JW, Li YAims. This study aims to identify the needs, concerns and problems of pregnant women when using maternity support garments. Background. Maternity support belt is regarded as helpful in reducing low back pain during pregnancy. However, several garment-related problems exist which might lead to poor adherence behaviour undermining the benefit of garment therapy. Design. A qualitative exploratory study. Methods. Semi-structured interviews were conducted with 10 pregnant Chinese women who experienced low back pain during pregnancy. All the interviews followed an interview guide and different maternity support garments were shown to the participants as a method of tangible objects to stimulate responses. Content analysis was used to analyse the data. Results. The results showed that 60% of pregnant women discontinued using maternity support garments due to excessive heat, perceived ineffectiveness, itchiness, excessive pressure around the abdomen and inconvenience of adjustment. The content analysis generated five main themes of needs including effective function, safety, skin comfort, ease to put on and take off and aesthetics of maternity support garments. Discussion. The findings of the five main themes of needs were largely consistent with previous studies examining medical garments for overall satisfaction and compliance. The results revealed that women's physiological and psychological changes during pregnancy influenced their clothing preferences on both functional and aesthetical values. Conclusions. Maternity support garments are convenient and easily-accessible therapy to manage LBP during pregnancy and are frequently recommended and worn by pregnant women. However, inappropriate choice of garment therapy not only led to ineffectiveness but also undesirable effects. The key findings of the five main themes of garment needs in pregnant women will facilitate healthcare professionals in providing evidence-based advice to assist patients in the selection of an appropriate and optimal maternity support garment. Relevance to clinical practice. These recommendations in the clinical practice will assist patients in making well informed treatment decisions and ultimately improve the quality of care.

Gesundheitswesen. 2009 Jul 20; Kriesch M, Farin EOBJECTIVE OF THE STUDY: Health valuations are one way of measuring patient preferences with respect to the results of their treatment. The study examines three different methods of health valuations - willingness to pay (WTP), visual analogue scale (VAS), and a rating question for evaluating the subjective significance. The goal is to test the understandability and acceptance of these methods for implementation in questionnaires. METHOD: In various rehabilitation centres, a total of six focus groups were conducted with 5-9 patients each with a mean age of 57.1 years. The illnesses considered were chronic-ischaemic heart disease, chronic back pain, and breast cancer. Patients filled out a questionnaire that was then discussed in the group. In addition to the quantitative evaluation of the data in the questionnaire, a qualitative analysis of the contents of the group discussion protocols was made. RESULTS: We have results from a total of 42 patients. 14.6% of the patients had "great difficulties" understanding the WTP or rated it as "completely incomprehensible"; this value was 7.3% for VAS and 0% for the rating scale. With respect to acceptance, 31.0% of the patients indicated that they were "not really" or "not at all" willing to answer such a WTP question in a questionnaire; this was 6.6% for the VAS, and again 0% for the rating scale. The qualitative analysis provided an indication as to why some patients view the WTP question in particular in a negative light. Many difficulties in understanding it were related to the formulation of the question and the structure of the questionnaire. However, the patients' statements also made it apparent that the hypothetical nature of the WTP questionnaire was not always recognised. The most frequent reason for the lack of acceptance of the WTP was the patients' fear of negative financial consequences of their responses. DISCUSSION: With respect to understandability and acceptance, VAS questions appear to be better suited for reflecting patient preferences than WTP questions. The rating scale for assessing the personally estimated importance was understandable, but had poor distribution properties and was considered by patients to be superfluous.

Disabil Rehabil. 2009 May 21; 1-9Sloots M, Scheppers EF, Bartels EA, Dekker JH, Geertzen JH, Dekker JPurpose. To explore which factors lead to tension in the patient-physician interaction in the first consultation by rehabilitation physicians of patients with chronic non-specific low back pain of Turkish and Moroccan origin. Method. In-depth semi-structured, face to face interviews were conducted with 12 patients of Moroccan and Turkish origin and four native Dutch rehabilitation physicians. Interviews were transcribed and/or summarised. All interviews were subsequently coded and analysed according to themes. Results. Factors that lead to tension in the patient-physician interaction were as follows: differences in expectations regarding the aim of treatment, symptom presentation, views on responsibilities with regard to rehabilitation treatment, lack of trust, contradicting views of physicians from patients' country of origin with regard to the cause and treatment of pain and communication problems. Conclusion. Sources of tension were identified during the interaction between Dutch physicians and patients of Turkish and Moroccan origin. These factors potentially are associated with future drop-out. Future research should clarify whether these factors indeed are associated with drop-out.

Acta Ortop Mex. 2009 Mar-Apr; 23(2): 90-3Lara-de-la-Fuente R, Alanís-Cruces JMINTRODUCTION: Postoperative fibrosis is the excessive scarring resulting from any surgery; that is, the formation of more fibrous tissue than is normal. In some lumbar surgeries this fibrous tissue compresses or distends the dura mater and/or nerve roots, causing low back pain or radiculopathy. MATERIAL AND METHODS: This report considers the results of 680 simple lumbar discectomies and 80 repeated surgeries resulting from failed lumbar operations. Among both groups an important reduction of the postoperative fibrosis incidence was observed. All patients were operated by the same surgeons, using the same surgical technique (open technique) and the same implanted materials. A Gore's antifibrotic spinal membrane was applied in all patients. RESULTS: Among the 680 patients who underwent a simple lumbar discectomy, 98% experienced clinical improvement, while in the group of patients who were reoperated after a failed lumbar surgery the recovery index was 92%. The incidence of postoperative fibrosis in both groups was 0.58% and 2.5%, respectively. DISCUSSION: As compared to the postoperative fibrosis reported worldwide (2-18%) we believe this material has a great influence in the healing process.

Schmerz. 2009 Jul 9; Tlach L, Hampel PBACKGROUND: The aim of this study was to investigate the criterion validity of the Mainz Pain Staging System (MPSS), considering the four axes of the MPSS separately. METHODS AND DESIGN: Psychological and pain-related impairments were analysed depending on the stage of axis (I, II, III) for each single axis of the MPSS in a consecutive sample of 280 patients with chronic low back pain in orthopaedic inpatient rehabilitation. In addition, the distribution of frequency of clinically significant symptoms in depression, anxiety and somatisation were examined depending on the stage of axis. RESULTS: For all axes, an increasing stage was associated with greater psychological and pain-related impairments. Particularly patients assigned to stage III on axis 1 (temporal aspects) and 2 (spatial aspects) and patients assigned to stage II on axis 3 (drug intake) and 4 (utilisation of the health care system) showed enhanced psychosocial impairments and more frequently had clinically relevant symptoms in psychological variables. CONCLUSION: Findings confirm the criterion validity of the MPSS for chronic low back pain. In addition, results support the significance of psychosocial factors for the further development of chronicity.

Ergonomics. 2009 Jul 13; 1-7McGill SM, Fenwick CMProlonged sitting with spine flexion has been linked to low back disorders. A variety of mechanisms account for this based on biomechanical and neurological variables. Airline seats typically cause pronounced lumbar flexion due to their hollowed seat back design. A pneumatic support, placed between the seat back and the lumbar spine, was tested to see if lumbar flexion was reduced. Results showed that when the seats were positioned in the upright position, 15 of 20 participants experienced reduced lumbar flexion (by 15 degrees on average) with the support. The study was repeated on the five non-responders with the seatback set in the reclined position. This resulted in another four experiencing less lumbar flexion. Since seated flexion is associated with disc stress, reducing flexion with the support reduced lumbar stress. Spine flexion that results from prolonged sitting is associated with disc stress and pain. The pneumatic support tested here reduced spine flexion. While it is not known why airline seats are designed with no lumbar support, which causes excessive lumbar flexion while seated, the pneumatic support corrected this deficit. Reclining the seatback enhanced this effect.

J Spinal Cord Med. 2009; 32(2): 191-7Singh PK, Singh VK, Azam A, Gupta SBACKGROUND/OBJECTIVE: Tarlov cysts or spinal perineurial cysts are uncommon lesions. These are mostly incidental findings on magnetic resonance imaging or myelograms. The objectives of this study were to describe Tarlov cysts of the sacral region as a potential cause for retrograde ejaculations and review available management options. METHODS: Case report and literature review. RESULTS: A 28-year-old man presented with back pain and retrograde ejaculations resulting in infertility. After microsurgical excision of large perineurial cysts, back pain resolved, but semen quality showed only marginal improvement. Later, the couple successfully conceived by intrauterine insemination. To the best of our knowledge, this is the first reported case of Tarlov cyst associated with retrograde ejaculation and infertility. CONCLUSIONS: Despite being mostly asymptomatic and an incidental finding, Tarlov cyst is an important clinical entity because of its tendency to increase in size with time. Tarlov cysts of the sacral and cauda equina region may be a rare underlying cause in otherwise unexplained retrograde ejaculations and infertility. Microsurgical excision may be a good option in a select group of patients.

Zhonghua Wai Ke Za Zhi. 2009 Feb 1; 47(3): 194-6Xu ZW, Zhuang QS, Wang BW, Sui GX, Li F, Liu WQ, Ji XBOBJECTIVE: To evaluate the biomechanical and clinical effect of the treatment of thoracolumbar fracture with monosegmental pedicle instrumention in the fracture vertebrae by endplant method. METHODS: Twenty-four porcine thoracolumbal spinal model, divided into four groups randomly, compared the stability of these four groups through pull-out testing. Retrospective study of 49 patients with thoracolumbar fracture who were treatmented with this technique, to observe the fusion of bone graft, the height of the anterior and posterior range, the angle of kyphosis and the volume of spinal canal, the loss of rectification, low back pain, and the limitation of activity of lumbar. RESULTS: The endplant method group is more stability than the parallel method group, and the pedicle screw in the fracture vertebrae can get enough stability. After operation all 49 cases achieved satisfactory reduction, strong bone fusion, no reduction loss, no refractoriness low back pain, limitation of motion of lumbar et al. CONCLUSION: Monosegmental pedicle instrumention by endplant method in the fracture vertebrae for thoracolumbar fracture can get enough extraction stability, and get satisfied clinical effect.

Zhonghua Wai Ke Za Zhi. 2009 May 1; 47(9): 689-92Wang ZX, Hu YGOBJECTIVE: To explore the prevalence, distribution and clinical significance of high-intensity zone (HIZ) in anterior annulus fibrosus (AF) in comparison with HIZ in posterior AF of lumbar disc. METHODS: According to the diagnosis and location of HIZ, 610 lumbar magnetic resonance images with entire clinical materials were divided into control group (without HIZ), anterior AF group (HIZ), posterior AF group (HIZ) and anterior & posterior (AP) AF group (HIZ). The incidence of HIZ was summarized. The clinical data, such as male/female ratio, age, and body weight, prevalence of low back pain (LBP) and distribution of HIZ, were compared and analyzed between the groups. RESULTS: Three hundred and fifteen cases shown no HIZ (51.6%), 95 cases presented HIZ in anterior AF (15.6%, 119 discs), 159 cases presented HIZ in posterior AF (26.1%, 189 discs) and 41 cases presented HIZs in both anterior and posterior AF (6.7%, 96 discs). There was significant difference between the prevalence of HIZ in anterior AF and that in posterior AF (P < 0.01). The male/female ratio and body weight of each groups showed no difference (P > 0.05), and the age was proved to be statistically different between four groups (P < 0.01, control group < posterior AF group < AP AF group < anterior AF group). HIZs in anterior AF often occurred at L(1,2)-L(4,5), whereas, they usually developed at L(3,4)-L(5)S(1) in posterior AF. The incidence of LBP in control group, anterior AF group, posterior AF group, AP AF group were 40.0%, 52.6%, 55.4% and 65.8%, respectively. The LBP prevalence of control group was lower than that of other three groups (P < 0.05), and the prevalence of last three groups showed no difference (P > 0.05). CONCLUSIONS: Compared with HIZ in posterior AF, the HIZ in anterior AF of lumbar disc has a lower prevalence, often develops in elder patients and in upper motion segments. It also indicates an obvious relation to LBP as the former.

J Korean Neurosurg Soc. 2009 Jun; 45(6): 378-80Kim HW, Song JW, Kwon A, Kim IHOsteoporotic patients who undergo percutaneous vertebroplasty (PVP) have the risk of a repeated collapse of their adjacent vertebral body due to alteration of load transfer into the adjacent vertebral body. The authors have experienced a rare case of repeated osteoporotic vertebral compression fractures (VCF) resulting in extreme multi-level PVP. A 74-year-old female developed severe back pain after slipping down one month ago. Her X-ray and MR images indicated a T11 VCF. She underwent successful PVP with polymethylmethacrylate (PMMA). Two weeks later, she returned to our hospital due to a similar back pain. Repeated X-ray and MR images showed an adjacent VCF on T12. A retrial of PVP was performed on T12, which provided immediate pain relief. Since then, repeated collapses of the vertebral body occurred 12 times in 13 levels within a 24-month period. Each time the woman was admitted to our hospital, she was diagnosed of newly developed VCFs and underwent repeated PVPs with PMMA, which finally eased back pain. Based on our experience with this patient, repeated multiple PVP is not dangerous because its few and minor complications. Therefore, repeated PVP can serve as an effective treatment modality for extreme-multi level VCFs.

J Sport Rehabil. 2009 May; 18(2): 269-82da Fonseca JL, Magini M, de Freitas THObjective: To evaluate the influence of pain on vertical ground-reaction force (VGRF) in patients with low back problems and the effect of the Pilates method on the gait of these patients. Design: A single-blind randomized controlled trial. Participants: 28 individuals assigned to a control group (n = 11) and a low-back group (n = 17), the latter of which was subdivided into a Pilates group (n = 8) and a no-Pilates group (n = 9). Intervention: The Pilates group undertook 15 sessions of Pilates. Main Outcome Measures: The VGRF parameters were recorded during preferred and faster walking speeds. The data were collected before and after the intervention. Results: The weight-acceptance rate and push-off rate were significantly less in the right lower limb of low-back group than of the control group at preferred speed. Improvements were seen in the Pilates group postintervention, with increased middle-support force for the left lower limb at faster walking speed and decreased pain; this did not occur in the no-Pilates group. Conclusions: These results suggest that patients with low back pain use strategies to attenuate the amount of force imposed on their body. The Pilates method can improve weight discharge in gait and reduce pain compared with no intervention.

J Rehabil Med. 2009 Jul; 41(8): 620-5Meyer K, Tschopp A, Sprott H, Mannion AFBACKGROUND: Catastrophizing plays an important role in models of pain chronicity, showing a consistent correlation with both pain intensity and disability. It is conceivable that these associations are mediated or confounded by other psychological attributes. OBJECTIVE: To examine the relative influence of catastrophizing and other psychological variables on pain and disability in patients with chronic low back pain. METHODS: Seventy-eight patients completed the Pain Catastrophizing Scale, Roland Morris Disability Questionnaire, Fear-Avoidance Beliefs Questionnaire (work/activity), Modified Somatic Perception Questionnaire, Modified Zung Depression Scale, and Pain Intensity scale. RESULTS: Catastrophizing was significantly correlated with both Pain intensity and Roland and Morris Disability, and with all other psychological variables (all p < 0.001). However, multiple regression analyses showed that Catastrophizing explained no significant variance in Pain intensity beyond that explained by the unique contributions of Modified Somatic Perception and Fear-Avoidance Beliefs (work) and explained no further variance in Disability beyond that explained by the unique contributions of Fear-Avoidance Beliefs (work) and Depression. CONCLUSION: These findings are consistent with previous models proposing that negative psychological attributes are associated with greater perceptions of pain and disability. Nonetheless, our study indicates that measures of catastrophizing show notable measurement overlap in multivariate models.

Reg Anesth Pain Med. 2009 Jul-Aug; 34(4): 340-2Rauch S, Kasuya Y, Turan A, Neamtu A, Vinayakan A, Sessler DIBACKGROUND AND OBJECTIVES: Obesity is a major risk factor for lower back pain. Fluoroscope-guided medial branch block is a common diagnostic tool in these patients. Although approach to the facet joint guided by ultrasound has been demonstrated successfully in lean patients, its success in obese patients is unknown.We therefore evaluated the success rate of real-time ultrasound approach in obese patients in a clinical feasibility study. METHODS: We performed a total of 84 medial branch blocks in 20 obese patients (body mass index, >30 kg/m2) using ultrasound. We studied the success rate, measured depth to the facet joint, and assessed radiation dose and pain relief. RESULTS: Our success rate was 62% (52/84 blocks) when using ultrasound to guide needle placement. The average distance from skin to target point at the transverse process was 76 mm (SD, 15 mm). Skin-target depth was significantly different between L4 and L5 on both sides (P = 0.01). The needle advancement could not be tracked to the target. The verbal rating scale scores before, immediately after, and 24 hrs after the procedure were 7.1 (SD, 2.4), 4.3 (SD, 3.1), and 3.8 (SD, 2.7), respectively. The average radiation dose was 0.226 mGy/m2 (SD, 0.196 mGy/m2). CONCLUSION: Medial branch blocks in obese patients cannot be performed by ultrasound guidance exclusively.

Eur Spine J. 2009 Jun 30; Heitz CA, Hilfiker R, Bachmann LM, Joronen H, Lorenz T, Uebelhart D, Klipstein A, Brunner FThe objective of the study was to provide an inventory of predictive instruments and their constituting parameters associated with return to work in patients with subacute (2-10 weeks pain duration) and chronic (10-24 weeks pain duration) non-specific low back pain (NSLBP). Data sources included systematic review in Medline, Embase, Cinahl, Central, PEDro, Psyndex, PsychInfo/PsycLit, and Sociofile up to September 2008, in reference lists of systematic reviews on risk factors, and of included studies. For the systematic review, two reviewers independently assessed study eligibility and quality, and extracted data. Disagreements were resolved by consensus. Risk factors were inventorised and grouped into a somatic and psychosocial domain. 23 studies reporting on subacute and 16 studies reporting on chronic patients were included. The studies on subacute patients reported on a total of 56 biomedical factors out of which 35 (63%) were modifiable and 61 psychosocial factors out of which 51 (84%) were modifiable. The corresponding values in studies on chronic patients were 44 biomedical [27 (62%) modifiable] and 61 [40 (66%) modifiable] respectively. Our data suggest that the interdisciplinary approach in patients at risk to develop persistent NSLBP is justified in both, the subacute and chronic disease stages. Psychosocial interventions might be more effective in subacute stages since a higher proportion of modifiable risk factors were identified in that group.

J Korean Neurosurg Soc. 2009 Jun; 45(6): 369-74Lim BS, Chang UK, Youn SMOBJECTIVE: Percutaneous vertebroplasty (VP) can provide immediate stabilization in pathologic fractures of spinal tumors. However, long term follow-up data in cases of pathologic fractures are lacking. The authors report follow-up results of VP in 185 pathologic fractures of 102 spinal tumor patients. METHODS: Percutaneous VP was performed at 185 vertebral bodies of 102 patients from 2001 to 2007. Retrospective analysis was done with medical records and radiological data. The change of visual analogue score (VAS), vertebral body (VB) height and kyphotic angle were measured preoperatively and on postoperative one day and at 3, 6, and 12 months. RESULTS: The patients were composed of metastatic spine tumors (81%) and multiple myeloma (19%). Involved spinal segments were between T6 and L5. Mean follow-up period was 12.2 months. VAS for back pain was 8.24 preoperatively, 3.59 (postoperative one day), 4.08 (three months) and 5.22 (one year). VB compression ratio changed from 21.33% preoperatively to 13.82% (postoperative one day), 14.36% (three month), and 16.04% (one year). Kyphotic angle changed from 15.35 degrees preoperatively to 12.03 degrees (postoperative one day), 13.64 degrees (three month), and 15.61 degrees (one year). CONCLUSION: Immediate pain relief was definite after VP in pathologic compression fracture of osteolytic spinal disease. Although VAS was slightly increased on one year follow-up, VP effect was maintained without significant change. These results indicate that VP could be a safe and effective procedure as a palliative treatment of the spinal tumor patients.

Med Sci Sports Exerc. 2009 Jun 30; Marshall PW, McKee AD, Murphy BAPURPOSE:: To examine differences between subjects with and without functional ankle instability (FAI) for measures of trunk and ankle stability. METHODS:: Twelve healthy individuals and 12 individuals with FAI participated. Subjects were assessed for self-rated disability, time to stabilization (TTS), and muscle reflex responses to sudden trunk perturbation. TTS results were calculated using an unbounded third-order polynomial. Trunk reflexes to a sudden unloading task were tested during flexion and extension movements. Loads were 65 N for males and 40 N for females. ANOVA procedures were used to compare TTS times, latency times, and trunk displacement data between groups. Regression analyses were used to determine the relationship between TTS and trunk latency times. RESULTS:: Subjects with FAI had worse perceptions of their ankle disability but had the same vertical jump height. TTS times were delayed in the FAI group (6.0 +/- 2.8 vs 2.9 +/- 1.0 s; F(1,22) = 12.7, P = 0.002). Trunk muscle onsets were delayed in FAI subjects in both flexion (F(1,22) = 7.6, P = 0.01) and extension (F(1,22) = 4.5, P = 0.04). Regression and analysis identified x-axis TTS times as significantly associated with extension latency times (r = 0.19, P = 0.043). CONCLUSIONS:: This study has provided evidence for proximal nervous system adaptations associated with FAI. Delayed trunk reflexes have been shown to predispose individuals to developing low back pain. A cause or effect relationship between trunk and ankle instability has not been established here.

Ergonomics. 2009 Jul; 52(7): 830-9Kingma I, van Dieën JHThe aim of this study was to test the effect of a movable backrest on vibration transmission through the trunk during driving and on the physiological consequences thereof. Eleven healthy male subjects drove for about 1 h on normal roads with a movable and with a fixed backrest while surface electromyography (EMG) was measured at the level of the fifth lumbar vertebra (L5) and vertical accelerations were measured at the seat, backrest and at the spine at the levels of the second sacral vertebra (S2) and seventh cervical vertebra (C7). The movable backrest significantly reduced accelerations at C7 by up to 11.9% at the 5 Hz frequency band. The movable backrest also significantly reduced the coherence and transmission between S2 and C7 accelerations, but not the differential motion between these sensors. EMG at both sides of L5 was on average 28% lower when using the movable backrest. Spinal shrinkage was unaffected by backrest type. It is concluded that a movable backrest reduces the transmission of vibration through the trunk and that it reduces low back EMG. Car driving is associated with the risk of developing low back pain and this may be related to exposure to whole body vibration. This study found an effect of a simple ergonomics measure on the transmission of vibration through the trunk as well as on back muscle activation.

Spinal Cord. 2009 Jul 7; Tavares IR, Franzoi AC, Araújo AQStudy design:Cross-sectional.Objectives:To describe characteristics of low-back pain in human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) patients and to identify its neuropathic and/or non-neuropathic pain components.Setting:A reference center for the care of patients with HAM/TSP in Rio de Janeiro, Brazil.Methods:A total of 90 patients with HAM/TSP referred by tertiary care centers were consecutively assessed. The patients were submitted to a clinical protocol that included Visual Analogue Scale (VAS), Timed Up and Go Test, Bodily Pain Domain of the Short Form 36 Health Status Questionnaire, Douleur Neuropathique 4 Questions (Neuropathic Pain 4 Questions) (DN4) and McGill Pain Questionnaire.Results:The prevalence of low-back pain in the studied sample was 75.5%; pain interferes with physical functioning and worsens with movement and physical effort. It can be relieved by analgesics and rest. Average pain intensity was 51.2 mm on VAS and 1.72 on DN4. The most frequent words used to describe low-back pain were throbbing, burning, jumping and aching. Surprisingly, 32.4% patients pointed the lower extremities as the most painful and used different descriptors. The most common drugs used were analgesics, nonsteroidal anti-inflammatory drugs and tricyclic antidepressants.Conclusions:Low-back pain in HAM/TSP patients has mainly nociceptive characteristics. Conversely, descriptors for lower extremities pain suggest a neuropathic origin.Spinal Cord advance online publication, 7 July 2009; doi:10.1038/sc.2009.83.

Phys Ther. 2009 Jul 16; George SZ, Valencia C, Zeppieri G, Robinson MEBackground Self-report measures for assessing specific fear of activities have not been reported in the peer-reviewed literature, but are necessary to adequately test treatment hypotheses related to fear-avoidance models. Objective This study described psychomotor properties of a novel self-report measure, the Fear of Daily Activities Questionnaire (FDAQ). Design A prospective cohort design was used. METHODS:/b> Reliability and validity cohorts were recruited from outpatient physical therapy clinics. Analyses for the reliability cohort included internal consistency and 48-hour test-retest coefficients, as well as standard error of measurement and minimal detectable change estimates. Analyses for the validity cohort included factor analysis for construct validity and correlation and multiple regression analyses for concurrent and predictive validity. Four-week responsiveness was assessed by paired t test, effect size calculation, and percentage of patients meeting or achieving MDC criterion. RESULTS: /b> The FDAQ demonstrated adequate internal consistency (Cronbach alpha=.91, 95% confidence interval=.87-.95) and 48-hour test-retest properties (intraclass correlation coefficient=.90, 95% confidence interval=.82-.94). The standard error of measurement for the FDAQ was 6.6, resulting in a minimal detectable change of 12.9. Factor analysis suggested a 2- or 3-factor solution consisting of loaded spine, postural, and spinal movement factors. The FDAQ demonstrated concurrent validity by contributing variance to disability (baseline and 4 weeks) and physical impairment (baseline) scores. In predictive validity analyses, baseline FDAQ scores did not contribute variance to 4-week disability and physical impairment scores, but changes in FDAQ scores were associated with changes in disability. The FDAQ scores significantly decreased over a 4-week treatment period, with an effect size of .86 and 55% of participants meeting the minimal detectable change criterion. Limitations The validity cohort was a secondary analysis of a clinical trial, and additional research is needed to confirm these findings in other samples. CONCLUSIONS:/b> The FDAQ is a potentially viable measure for fear of specific activities in physical therapy settings. These analyses suggest the FDAQ may be appropriate for determining graded exposure treatment plans and monitoring changes in fear levels, but is not appropriate as a screening tool.

J Neurosurg Pediatr. 2009 Jul; 4(1): 28-36Al-Holou WN, Muraszko KM, Garton HJ, Buchman SR, Maher COObject After primary repair of a myelomeningocele or a lipomyelomeningocele, patients can present with symptoms of secondary tethered cord syndrome (TCS). After surgical untethering, a small percentage of these patients can present with multiple repeat TCS. In patients presenting with secondary or multiple repeat TCS, the role as well the expected outcomes of surgical untethering are not well defined. Methods Eighty-four patients who underwent spinal cord untethering after at least 1 primary repair were retrospectively evaluated using scaled and subjective outcome measures at short-term and long-term follow-up visits. Outcomes were analyzed for predictive measures using multivariate logistic regression. Results Surgical untethering was performed in 66 patients with myelomeningoceles and 18 patients with lipomyelomeningoceles. Fourteen patients underwent multiple repeat spinal cord untethering. Patients were followed up for an average of 6.2 years. Most patients had stability of function postoperatively. Motor function and weakness improved in 7 and 16% of patients at 6 months, respectively, and 6 and 19% of patients at long-term follow-up evaluation, respectively. Of the patients who presented with back pain, 75% had improvement in symptoms at 6 months postoperatively. Younger age at untethering was significantly associated with worse long-term neurological outcomes. The number of previous untethering procedures, original diagnosis, sex, anatomical level, and degree of untethering had no effect on surgical outcomes. Conclusions Patients presenting with secondary or multiple repeat TCS may benefit from surgical untethering.

Spine. 2009 Jul 1; 34(15): E513-8Sakkas LI, Davas EM, Kapsalaki E, Boulbou M, Makaritsis K, Alexiou I, Tsikrikas T, Stathakis NSTUDY DESIGN: We retrospectively analyzed spinal infection (SpI), in a teaching Hospital, in Central Greece. OBJECTIVE: To study presentation, etiology, and outcome of SpI in Central Greece. SUMMARY OF BACKGROUND DATA: SpI most frequently involves the intervertebral disc and adjacent vertebral bodies and can cause neurologic impairment. METHODS: Thirty three patients (23 men; age [mean +/- standard deviation], 60.6 +/- 11.3 years; disease duration, 44.5 [+/-54.7] days) hospitalized with SpI between January 2000 and December 2007 were included in the study. All patients had magnetic resonance imaging of the spine. RESULTS: Nineteen patients had pyogenic SpI (57.6%) and 14 patients had granulomatous SpI, 11 due to Brucella spp (34.4%), 3 due to Mycobacterium tuberculosis (9.4%). Staphylococcus aureus was the most frequent cause of pyogenic SpI, and spondylodiscitis (SpD) was the most frequent localization. Epidural entension was found in 8 of 17 pyogenic SpD and in 2 of 11 brucellar SpD patients. Subdural extension was detected in 3 patients with pyogenic SpD. Blood cultures were positive in 17 of 19 patients with pyogenic SpI. Two patients had concomitant endocarditis (staphylococcal 1, enterococcal 1). The most common associated disease was diabetes mellitus. All but 2 patients received medical treatment alone. Two patients died of uncontrollable sepsis. CONCLUSION: Back pain in presence of fever, constitutional symptoms, and/or high inflammation markers should alert physicians for spinal infection. In endemic areas, Brucella is a frequent cause of SpI.

Spine J. 2009 Jun 30; Mohseni-Bandpei MA, Fakhri M, Ahmad-Shirvani M, Bagheri-Nessami M, Khalilian AR, Shayesteh-Azar M, Mohseni-Bandpei HBACKGROUND: Low back pain (LBP) is a common and costly problem in pregnancy. It is one of the main reasons for disability, absence from work, and responsible for huge direct and indirect economical impact. PURPOSE: The purpose of this study was to determine the prevalence and risk factors of LBP during pregnancy. STUDY DESIGN: A cross-sectional study was carried out on Iranian pregnant women. PATIENT SAMPLE: Eleven hundred randomly selected pregnant women. OUTCOME MEASURES: A structured questionnaire including demographic, lifestyle, as well as prevalence and characteristics of LBP was used. Visual Analog Scale and Oswestry low back disability questionnaires were also used to assess the pain intensity and functional disability, respectively. METHODS: After ethical approval from Medical Ethics Board at the Mazandaran University of Medical Sciences and Health Services, a cross-sectional study was conducted on 1,100 pregnant women from 18 health centers in Sari district, at northern Iran. RESULTS: Point, last-month, last 6-month, last-year, and lifetime prevalence of LBP were 40.2%, 55.9%, 59.4%, 76.2%, and 84.1%, respectively. Prolonged standing and rest were found to be the most significant aggravating and relieving factors (76.3% and 87.7%, respectively). LBP was significantly correlated with history of previous LBP and LBP in previous pregnancy (p=.000 in both cases). CONCLUSION: The prevalence of LBP in pregnant women appears to be high and future research should focus on different preventive strategies during pregnancy.

Clin J Pain. 2009 May; 25(4): 334-9Witt CM, Lüdtke R, Baur R, Willich SNOBJECTIVES: To evaluate the details and effects of an individualized homeopathic treatment in patients with chronic low back pain in usual care. METHODS: Prospective multicenter observational study. Consecutive patients beginning homeopathic treatment in primary care practices were evaluated over 2 years by using standardized questionnaires. Diagnoses (ICD-9) and symptoms with severity, health-related quality of life (QoL), medical history, consultations, homeopathic and conventional treatments, and other health service use were recorded. RESULTS: One hundred twenty-nine adults (64.3% women, mean age 43.6 +/- 12.7 y) were treated by 48 physicians. The patients mainly had chronic low back pain (average duration 9.6 +/- 9.0 y) and other chronic diseases. Nearly all the patients (91.3%) had been pretreated. The initial case-taking took 113 +/- 36, and the case analysis took 31 +/- 38 minutes. The 7.4 +/- 8.1 subsequent consultations (duration: 23.7 +/- 15.2 min) cumulated to 204.5 +/- 184.6 minutes. The patients received an average of 6.8 +/- 6.3 homeopathic prescriptions. The severity of the diagnoses and complaints showed marked and sustained improvements with large effect sizes (Cohen's d from 1.67 to 2.55) and QoL improved accordingly (SF-36 physical component scale d = 0.33; mental component scale d = 0.54). The use of conventional treatment and health services decreased markedly: the number of patients using low back pain-related drugs was half of the baseline. DISCUSSION: Classic homeopathic treatment represents an effective treatment for low back pain and other diagnoses. It improves health-related QoL and reduces the use of other healthcare services.

Zhonghua Wai Ke Za Zhi. 2009 Mar 1; 47(5): 326-8Jiang KR, Miao Y, Xu ZK, Qian ZY, Dai CC, Xie L, Wu JL, Li Q, Xi CH, Guo F, Chen JM, Gao WT, Liu XLOBJECTIVE: To evaluate the methods of diagnosis and surgical treatment for nonfunctional islet cell tumor (NICT). METHODS: Forty-four patients with non-functional islet cell tumor treated at the First Affiliated Hospital of Nanjing Medical University during January 1968 to June 2008 were analyzed retrospectively. There were 9 males and 35 females, aged from 7- to 70-years-old. Clinical manifestation: 15 cases (34.1%) of abdominal masses, 17 patients (38.6%) with epigastric or back pain, 5 cases of juandice, 5 cases (11.4%) for upper abdominal fullness or vomiting, 10 cases (22.7%) of pancreatic tumor noticed by routine health checkups or imaging examinations. Imaging examination: CT scan, sonography, ERCP, MRI, upper GI series were performed in 33 (75.0%), 16 (36.4%), 6 (13.6%), 2 (4.5%), and 10 cases (22.7%) respectively. Operation methods: 39 patients (88.6%) underwent surgical resection and the other 5 patients did not. RESULTS: Complications: pancreatic fistula in 7 patients (15.9%), intra-abdominal bleeding in 4 (9.1%), gastrojejunal anastomosis outlet obstruction in 1 (2.3%), biliary fistula in 2 (4.5%) and incisional infection in 3 (6.8%). Surgery related mortality happened in 2 patients (4.5%), both treated before 1999. Twenty-five patients underwent operation between January 1999 and June 2008 were followed up for 6 to 108 months. All survive except one died 75 months after the surgery for unknown reason. CONCLUSIONS: No specific clinical manifestation is recognized for non-functional islet cell tumor. Spiral CT is an optimal diagnostic method, while surgery is the first choice for treatment. Middle segmental pancreatectomy has become an alternative surgical protocol for NICT.

Zhonghua Yi Xue Za Zhi. 2009 May 5; 89(17): 1166-70Sun ZM, Zhao D, Deng SC, Zhao HYOBJECTIVE: To investigate the clinical and radiographic outcomes for varying degrees of degenerative lumbar scoliosis using different surgical options with a minimal 5-year follow-up. METHODS: From May 1998 to November 2002, 31 patients with degenerative lumbar scoliosis underwent operations at our hospital. The mean age of 19 females and 12 males was 55.8 years old (range: 45 to 71). All patients were divided into 4 groups: Group A, mild coronal deformity with obvious sagittal deformity, 13 cases; Group B, obvious coronal deformity with mild sagittal deformity; Group C, both significant coronal and sagittal deformities; Group D, both mild coronal and sagittal deformities. Posterior decompression, internal fixation and bone graft fusion were performed in Groups A, B and C. And posterior decompression was performed in Group D. All patients were followed up for at least 5 years. Patients answered the Oswestry low back pain disability questionnaire at pre-operation, and 1 year, 5 year post-operation. RESULTS: Thirty patients were followed up for the whole process. According to Cobb's angle methods, there was great post-operative improvement for patients with internal fixation (Groups A, B, C) while there was no significant difference for patients with posterior decompression at pre-and post-operation. After surgery, the average Oswestry Disability Index score in the patients with internal fixation (Groups A, B, C) was significantly lower than the preoperative score (25.8 vs 58.0; P < 0.001). However there was statistical difference for patients with internal fixation between 1 year and 5 year postoperatively. No perioperative death or major medical complications occurred. Ten patients had adjacent segment degeneration. CONCLUSIONS: The surgical aim for adults with a spinal deformity is to achieve a stable, balanced and pain-free spine. Surgical treatments should consist of decompression and fusion with segmental instrumentation to avoid instability and curb progression. Despite the complexity of adult lumbar degenerative scoliosis, it might improve the quality of life for patients by choosing an appropriate operation option on the basis of varying degrees of lumbar deformity.

Am J Dermatopathol. 2009 Jun 27; Fernando SL, Henderson CJ, O'Connor KSDrug-induced hypersensitivity syndrome (DIHS) is a rare and potentially fatal reaction characterized by fever, rash, and internal organ involvement that typically occurs between 3 and 6 weeks after commencing the drug. We describe such a case in a 26-year-old woman, who developed fever, exfoliative erythroderma, facial edema, cervical lymphadenopathy, hepatitis, and leukocytosis 6 weeks after commencing carbamazepine for lower back pain. Her serum angiotensin-converting enzyme level was also raised to 144 U/L (8-52 U/L). Skin biopsies demonstrated an unusual superficial dermal perivascular inflammatory infiltrate, which included conspicuous granulomas mixed with moderate numbers of lymphocytes. Eosinophils were not a feature. Her carbamazepine was withdrawn, and oral prednisone was commenced initially at a dose of 1 mg.kg.d and slowly weaned over a 6-week period. Her fever, rash, facial edema, and hepatitis gradually resolved within this period, and her serum angiotensin-converting enzyme level returned to within the normal range. Although the patient's clinical course was consistent with a DIHS, it was accompanied by a previously unreported finding of a superficial granulomatous dermatitis. Granuloma formation as a sequel to medication use is a feature of interstitial granulomatous drug reaction. However, interstitial granulomatous drug reaction consists of localized violaceous plaques with a predilection for skin fold areas and liver function abnormalities have not been described. Granulomatous inflammation in other organ systems, including the liver and kidney, has also been described after the use of carbamazepine, but these reactions are not associated with the systemic manifestations observed in DIHS.

Eur J Pain. 2009 Jun 29; Schulte E, Hermann K, Berghöfer A, Hagmeister H, Schuh-Hofer S, Schenk M, Kopf A, Vilain M, Martus P, Willich SN, Boemke WThis paper presents the results of a prospective observational cohort study investigating referral practices to six specialized pain centres (SPCs) in 303 patients with headache (HD), low back pain (LBP), and neuropathic pain (NP). The study was divided into three parts. Part 1: The pain health care history (contacts with general practitioners and specialists, further referrals, time spans, therapies) before first contact with the SPC. Part 2: Reality of pain therapy and management in the SPC (patients' attrition, interdisciplinarity of therapy and novel therapeutic strategies instigated). Part 3: Follow-up and assessment of pain levels (NRS, SES), disability scores (PDI), QoL scores (SF 12), and anxiety and depression scores (HADS) at 0, 6 and 12 months. Using an ordinal linear regression model, factors predicting a good treatment outcome were identified. On average it took 3 years of pain symptoms before first consultation with GP. The median time period from the first pain sensations until the appointment in the SPC was 12 years. Nearly half of the referrals to specialists or SPCs were initiated by a non-professional. In the SPC the medication was changed in 71% of cases. Care was interdisciplinary in only 32%. At 6 and 12 months after the first contact with the SPC, only 20% of the patients had improved with respect to levels of pain and psychometric data. A high degree of chronicity, a history of pain-associated surgeries and low social support were negative predictors for treatment outcome.

Neurosurgery. 2009 Jul; 65(1): E216-7; discussion E217Sridharan A, Heilman CBOBJECTIVE: We present a case of syringomyelia attributed to a transverse thoracic arachnoid web at T4. The cerebrospinal fluid pressure caudal to the web was higher than the cerebrospinal fluid pressure rostral to the web, causing a syrinx in the thoracic and cervical spinal cord above the web. CLINICAL PRESENTATION: A 43-year-old man presented with numbness and a burning pain in his left upper back and extremities. Magnetic resonance imaging showed a cervical-thoracic syrinx that terminated relatively abruptly at T4. Because of the abrupt termination of the syrinx at T4 and the slight ventral displacement of the spinal cord at this level, a dorsal arachnoid web was suspected. INTERVENTION: A T4 laminectomy was performed. Intraoperative ultrasound before opening of the thecal sac showed a pulsating transverse dorsal arachnoid web. The dura was opened and the web resected, thus widely communicating the dorsal subarachnoid space. The syrinx dramatically decreased in size and the patient's pain improved but did not resolve completely. CONCLUSION: In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. Surgical resection of a transverse thoracic arachnoid web with syringomyelia can result in resolution of the syringomyelia and improvement in neurological function. Syrinx formation in patients with these webs may occur in the area of the spinal cord where there is lower cerebrospinal fluid pressure, which may be either rostral or caudal to the arachnoid web. We evaluate this hypothesis by comparing our case with other published cases.

Neurosurgery. 2009 Jul; 65(1): 95-9; discussion 99Kim JS, Lee SH, Moon KH, Lee HYOBJECTIVE: This study was conducted to investigate the efficacy of treating central or paramedian disc herniations of the upper lumbar levels, including the thoracolumbar junction, through the oblique paraspinal approach. We published a technical case report on this subject in 2004. METHODS: Nineteen consecutive patients with intracanalicular disc herniations of the upper lumbar levels underwent the oblique paraspinal approach, which utilizes an operating microscope, from March 2005 through January 2008. Their clinical and radiological data were collected and analyzed. The patients were assessed with standard examinations preoperatively and evaluated with dynamic lumbar x-rays, 3-dimensional computed tomographic scans, magnetic resonance imaging, standard pain and disability measurements, a visual analogue scale, the Oswestry disability index, and a patient satisfaction rate that checked their pain scores postoperatively. RESULTS: The average follow-up period was 28.1 months, with a maximum of 48 months. The visual analogue scale for back and leg pain and the Oswestry disability index, which recorded a preoperative mean of 6.7%, 7.2%, and 64.7% and a postoperative mean of 3.2%, 3.0%, and 21.47%, respectively, showed statistically significant improvement at the time of the last follow-up evaluation, compared with preoperative scores. There have been neither recurrent disc herniations nor spinal instability during the follow-up period. CONCLUSION: In this study, 19 cases of intracanalicular disc herniations at the upper lumbar levels, including the thoracolumbar junction, were successfully excised with the oblique paraspinal approach without recurrence or instability. We found that the oblique paraspinal approach, which resulted in satisfactory clinical outcomes with few complications, could be one of the main surgical procedures used to treat intracanalicular disc herniations at the upper lumbar levels.

Medicine (Baltimore). 2009 Jul; 88(4): 193-201van Bommel EF, Jansen I, Hendriksz TR, Aarnoudse ALRetroperitoneal fibrosis (RPF) is a rare disorder of unknown etiology. Its incidence is unknown, and the insidious and nonspecific nature of symptoms may contribute to considerable diagnostic delay. We conducted the current study to assess the incidence and clinicoradiologic characteristics of idiopathic RPF. For this, we evaluated prospectively 53 consecutive patients with a diagnosis of idiopathic RPF at our tertiary care referral center from April 1998 through January 2008.Calculated annual incidence of RPF was 1.3/100,000 inhabitants. Mean age was 64 +/- 11.1 (SD) yr; male-female ratio was 3.3:1.0. Median duration of symptoms was 6.0 mo (IQR 3.0-12.0). Abdominal, flank, and/or back pain and discomfort were the major symptoms, with visual analogue scale scores of 49 +/- 27.2 mm and 43 +/- 29.4 mm for pain and discomfort, respectively. Female patients had higher erythrocyte sedimentation rate (ESR), higher white blood cell count, and lower hemoglobin content than male patients at presentation. Computed tomography-documented maximal mass thickness amounted to 35 +/- 16.6 mm; craniocaudal length amounted to 137 +/- 48.8 mm. RPF mass extension up to or above the level of the renal vessels was noted in 3 patients (6%). Six patients (11%) presented with atypical RPF localization and/or bulky mass. Localized lymphadenopathy adjacent to the RPF mass was observed frequently (25%). Patients with hydronephrosis (56%) presented earlier than patients without hydronephrosis, with higher creatinine and greater mass thickness but similar pain severity. Patients were typically at high cardiovascular risk with increased-often aneurysmal-infrarenal aortic diameter (25.0 mm, IQR 22.0-30.0). RPF mass distribution was similar in patients with or without aneurysmal dilation. Occupational asbestos exposure (20%) and asbestos-related pleural changes (17%) were frequent among males. Previous or concurrent chronic inflammatory disease and/or autoimmune disease was noted in 8 patients (15%). Multivariate analysis revealed an independent association of ESR values with severity of pain and discomfort. Smoking was independently associated with infrarenal aortic diameter.In summary, annual RPF incidence is higher than previously assumed. Age at diagnosis and male-female ratio seem to have changed over time. RPF typically affects patients at high cardiovascular risk, including increased aortic diameter. Clinical presentation is influenced by sex, severity of inflammation and presence of hydronephrosis. Prolonged asbestos exposure and asbestos-related pleural changes were frequent among males. Localized lymphadenopathy adjacent to the RPF mass occurs frequently and should not confuse RPF diagnosis.

Eur J Gen Pract. 2009 Jul 4; 1-6Werner EL, Cote PBackground: Low back pain (LBP) is a frequent diagnosis for sickness absence. The process of sick-listing is complex, and the doctor must integrate information from several levels in the decision. Objective: The aim of this paper is to describe the main determinants of sickness absence for LBP. Methods: We conducted a non-systematic search in Medline and personal files to identify determinants of sickness absence, and structured these into four levels of the sick-listing process. These levels are characteristics of 1) the sick-listed worker, 2) the sick-listing doctor, 3) the workplace, and 4) the cultural and economic conditions of the society. Results: Important characteristics of the sick-listed person seem to be poor mental health, including negative beliefs about LBP. Also, comorbidity and lack of coping abilities are found associated to sickness absence. The impact of the doctors' personal beliefs about LBP is not clear. Doctors in general seem to be frustrated by their gatekeeper role and the influence of other healthcare providers on the sick-listing decision. The workplace is an important factor in the sick-listing process, but the impact of physical working conditions is of less importance than social support, job control, and demands. On the society level, the economic awards in sickness absence and the general acceptance of being sick listed seem to be of importance for the individual's decision to claim sick leave. Conclusion: The sick-listing process for LBP is complex, and the determinants are mostly non-medical. It seems important to adopt a broad perspective of how a worker copes with pain and how these coping strategies interact with cultural, economic, and societal determinants of sickness certification.

J Orthop Sports Phys Ther. 2009 Jul; 39(7): 541-9Crowell MS, Gill NWSTUDY DESIGN: Resident's case problem. BACKGROUND: Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential. DIAGNOSIS: A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit. DISCUSSION: This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999.

J Neurosurg Spine. 2009 Jul; 11(1): 64-70Yagi M, Ninomiya K, Kihara M, Horiuchi YWhereas osteochondroma is a common benign bone tumor in adolescence, it is rarely observed in elderly patients. It is unknown why osteochondromas, which usually develop during skeletal growth, rarely develop in elderly patients. The authors report 3 cases of symptomatic spinal osteochondroma in elderly patients and discuss the possible reasons for the onset of the enlargement of osteochondromas in elderly patients. Clinical history, radiographs, MR images, and CT myelography studies were obtained in each patient and are described. A review of the relevant literature is also presented. In the first case, the cervical osteochondroma caused spinal canal compression and occipital nerve irritation. It was totally excised, which successfully relieved the pain and allowed the patient to return to normal neurological function. In the second case, total removal of the tumor was effective in alleviating clinical symptoms. In the last case, ablation of the articular facet joint partially relieved the patient's lower-back pain. In the first 2 cases, the patients suffered from psoriasis and associated psoriatic arthritis and in the last case, the patient suffered from HIV-associated psoriatic arthritis. The psoriatic arthritis was characterized as asymmetric chronic multiple-joint arthritis and was HLA B27 positive. The pathology of psoriatic arthritis was the accelerating bone turnover and ankylosis. Symptomatic osteochondroma of the spine in elderly patients is extremely rare since it typically develops during skeletal growth. In this report, the authors show that pathological accelerating bone turnover such as psoriatic arthritis may be a possible mechanism for the onset of the enlargement of osteochondromas in elderly patients. The age of the patients in this report suggests that growth of the osteochondroma continues after skeletal development.