ABSTRACT: Achtergrond. Oefenen is een veel voorgeschreven behandeling voor chronische lage-rugpijn, met een aangetoonde effectiviteit
voor verbetering van functie en werk.
Doel. Het doel van dit artikel is een overzicht te geven van verschillende sleutelelementen met betrekking tot veiligheid
en effectiviteit van het oefenen. Dit kan behandelaars helpen het nut ervan bij de behandeling van chronische rugpijn te begrijpen.
Onderzoeksopzet/kader. Op MEDLINE is een geautomatiseerde zoektocht door de literatuur uitgevoerd met behulp van de zoektermen:
‘exercise’, ‘fitness’, ‘back pain’, ‘backache’ en ‘rehabilitation’. Van de gevonden artikelen werden de samenvattingen gescand
en nuttige artikelen werden voor nadere beoordeling opgevraagd. Extra referenties werden verkregen uit onderzoeksartikelen
in het bezit van de auteurs en door het opnieuw bekijken van eerdere besprekingen van dit onderwerp. Deze laatste artikelen
werden nageplozen op gegevens die relevant waren voor de sleutelelementen van het oefenen die in dit artikel worden behandeld.
Resultaten. Er bestaat geen bewijs dat oefenen het risico van extra rugproblemen of arbeidsongeschiktheid vergroot voor mensen
met acute, subacute of chronische lage-rugpijn. De huidige medische literatuur lijkt er juist op te wijzen dat oefenen ofwel
een neutraal effect heeft of het risico van toekomstig rugletsel iets kan verminderen. Er zijn drie duidelijke doelstellingen
om oefenen aan patiënten met lage-rugpijn voor te schrijven. Het eerste en meest voor de hand liggende doel is het verbeteren
of doen verdwijnen van beperkingen in rugmobiliteit en -kracht en het verbeteren van de prestaties bij duuractiviteiten. Er
is zeer veel bewijs dat een meerderheid van patiënten met chronische lage-rugpijn dit doel kan bereiken. Het tweede doel van
oefenen is het verminderen van de intensiteit van rugpijn. In de meeste onderzoeken naar oefenen is na oefentherapie een globale
afname van rugpijnintensiteit waargenomen. Deze afname varieert van 10 tot 50 procent. Het derde doel van oefenen is de met
de rugpijn gepaard gaande beperkingen te verminderen door de patiënt minder gevoelig te maken voor angsten en zorgen, de houding
tegenover pijn te veranderen en de gemoedstoestand te verbeteren. De mechanismen waardoor oefenen dit doel kan bereiken, is
het onderwerp geweest van veel onderzoek.
Conclusies. Oefenen is veilig voor mensen met rugpijn, omdat het het risico van toekomstig rugletsel of arbeidsverzuim niet
vergroot. Er bestaat substantieel bewijs dat oefenen gebruikt kan worden als een therapeutisch middel om stoornissen in flexibiliteit
en kracht van de rug te verbeteren. Uit de meeste onderzoeken blijken globale pijnscores na oefenprogramma’s te verbeteren
en vaak blijkt dat oefenen aspecten op gebied van gedrag, cognitie, gemoedstoestand en beperkingen bij rugpijnsyndromen kan
ABSTRACT: To determine whether older adults (aged ≥ 60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (< 60).
Prospective longitudinal comparative cohort study.
Outpatient specialty spine clinic.
One hundred thirty-three consecutive patients with radicular pain and magnetic resonance-confirmed acute LDH (89 younger, 44 older).
Nonsurgical treatment customized for the individual patient.
Patient-reported disability on the Oswestry Disability Index (ODI), leg pain intensity, and back pain intensity were recorded at baseline and 1, 3, and 6 months. The primary outcome was the ODI change score at 6 months. Secondary longitudinal analyses examined rates of change over the follow-up period.
Older adults demonstrated improvements in ODI (range 0-100) and pain intensity (range 0-10) with nonsurgical treatment that were not significantly different from those seen in younger adults at 6 month follow-up, with or without adjustment for potential confounders. Adjusted mean improvement in older and younger adults were 31 versus 33 (P = .63) for ODI, 4.5 versus 4.5 (P = .99) for leg pain, and 2.4 versus 2.7 for back pain (P = .69). A greater amount of the total improvement in leg pain and back pain in older adults was noted in the first month of follow-up than in younger adults.
These preliminary findings suggest that the outcomes of LDH with nonsurgical treatment were not worse in older adults (≥ 60) than in younger adults (< 60). Future research is warranted to examine nonsurgical treatment for LDH in older adults.
Journal of the American Geriatrics Society 03/2011; 59(3):423-9. · 3.74 Impact Factor
ABSTRACT: Pain variability in acute LBP has received limited study. The objectives of this pilot study were to characterize fluctuations in pain during acute LBP, to determine whether self-reported 'flares' of pain represent discrete periods of increased pain intensity, and to examine whether the frequency of flares was associated with back-related disability outcomes.
We conducted a cohort study of acute LBP patients utilizing frequent serial assessments and Internet-based data collection. Adults with acute LBP (lasting ≤3 months) completed questionnaires at the time of seeking care, and at both 3-day and 1-week intervals, for 6 weeks. Back pain was measured using a numerical pain rating scale (NPRS), and disability was measured using the Oswestry Disability Index (ODI). A pain flare was defined as 'a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently'. We used mixed-effects linear regression to model longitudinal changes in pain intensity, and multivariate linear regression to model associations between flare frequency and disability outcomes.
42 of 47 participants (89%) reported pain flares, and the average number of discrete flare periods per patient was 3.5 over 6 weeks of follow-up. More than half of flares were less than 4 hours in duration, and about 75% of flares were less than one day in duration. A model with a quadratic trend for time best characterized improvements in pain. Pain decreased rapidly during the first 14 days after seeking care, and leveled off after about 28 days. Patients who reported a pain flare experienced an almost 3-point greater current NPRS than those not reporting a flare (mean difference [SD] 2.70 [0.11]; p < 0.0001). Higher flare frequency was independently associated with a higher final ODI score (ß [SE} 0.28 (0.08); p = 0.002).
Acute LBP is characterized by variability. Patients with acute LBP report multiple distinct flares of pain, which correspond to discrete increases in pain intensity. A higher flare frequency is associated with worse disability outcomes.
BMC Musculoskeletal Disorders 01/2011; 12:220. · 1.58 Impact Factor
ABSTRACT: Cross-sectional study with prospective recruitment. OBJECTIVE.: To determine the accuracy of the physical examination for the diagnosis of midlumbar nerve root impingement (L2, L3, or L4), low lumbar nerve root impingement (L5 or S1) and level-specific lumbar nerve root impingement on magnetic resonance imaging, using individual tests and combinations of tests.
The sensitivity and specificity of the physical examination for the localization of nerve root impingement has not been previously studied.
Sensitivities, specificities, and likelihood ratios (LRs) were calculated for the ability of individual tests and test combinations to predict the presence or absence of nerve root impingement at midlumbar, low lumbar, and specific nerve root levels.
LRs ≥5.0 indicate moderate to large changes from pre-test probability of nerve root impingement to post-test probability. For the diagnosis of midlumbar impingement, the femoral stretch test (FST), crossed FST, medial ankle pinprick sensation, and patellar reflex testing demonstrated LRs ≥5.0 (LR ∞). LRs ≥5.0 were observed with the combinations of FST and either patellar reflex testing (LR 7.0; 95% confidence interval [CI] 2.3-21) or the sit-to-stand test (LR ∞). For the diagnosis of low lumbar impingement, the Achilles reflex test demonstrated an LR ≥5.0 (LR 7.1; 95% CI 0.96-53); test combinations did not increase LRs. For the diagnosis of level-specific impingement, LRs ≥5.0 were observed for anterior thigh sensation at L2 (LR 13; 95% CI 1.8-87); FST at L3 (LR 5.7; 95% CI 2.3-4.4); patellar reflex testing (LR 7.7; 95% CI 1.7-35), medial ankle sensation (LR ∞), or crossed FST (LR 13; 95% CI 1.8-87) at L4; and hip abductor strength at L5 (LR 11; 95% CI 1.3-84). Test combinations increased LRs for level-specific root impingement at the L4 level only.
Individual physical examination tests may provide clinical information that substantially alters the likelihood that midlumbar impingement, low lumbar impingement, or level-specific impingement is present. Test combinations improve diagnostic accuracy for midlum-bar impingement.
Spine 01/2011; 36(1):63-73. · 2.08 Impact Factor
Spine Journal Meeting Abstracts. 09/2010;
ABSTRACT: No prior study has investigated the frequency of patient-identified inciting events in lumbar disc herniation (LDH) or their clinical significance.
To examine the clinical frequency of patient-identified inciting events in LDH, and to identify associations between the presence of inciting events and the severity of the clinical presentation.
Cross-sectional analysis of data from a cohort study with prospective recruitment, with retrospective data collection on inciting events. The setting was a hospital-based specialty spine clinic.
One hundred fifty-four adults with lumbosacral radicular pain and LDH confirmed by magnetic resonance imaging.
Self-report measures of disability measured by the Oswestry Disability Index (ODI), the visual analog scale (VAS) for leg pain, and the VAS for back pain.
Dependent variables included the presence of a patient-identified inciting event, which were categorized as spontaneous onset, nonlifting physical activity, heavy lifting (>35 lbs), light lifting (<35 lbs), nonexertional occurrence, or physical trauma. We examined the association of an inciting event, or a lifting-related event, with each outcome, first using univariate analyses, and second using multivariate modeling, accounting for important adjustment variables.
Sixty-two percent of LDH did not have a specific patient-identified event associated with onset of symptoms. Nonlifting activities were the most common inciting event, comprising 26% of all LDH. Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. Patient-identified inciting events were not significantly associated with a more severe clinical presentation in crude analyses. Spontaneous LDH was significantly associated with higher baseline ODI scores in multivariate analysis, although the magnitude of this effect was small. There were no significant associations (p< or =.05) between the presence of a lifting-associated event and the outcomes of ODI, VAS leg pain, or VAS back pain.
The majority of LDH occurred without specific inciting events. A history of an inciting event was not significantly associated with a more severe clinical presentation. There was no significant association between the occurrence of a lifting-related event and the severity of the clinical presentation. This information may be useful in the counseling of patients recovering from acute LDH.
The spine journal: official journal of the North American Spine Society 03/2010; 10(5):388-95. · 2.90 Impact Factor
ABSTRACT: Rehabilitation services using intensive exercise for the treatment of chronic spinal pain have traditionally been scheduled at a frequency of three times per week.
In an attempt to reduce the cost of rehabilitation services, this study was designed to determine whether treatment offered two times per week could produce similar outcomes when compared with an established three times per week spine therapy program.
Prospective cohort study.
Seventy-seven consecutive patients with chronic spinal pain were treated with aggressive spine rehabilitation either two or three times per week.
Flexibility, trunk strength and lifting capacity were quantified before and after treatment. Pain visual analog scores and Oswestry disability scores were measured before and after treatment, as well as 12 months after treatment.
A two times per week physical therapy program was developed to be identical in its treatment method to an established three times per week, group-oriented physical therapy program used for the treatment of chronic spinal pain. Patients with spinal pain who continued to work despite chronic pain complaints were allowed to choose between the two therapy programs based on availability of treatment slots and convenience. Treatment consisted of non-pain contingent quota-based exercises targeting identified physical impairments. Treatment sessions lasted for 2 hours and consisted of 30 minutes of stretching, 30 minutes of low-impact step aerobics class and 1 hour of exercise on strength and endurance equipment. Therapy occurred in groups consisting of a maximum of eight patients who were closely supervised by two therapists. Targeted treatment time was 6 weeks. At 12 months after treatment, subjects were surveyed by mailed questionnaires.
Seventy-seven patients with chronic spinal pain with a mean duration of symptoms of 32 months underwent treatment. Twenty-four subjects opted for the twice per week and 53 opted for the three times per week treatment. Seventy-one percent of subjects responded to the 12-month follow-up questionnaire. Physical and self-reported measures improved with both treatment frequencies. There were no differences in outcomes between treatment frequencies for measured flexibility, trunk strength, lifting capacity, pain intensity scores or Oswestry scores at the completion of treatment. At 12-month follow-up, no differences were noted between treatment frequencies for pain scores, Oswestry scores, patients' perceptions of adequacy of treatment, posttreatment exercise compliance or use of other treatments for their spinal problem. Total therapy visits were less in the two than three times per week groups (12 vs 15 visits).
Similar outcomes were obtained from aggressive spine rehabilitation occurring two versus three times per week in patients presenting with moderate levels of chronic spinal pain. Reduction in physical therapy services and therefore cost did not adversely affect clinical outcomes in the treatment of this patient population.
The Spine Journal 2(6):402-7. · 3.29 Impact Factor
ABSTRACT: Pain anticipated before and induced by physical activities has been shown to influence the physical performance of patients with chronic back pain. Limited data exist as to the influence of treatment on this component of pain.
This study attempted to determine if pain anticipated before and induced by physical activities was altered during an exercise-oriented physical therapy program for chronic back pain.
Subjects were recruited from three physical therapy sites with similar spine rehabilitation programs that used intense exercise delivered in a group format. During the recruitment period, 70 subjects with chronic low back pain and disability agreed to participate and complied with recommended treatments. The primary outcome measures were anticipated and induced pain as assessed by visual analog scales (VAS) during six tests of back flexibility and strength. Additional outcome measures included the performance levels of these six tests (trunk flexion, extension, straight leg raising, back strength, lifting from floor to waist and waist to shoulder height), global back and leg VAS and Oswestry Low Back Pain Disability Questionnaire scores.
At evaluation for the spine rehabilitation programs, we recorded the anticipated and induced pain levels associated with the six tests of back function, the performance levels on each test and global pain and disability scores. Subjects then participated in the spine rehabilitation program that consisted of intense exercise delivered up to three times per week, for 2 hours over a period of 6 weeks. All outcome measures were reassessed at discharge. Pre- and posttreatment outcome scores were statistically compared using paired sample t tests and chi-squared test. Spearman correlation coefficients were used to compare anticipated and induced pain results with global back and leg pain VAS scores, Oswestry scores and physical performance levels for each physical test.
Most measures of anticipated and induced pain improved between evaluation and discharge. Improvements were noted for global back pain (p<.001), leg pain (p=.001), disability (p<.001) and performance on each physical testing (p<.001) after treatment. Performances on all physical testing correlated with anticipated and induced pain for all tests at evaluation but only for measures of flexibility at discharge. Improvements in global pain and disability correlated with improvements in anticipated and induced pain with physical testing.
Anticipated and induced pain with physical activities was lessened after physical therapy using exercise. Anticipated and induced pain with physical activities related to physical performance levels, global pain and disability ratings. These findings may help explain how exercise exerts a positive influence on chronic back pain and disability.
The Spine Journal 4(2):176-83. · 3.29 Impact Factor
ABSTRACT: Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work.
The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain.
A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article.
For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research.
Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.
The Spine Journal 4(1):106-15. · 3.29 Impact Factor