ArticleLiterature Review

The Impact of Low Back-related Leg Pain on Outcomes as Compared With Low Back Pain Alone

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Abstract

Objectives: Low back pain (LBP) with leg pain, especially with findings of nerve root involvement, is considered as a poor prognostic indicator although it seems to have a favorable natural resolution. It is unclear whether patients with LBP and leg pain are at the more severe end of the spectrum as compared with patients with LBP alone or whether they are a distinct subgroup that would perhaps benefit from early identification of the condition and more targeted interventions. The purpose of this study was to investigate the impact of LBP-related leg pain on outcomes and use of health resources as compared with patients with LBP alone. Methods: Systematic review of studies reporting separate outcomes of patients with LBP and LBP with leg pain and synthesis of available evidence. Literature search of all English language peer-reviewed publications was conducted using MEDLINE, EMBASE, and CINAHL for the years 1994 to 2010. Results: Of the papers retrieved, 9 were included in the review. The heterogeneity of studies allowed only narrative analysis of findings. All studies reported worse health outcomes and increased use of health care with radiation of leg pain distally and with neurological findings, with the exception of psychological outcomes. Discussion: LBP with pain radiating to the leg appears to be associated with increased pain, disability, poor quality of life, and increased use of health resources compared with LBP alone. These findings argue for early identification of these cases by health care professionals and pursuing effective treatments.

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... [14][15][16][17][18] Therefore, at least one-third of patients continue to suffer with pain for ≥ 1 year. The personal, social and economic burdens are significant, 19,20 with UK annual costs estimated at £268M in direct medical costs and £1.9B in indirect costs. 21 Treatments for, and current clinical management of, sciatica ...
... The baseline characteristics for each trial arm, stratified by sciatica groups (1, 2 and 3), are summarised in Table 3. Age was similar across all strata (the mean age ranged between 50.1 and 55.3 years). Duration, n (%) < 2 weeks 2 (4) 11 (20) 10 (10) 12 (11) 3 (4) 10 (13) 2-6 weeks 26 (49) 20 (37) 36 (34) 42 (40) 37 (47) 36 (46) 6-12 weeks 13 (25) 10 (19) 29 (28) 25 (24) 16 (20) 11 (14) 3-6 months 4 (7) 8 (15) 12 (11) 9 (8) 15 (19) 12 (15) 6-12 months 2 (4) 1 (2) 4 (4) 7 (7) 4 (5) 2 (3) > 12 months 6 (11) 4 (7) 14 (13) 11 (10) 4 (5) 7 (9) RMDQ score, e mean (SD) 5. (27) 18 (23) 16 (21) Yes 18 (34) 25 (46) 70 (67) 77 (73) 61 (77) 62 (79) General health, n (%) Excellent 4 (7) 7 (13) 4 (4) 4 (4) 3 (4) 2 (3) Very good 17 (32) 18 (33) 15 (14) 21 (20) 20 (25) 10 (13) Good 28 (53) There was a slight trend towards an increasing proportion of females from group 1 (≈50%) through group 2 (≈55%) to group 3 (≈60%). The centre in North Shropshire/Wales had a higher proportion of group 1 participants (28%) than the centres in North Staffordshire and Cheshire (17% each). ...
... 33 However, to the best of our knowledge, a model of SC had not yet been specifically developed or tested for patients in primary care with sciatica. We developed a SC model for sciatica, which we tested in the SCOPiC RCT, taking into account that patients with sciatica have more severe symptoms overall than those with non-specific LBP, 20 and that there are other treatment options for patients with sciatica, such as spinal injections and spinal surgery, in addition to conservative treatment. ...
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Background Sciatica has a substantial impact on patients and society. Current care is ‘stepped’, comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. Objectives The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. Design This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. Setting Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. Participants Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. Interventions In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. Main outcome measures The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost–utility analysis was undertaken over 12 months. A qualitative study explored patients’ and clinicians’ views of the fast-track care pathway to a spinal specialist. Results A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. Conclusions The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. Limitations Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. Future work Other approaches to stratified care may provide superior outcomes for sciatica. Trial registration Current Controlled Trials ISRCTN75449581. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.
... Low-back-related leg pain (LBLP) is one of the most common subgroups of lowback pain (LBP), 1,2 but LBLP is usually associated with more serious disability and pain and poorer outcomes and recovery than LBP alone. 3 Additionally, LBLP patients also experience pain sensation and/or movement coordination impairment. [3][4][5] Neuroimaging findings are considered to be evidence in support of this observation, that is, significant structural and functional alterations occur in chronic pain or chronic lowback pain, especially in the "pain matrix" brain regions, such as the anterior cingulate cortex, 6 medial prefrontal cortex, 7,8 and primary somatosensory (S1) cortex. ...
... 3 Additionally, LBLP patients also experience pain sensation and/or movement coordination impairment. [3][4][5] Neuroimaging findings are considered to be evidence in support of this observation, that is, significant structural and functional alterations occur in chronic pain or chronic lowback pain, especially in the "pain matrix" brain regions, such as the anterior cingulate cortex, 6 medial prefrontal cortex, 7,8 and primary somatosensory (S1) cortex. [9][10][11] Therein, the S1 cortex, as an important sensory processing area, plays a prominent and highly regulatory role in pain perception, including localization and discrimination. ...
... Dynamic FC was measured by a sliding window correlational analysis for each ROI, and the coefficient of variation (CV: SD/mean) map was computed across time windows. In brief, the dFC analysis was performed as follows: (1) the time-series signals from each ROI were extracted; (2) a rectangular sliding window length of 30 TR (60 s) and a step of 1 TR was selected based on previous studies; 30 (3) within each window (201 windows in total), the temporal correlation coefficient to other voxels throughout the whole brain was computed for each ROI (in total of 12), and a correlation coefficient map was created for each participant; and (4) the CV map was calculated over time to quantify temporal variations of dFC. To improve the normality of the correlation distribution, a Z-standardization was applied to all maps. ...
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Objective: To investigate the functional connectivity (FC) and its variability in the primary somatosensory cortex (S1) of patients with low-back-related leg pain (LBLP) in the context of the persistent stimuli of pain and numbness. Patients and methods: We performed functional magnetic resonance imaging on LBLP patients (n = 26) and healthy controls (HCs; n = 34) at rest. We quantified and compared static FC (sFC) using a seed-based analysis strategy, with 6 predefined bilateral paired spherical regions of interest (ROIs) in the S1 cortex. Then, we captured the dynamic FC using sliding window correlation of ROIs in both the LBLP patients and HCs. Furthermore, we performed a correlational analysis between altered static and dynamic FC and clinical measures in LBLP patients. Results: Compared with controls, the LBLP patients had 1) significantly increased static FC between the left S1back (the representation of the back in the S1) and right superior and middle frontal gyrus (SFG/MFG), between the left S1chest and right SFG/MFG, between right S1chest and right SFG/MFG, between the left S1face and right MFG, and between the right S1face and right inferior parietal lobule (P < 0.001, Gaussian random field theory correction); 2) increased dynamic FC only between the right S1finger and the left precentral and postcentral gyrus and between the right S1hand and the right precentral and postcentral gyrus (P < 0.01, Gaussian random field theory correction); and 3) a negative correlation between the Barthel index and the increased static FC between the left S1face and right inferior parietal lobule (P = 0.048). Conclusion: The present study demonstrated the hyperconnectivity of the S1 cortex to the default mode and executive control network in a spatial pattern and an increase in the tendency for signal variability in the internal network connections of the S1 cortex in patients with LBLP.
... 5 When comparing to LBP without radicular symptoms, lumbar radiculopathy is associated with more disability and pain, and thus causes decreased quality of life and increased utilization of health resources. 6 Per current guidelines around the world, treatment for lumbar radiculopathy includes spinal injections, specifically lumbar epidural steroid injections. Offer or provide this service. ...
... The Superion device (Vertiflex, Inc., San Clemente, CA; percutaneous interspinous process device [IPD]) is ODI=18. 6 The change in VAS from baseline to week 6 and baseline to week 12 was significant (p< 0.01), but the change from week 6 to week 12 was not significant. ...
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Introduction: Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective: The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results: After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion: The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
... Some musculoskeletal pain conditions classified as nociceptive pain (i.e., knee osteoarthritis [6], rotator cuff tears [7], and impingement syndrome of the shoulder [8]) may present neuropathic-like symptoms. Although there is an exchange of several pain characteristics that classify the predominance of nociceptive pain or neuropathiclike symptoms, previous studies showed that neuropathic-like symptoms patients had unfavorable outcomes [9][10][11][12][13]. For instance, increased pain and disability, low quality of life, and increased use of health resources are more reported by patients with low back pain radiating to the leg than in patients with low back pain alone [9]. ...
... Although there is an exchange of several pain characteristics that classify the predominance of nociceptive pain or neuropathiclike symptoms, previous studies showed that neuropathic-like symptoms patients had unfavorable outcomes [9][10][11][12][13]. For instance, increased pain and disability, low quality of life, and increased use of health resources are more reported by patients with low back pain radiating to the leg than in patients with low back pain alone [9]. Also, other studies reported more severe pain, poorer physical health, symptoms of depression, and psychological distress in neuropathic-like symptoms when compared to patients with nociceptive pain [10][11][12][13]. ...
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Background: Musculoskeletal pain patients present similar pain characteristics regardless of the clinical diagnosis. PainDETECT questionnaire is useful for screening neuropathic-like symptoms in many musculoskeletal conditions. However, no previous studies compared pain phenotypes of patients with musculoskeletal pain using the painDETECT. Therefore, the current study aimed to compare the pain characteristics of patients with musculoskeletal pain classified according to the painDETECT as nociceptive pain, unclear, and neuropathic-like symptoms. Methods: A cross-sectional study was conducted in 308 participants with musculoskeletal pain. Demographic and clinical characteristics of the participants were examined. Neuropathic-like symptoms, pain intensity, pain area, Central Sensitization-related sign and symptoms, functional limitation, and conditioned pain modulation were assessed in patients with musculoskeletal pain. Independent one-way analysis of variance (ANOVA) was used to test for between-group differences for the outcome measures with continuous variables and Pearson chi-square test verified between-group differences on the efficiency of the conditioned pain modulation. Results: Participants had a mean age of 52.21 (±15.01) years old and 220 (71.42%) were females. One hundred seventy-three (56.16%) participants present nociceptive pain, 69 (22.40%) unclear, and 66 (21.42%) neuropathic-like symptoms. A one-way ANOVA showed differences for the pain intensity [F (2,305) = 20.097; p < .001], pain area [F (2,305) = 28.525; p < .001], Central Sensitization-related sign and symptoms [F (2,305) = 54.186; p < .001], and functional limitation [F (2,256) = 8.061; p < .001]. However, conditioned pain modulation was similarly impaired among the three groups (X2 = 0.333, p = 0.847). Conclusion: Patients with neuropathic-like symptoms revealed unfavorable pain characteristics compared to their counterparts, including pain intensity, generalized pain, Central Sensitization-related sign and symptoms, and functional limitation.
... This type of pain is usually referred to as nociceptive pain [3,5]. LBLP coincides with increased disability and health costs compared with LBP [6][7][8], and visitations to primary care units are frequent among LBLP patients [9]. In this group, the prognosis is worse [8], with an increased need for healthcare and more prolonged periods of sick leave from work than low back pain alone [7]. ...
... LBLP coincides with increased disability and health costs compared with LBP [6][7][8], and visitations to primary care units are frequent among LBLP patients [9]. In this group, the prognosis is worse [8], with an increased need for healthcare and more prolonged periods of sick leave from work than low back pain alone [7]. Lumbar spine magnetic resonance imaging (MRI) is widely used to investigate patients with LBP and LBLP, and is a valuable technique to assess disc and facet joint abnormalities [10]; however, it lacks specificity regarding the causes of LBP because these abnormalities are common in asymptomatic subjects [11][12][13]. ...
Article
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This retrospective observational study was conducted to identify factors associated with low back-related leg pain (LBLP) using axially loaded magnetic resonance imaging (AL-MRI). Ninety patients with low back pain (LBP) underwent AL-MRI of the lumbar spine. A visual analog scale and patient pain drawings were used to evaluate pain intensity and location and determine LBLP cases. The values of AL-MRI findings were analyzed using a logistic regression model with a binary dependent variable equal to one for low back-related leg pain and zero otherwise. Logistic regression results suggested that intervertebral joint effusion (odds ratio (OR) = 4.58; p = 0.035), atypical ligamenta flava (OR = 5.77; p = 0.003), and edema of the lumbar intervertebral joint (OR = 6.41; p = 0.003) were more likely to be present in LBLP patients. Advanced disc degeneration (p = 0.009) and synovial cysts (p = 0.004) were less frequently observed in LBLP cases. According to the AL-MRI examinations, the odds of having LBLP are more likely if facet effusion, abnormal ligamenta flava, and lumbar facet joint edema are present on imaging than if not. The assessment of lumbar spine morphology in axial loaded MRI adds value to the potential understanding of LBLP, but further longitudinal and loaded–unloaded comparative studies are required to determine the role of acute dynamic changes and instability in LBLP development.
... Forty-one unique reviews (Agnello et al., 2010;Alhowimel et al., 2018;Alzaharani et al., 2019;Ashworth et al., 2011;Balaji et al., 2014;Campbell et al., 2011Campbell et al., , 2013Campbell et al., , 2018Celestin et al., 2009;Chou & Shekelle, 2010;da Silva et al., 2017;Hallegraeff et al., 2012;Hayden et al., 2009Hayden et al., , 2019Hendrick et al., 2011;Iles et al., 2008Iles et al., , 2009Kamper et al., 2008;Kent & Keating, 2008;Konstantinou et al., 2013;Lakke et al., 2009;Oliveira et al., 2019;Oosterhuis et al., 2019;Pinheiro et al., 2016;Ramond et al., 2011;Rashid et al., 2017;Sarrami et al., 2017;Shearer et al., 2020;Steenstra et al., 2017;Valentin et al., 2016;Verkerk et al., 2012;Verwoerd et al., 2013Verwoerd et al., , 2019Walton, Carroll, et al., 2013;Wertli, Eugster, et al., 2014;Wilhelm et al., 2017) were identified for inclusion in this evidence synthesis (see the flowchart in Figure 1). ...
... Radiating/leg pain 6 reviews (Agnello et al., 2010;Chou & Shekelle, 2010;Kent & Keating, 2008;Konstantinou et al., 2013;Steenstra et al., 2017;Verkerk et al., 2012) 1 within last 5 years (Steenstra et al., 2017) ...
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Background: Numerous systematic reviews have attempted to synthesize evidence on prognostic factors for predicting future outcomes such as pain, disability and return-to-work/work absence in neck and low back pain populations. Databases and datatreatment: An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for each prognostic factor investigated. Searches were limited to the last 10 years (2008-11th April 2018, updated 28th September 2020). A two-stage approach was undertaken: in stage one, data on prognostic factors was extracted from systematic reviews identified from the systematic search that met the inclusion criteria. Where a prognostic factor was investigated in ≥1 systematic review and where 50% or more of those reviews found an association between the prognostic factor and one of the outcomes of interest, it was taken forward to stage two. In stage two, additional information extracted included the strength of association found, consistency of effects and risk of bias. The GRADE approach was used to grade confidence in the evidence. Results: Stage one identified 41 reviews (90 prognostic factors), with 35 reviews (25 prognostic factors) taken forward to stage two. Seven prognostic factors (disability/activity limitation, mental health; pain intensity; pain severity; coping; expectation of outcome/recovery and fear-avoidance) were judged as having moderate confidence for robust findings. Conclusions: Although there was conflicting evidence for the strength of association with outcome, these factors may be used for identifying vulnerable subgroups or people able to self-manage. Further research can investigate the impact of using such prognostic information on treatment/referral decisions and patient outcomes.
... For this study, individual predisposing variables include age and sex. 30 Individual need variables include timing of physical therapy initiation compared with onset of symptoms, 19 -21 baseline functional outcome score, percent change of function, 34 ,35 baseline pain score, percent Factors Impacting Physical Therapy Utilization for NSLBP change of pain intensity, 35 use of additional LBP ICD-10 codes as nonprincipal diagnoses, 36 presence of leg pain, 37 average length of physical therapist visits, receipt of previous physical therapy at a provider clinic, self-discharge from physical therapy, and prescription for opioid analgesic. Individual enabling variables include out-of-pocket expenditure per episode of care, 24 insurance type, and adherence to guideline recommendations for active physical therapist intervention. ...
... Individual enabling variables include out-of-pocket expenditure per episode of care, 24 insurance type, and adherence to guideline recommendations for active physical therapist intervention. 37 Race, ethnicity, co-morbidities, referring provider, and marital status were not included as they contained >20% missing values. Patient age and sex were self-reported. ...
Article
Objective: Payers use consumer-directed health care to reduce costs by discouraging utilization of low-value services and encouraging use of low-cost providers. Low back pain (LBP) is a costly condition for which physical therapy is a high-value service. Factors predicting physical therapy utilization for LBP remain unclear, limiting the development of value-based initiatives. The purpose of this study was to identify important factors that impact the number of physical therapist visits per episode of care for US adults with nonspecific LBP. Methods: This study was a retrospective observational cohort study of a clinical dataset derived from 80 clinics of a single physical therapy provider organization. Research variables were categorized at the individual (patient) level and the organization (therapist, clinic) level. A hierarchical regression model was designed to identify factors influencing the number of physical therapist visits per episode of care. Results: Higher out-of-pocket payments per visit, receipt of "active" physical therapy, longer average visit length, earlier use of physical therapy, and sex of the therapist (male) were found to predict fewer visits per episode of care. Percent change of function, prior receipt of physical therapy by the same provider organization, self-discharge from physical therapy, level of starting function, and therapist certification were found to predict more visits. Of the variance in number of visits, 8.0% is attributable to the health care organization. Conclusions: Individual factors, such as higher out-of-pocket payment, have a significant impact on reducing visits per episode of care and should be considered when developing value-based initiatives to optimize clinical and utilization outcomes.
... 8 With increased pain and disability, people suffering from back-related leg pain have poorer prognosis, quality of life and an increased use of health resources compared with people with LBP alone. 9 Spinal manual therapy (SMT) and corticosteroid nerve root injection (NRI) are two common conservative treatment methods in routine clinical care, but there is uncertainty regarding their effects. To assist patients, clinicians and policy-makers with decision making on the treatment of lumbar radiculopathy based on high-quality evidence, the SALuBRITY pilot trial-a two parallel group, double sham controlled, randomised clinical trial-is being developed. ...
Article
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Introduction: A patient and public involvement (PPI) project will be embedded within the SALuBRITY pilot trial, a two parallel group, double sham controlled, randomised clinical trial. The study aims to compare the effectiveness of spinal manual therapy and corticosteroid nerve root injections, two methods commonly used to treat patients with lumbar radiculopathy. We aim to gather patients' and clinicians' perspectives and involve them in decisions related to the research question and objectives, proposed trial recruitment processes and methods, and proposed outcome measures. Methods and analysis: A small group of patients with lived experience of lumbar radiculopathy and primary care clinicians with experience in the treatment of patients with lumbar radiculopathy are involved. An initial kickoff event will prepare and empower the advisors for involvement in the project, followed by semistructured patient group and one-on-one clinician interviews. We will follow the Critical Outcomes of Research Engagement framework for assessing the impact of patient engagement in research. We will summarise and feedback PPI content to the patient and clinician advisors during a member-checking process to ensure accurate interpretation of patient and clinician inputs. Inductive and deductive thematic analysis will be used for the qualitative analysis of the interviews. Two surveys will be completed at different points along the trial to track the advisors' and researchers' experiences over the course of the PPI project. Any modifications to the SALuBRITY trial methods due to PPI inputs will be thoroughly documented and recorded in an impact log. Ethics and dissemination: The independent research ethics committee of Canton Zurich confirmed that ethical approval for this PPI subproject was not required. PPI results will be disseminated in a peer-reviewed journal and presented at conferences.
... Sciatica is also known as lumbosacral radiculopathy that presents as a severe form of LBP characterised by radiating leg pain and is considered chronic when symptoms last more than 12 weeks [4]. Patients with sciatica have a worse prognosis, higher incidence of disability compensation, greater pain intensity and functional limitations compared to patients with localised LBP [5][6][7][8]. The success of the treatment is dependent on various identified prognostic factors such as sociodemographic (e.g. ...
... Sciatica is also known as lumbosacral radiculopathy that presents as a severe form of LBP characterised by radiating leg pain and is considered chronic when symptoms last more than 12 weeks [4]. Patients with sciatica have a worse prognosis, higher incidence of disability compensation, greater pain intensity and functional limitations compared to patients with localised LBP [5][6][7][8]. The success of the treatment is dependent on various identified prognostic factors such as sociodemographic (e.g. ...
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Advice to stay active is the primary management strategy for sciatica. Other conservative treatments such as neural management techniques may also contribute to sciatica recovery, but currently, the effects have not been robustly assessed. Thus, the aim of this study is to compare the effects of adding neural management to advice to stay active versus advice to stay active alone in improving pain intensity and functional limitation. Secondarily, to compare the effects of the experimental intervention in the sciatic neurodynamic, pain modulation, and psychosocial factors. A parallel-group, controlled, examiner-blinded superiority clinical trial randomised at a 1:1 allocation will be conducted in 210 participants with chronic sciatica. Patients will be recruited from outpatient physiotherapy clinics and community advertisements. The experimental group will receive neural mobilisation techniques and soft tissue mobilisation techniques for 30 minutes per session, 10 weekly sessions, plus advice to stay active on their activities of daily living, information on physical activity, imaging tests, and sciatica for 5 biweekly sessions lasting 25–30 minutes. The control group will receive advice to stay active only. The re-evaluation will be performed out after 5 weeks, 10 weeks, and 26 weeks after randomisation and primary endpoints will be pain intensity and functional limitation at 10 weeks. Secondary outcomes will include neuropathic symptoms, sciatic neurodynamic, pain modulation, and psychosocial factors. Adverse events and patient satisfaction will be assessed. Ethical approval has been granted from an Institutional Human Research Ethics Committee. Trial registration : Trial was prospectively registered in the Brazilian Registry of Clinical Trials (number: RBR-3db643c ).
... LBLP compared with LBP alone is associated with increased disability, pain and poorer quality of life. 6 Sciatica is a relatively common and often a persistent 'nuisance' 7 that leads to the use of health services, 8 prolonged sick leave 9 and has considerable economic consequence in terms of healthcare resources and lost productivity. 10 Although prognosis is good for most patients, a significant proportion (up to 30%) still have pain for a year or more. ...
Article
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Introduction: Sciatica is one of the most common reasons for seeking healthcare for musculoskeletal pain. Sciatica is primarily considered as neuropathic in nature when neural tissue in the low back is compromised, but sometimes other non-neural structures may be involved. Appropriate assessment and management are important for patients with sciatica. Therapists use several outcome measures to assess patients to inform selection of the most suitable treatment. There is limited evidence for the best treatment of sciatica, and this is likely contributed to by having no reliable algorithm to categorise patients based on their clinical characteristics to inform physiotherapy treatment. The purpose of this study is to develop a clinical prediction model to categorise patients with sciatica, in terms of early clinical outcome, based on their initial clinical characteristics. Methods and analysis: A prospective observational multicentre design will recruit consecutive patients (n=467) with sciatica referred for physiotherapy. Each patient will be evaluated to determine whether or not they will be accepted into the study by answering some questions that will confirm the study’s eligibility criteria. Patients’ basic characteristics, patient-reported outcome measures and performance-based measures will be collected at baseline from multiple sites in the Greek territory using this same protocol, prior to commencement of treatment. The main researcher of this study will be responsible for data collection in all sites. On completion of the standard referred physiotherapy treatment after 3 weeks’ time, participants will be asked by telephone to evaluate their outcome using the Global Perceived Effect Scale. For the descriptive statistical analysis, the continuous variables will be expressed in the form of ‘mean’ and ‘SD’. In order to assess the prognostic value of each predictor, in terms of the level of improvement or worsening of the symptoms, multiple variable regression analysis will be used.
... Sciatica is often experienced as acute symptoms resolving over several weeks or months, either naturally or with treatment; however, up to 30% of people will still experience pain after a year [1]. When compared to LBP alone, patients with sciatica have worse pain and disability, poorer quality of life and use more healthcare resources [3,4]. ...
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Background: Sciatica is common and associated with significant impacts for the individual and society. The SCOPiC randomised controlled trial (RCT) (trial registration: ISRCTN75449581 ) tested stratified primary care for sciatica by subgrouping patients into one of three groups based on prognostic and clinical indicators. Patients in one group were 'fast-tracked' for a magnetic resonance imaging (MRI) scan and spinal specialist opinion. This paper reports qualitative research exploring patients' and clinicians' perspectives on the acceptability of this 'fast-track' pathway. Methods: Semi-structured interviews were conducted with 20 patients and 20 clinicians (general practitioners, spinal specialist physiotherapists, spinal surgeons). Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and 'boundary objects' concept. Results: Whilst the 'fast-track' pathway achieved a degree of 'coherence' (i.e. made sense) to both patients and clinicians, particularly in relation to providing early reassurance based on MRI scan findings, it was less 'meaningful' to some clinicians for managing patients with acute symptoms, reflecting a reluctance to move away from the usual 'stepped care' approach. Both groups felt a key limitation of the pathway was that it did not shorten patient waiting times between their spinal specialist consultation and further treatments. Conclusion: Findings contribute new knowledge about patients' and clinicians' perspectives on the role of imaging and spinal specialist opinion in the management of sciatica, and provide important insights for understanding the 'fast-track' pathway, as part of the stratified care model tested in the RCT. Future research into the early referral of patients with sciatica for investigation and specialist opinion should include strategies to support clinician behaviour change; as well as take into account the role of imaging in providing reassurance to patients with severe symptoms in cases where imaging reveals a clear explanation for the patient's pain, and where this is accompanied by a thorough explanation from a trusted clinical expert.
... It is well-established that the presence of sciatica, compared with low back pain alone, or somatic referred leg pain, increases symptom severity, disability, absence from work and negatively impacts on health outcome. 3 Furthermore, patients report that sciatica can be incapacitating and severely limit daily activities. 4 Sciatica prevalence estimates vary widely, from 1.2% to 43%, reflecting differing diagnostic criteria and sampling methods. ...
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Objectives Amid a political agenda for integrated, high-value care, the UK is implementing its Low Back and Radicular Pain Pathway. To align care with need, it is imperative to understand the patients’ perspective. The purpose of this study was, therefore, to explore how people experience being managed for sciatica within an National Health Service (NHS) pathway. Design Qualitative interpretative study. Setting Musculoskeletal Service in an NHS, Primary Care Trust, UK. Participants The sample comprised 14 people aged ≥18 years with a clinical presentation of sciatica, who were currently under the care of a specialist physiotherapist (the specialist spinal triage practitioner), had undergone investigations (MRI) and received the results within the past 6 weeks. People were excluded if they had previously undergone spinal surgery or if the suspected cause of symptoms was cauda equina syndrome or sinister pathology. Participants were sampled purposively for variation in age and gender. Data were collected using individual semi-structured interviews (duration: 38–117 min; median: 82.6 min), which were audio-recorded and transcribed verbatim. Data were analysed thematically. Results A series of problems with the local pathway (insufficient transparency and information; clinician-led decisions; standardised management; restricted access to specialist care; and a lack of collaboration between services) made it difficult for patients to access the management they perceived necessary. Patients were therefore required to be independent and proactive or have agency. This was, however, difficult to achieve (due to the impact of sciatica and because patients lacked the necessary skills, funds and support) and together with the pathway issues, this negated patients’ capability to manage sciatica. Conclusions This novel paper explores how patients experience the process of being managed within a sciatica pathway. While highlighting the need to align with recommended best practice, it shows the need to be more person-centred and to support and empower patient agency. Trial registration number ClinicalTrials.gov reference (UOS-2307-CR); Pre-results.
... 3 Low backrelated leg pain (LBLP) compared with LBP alone is associated with increased disability, pain and poorer quality of life. 4 LBLP is generally clinically diagnosed as sciatica (lumbar radicular) or referred pain (involving nonneural structures); sciatica is considered neuropathic in nature whereas referred pain is considered nociceptive. 5 However, there is evidence to suggest the coexistence of both pain mechanisms in LBLP, 6 and evidence for sciatica presenting without neuropathic pain and referred pain presenting with neuropathic pain. ...
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Introduction Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. Patient examination guidelines and screening tools have been developed and validated for the purpose of diagnosing neuropathic pain in LBLP; however, there has been no systematic review conducted to compare the diagnostic validity of these methods. Therefore, this systematic review will investigate the diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in LBLP. Methods and analysis This protocol is informed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocols. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro, PubMed, key journals and grey literature will be searched rigorously to find diagnostic accuracy studies investigating patient examination data to identify neuropathic pain in LBLP patients. Two independent reviewers will conduct the search, extract the data and assess risk of bias for included studies using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. The overall quality of included studies will be evaluated using Grading of Recommendations, Assessment, Development and Evaluation guidelines. A meta-analysis will be conducted if deemed appropriate. Otherwise, a narrative synthesis will be conducted. Ethics and dissemination No research ethics is required for this systematic review since patient data will not be collected. This review will help to inform healthcare professionals and researchers on the most effective means in which to diagnose neuropathic pain in LBLP. Results of this review will be submitted for publication in a peer-review journal and conference presentations. PROSPERO registration number CRD42019140861
... Sciatica is considered to be a prognostic indicator of poor outcome among patients with low back pain. Patients with a clinical diagnosis of sciatica are about five times more likely to take drugs than those with low back pain only [21][22][23][24]. ...
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Background and objectives: The efficacy of commonly prescribed analgesic and adjuvant drugs for the management of patients with radiculopathy has not been well established. Oral steroids are commonly used to treat sciatica or radiculopathy due to a herniated disk but the effect remains controversial. L-lysine aescinate showed superiority over placebo or baseline therapy with NSAIDs alone in treating sciatica, but have not been evaluated in an appropriately powered clinical trial. Materials and methods: Randomized, double-blind clinical trial conducted in two health centers in collaboration with Uzhhorod Natioanl University in Ukraine. Adults (N = 90) with acute radicular pain and a herniated disk confirmed by MRI were eligible. Participants were randomly assigned to three groups (N = 30 in each) to receive a baseline therapy with lornoxicam (16 mg per day) and adjunctive 5-day course of IV dexamethasone (first group: 8 mg per day/40 mg total) or 0,1% solution of L-lysine aescinate (5 mL and 10 mL for group 2 and 3 respectively). Primary outcomes were Visual Analogue Scale changes and the straight leg raise angle at 15th and 30th day. Results: The level of pain improvement at 15th days after initiation of therapy with dexamethasone or solution of L-lysine aescinate at doses of 5 or 10 mL was not significantly different. The lowest levels of pain were achieved in patients who received the L-lysine aescinate 10 mL, but the range of decrease in pain was slightly greater in the group administered dexamethasone. Conclusions: Among patients with acute radiculopathy due to a herniated lumbar disk a short course of IV dexamethasone or L-lysine aescinate resulted in pain improvement at 15th and 30th day. Dexamethasone may be preferable if a longer-term analgesic effect is needed. Taking into account side effects of dexamethasone, a solution of L-lysine aescinate can be used to relieve pain symptoms.
... Prognostic studies and systematic reviews on LBP commonly evaluate specific prognostic factors [47,48] such as psychosocial distress [49][50][51][52], clinical features [53][54][55][56] and physical activity [57]. We are unaware of any high-quality studies evaluating a comprehensive range of biomedical (including pathoanatomical), psychological and social prognostic factors using multivariate methods in a large sample of people with LBP [46,58,59]. ...
Article
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Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.
... Commonly known as 'sciatica', LRP is a painful and disabling condition, resulting in worse pain, disability, and quality of life, and increased use of health resources compared with low back pain alone. 1 Repeated findings have challenged the adequacy of the pathoanatomical model to fully explain LRP pathology. Although LRP is often caused by an intervertebral disc prolapse, 2 nerve root compression is commonly seen in asymptomatic populations. ...
Article
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Background: Several pathological processes contribute to lumbar radicular pain (LRP), commonly known as sciatica. It is not known how patients rationalise the experience of sciatica or understand the diagnosis. Providing clinicians with a better understanding of how patients conceptualise sciatica will help them to tailor information for patients on the management and treatment of the condition. Aim: To understand patients' beliefs regarding their illness following a diagnosis of LRP, how these beliefs were developed, and the impact of illness beliefs on treatment beliefs. Design & setting: Qualitative interview study from a single NHS musculoskeletal interface service (in Wales, UK). Method: Thirteen patients recently diagnosed with LRP were consecutively recruited. Individual semi-structured interviews were recorded and transcribed. Data were analysed using a thematic approach. Results: Four main themes were generated: (1) the illness experience (2) the concept of sciatica, (3) treatment beliefs, and (4) the desire for credible information. Conclusion: The diagnosis of LRP is often communicated and understood within a compressive conceptual illness identity. Explaining symptoms with a compressive pathological model is easily understood by patients but may not accurately reflect the spectrum of pathological processes known to contribute to radicular pain. This model appears to inform patient beliefs about treatments. Clinicians should take care to fully explain the pathology prior to shared decision-making with patients.
... Koes et al., 2007 People with radicular ndings have been found to experience more fi severe pain, greater disability, worse outcome and require more sickness absence compared to people with low back pain alone ( ). Although the natural history and con- Konstantinou et al., 2013 servative treatment of radicular ndings are favourable for many, at fi least a third of people are likely to have on-going symptoms 12 months after onset ( ) and recent epidemiological work Vroomen et al., 2000 indicates this gure may be greater, with fi Konstantinou et al. (2018) finding that only 55% of patients experienced symptom improvement (of at least 30%) by 12 months. Recent work comparing the presentations of patients with radicular symptoms caused by a prolapsed disc compared to those with stenosis, indicates that people with stenosis tend to be older and experience milder and less disabling pain than those with disc prolapse ( ; Cummins et al., 2006 Rainville and; however, given the degenerative nature of stenosis, this subgroup may experience longer-lasting symptoms. ...
Article
Background Patients with radicular symptoms can experience high levels of pain and disability with at least a third experiencing on-going symptoms 12 months after onset. Aims To explore ‘what matters’ about living with radicular symptoms at the point of seeing a spinal specialist and to consider how care can be aligned to best address need. Methods In this qualitative study, based on the principles of interpretative phenomenological analysis, 14 participants with a clinical presentation of radicular symptoms were purposively recruited from an NHS, Musculoskeletal Service in the UK. Individual, semi-structured interviews were undertaken, audio-recorded and transcribed verbatim. Data were managed using a Framework approach and analysed thematically. Findings Radicular symptoms were experienced as a protracted journey of acute exacerbations of symptoms that were difficult to make sense of. Adversely affecting almost all aspects of life, participants struggled to maintain their physical and functional independence; their important relationships; social networks and the roles and activities that provided joy and purpose. The impact of radicular symptoms was a ‘life on hold’ and an uncertain future, and 3/14 reported suicidal thoughts. Conclusions This paper, the first to focus on the lived experience of radicular symptoms at the point of seeing a spinal specialist, reveals the severity and devastating impact of radicular symptoms. Important implications have been identified regarding the need for clinicians to legitimise the symptoms and impact of radicular symptoms; to identify early those patients who might benefit from injection/surgery; and to signpost appropriate patients to sources of psychological support.
... However, up to 30% of people will still experience pain after a year or more (Koes et al., 2007), and some may encounter recurrent episodes over time, thus representing a longer-term problem. Sciatica symptoms have been found to be particularly persistent and severe when compared with LBP alone, being associated with increased pain, disability, poor quality of life, and greater use of health resources (Boote et al., 2016;Konstantinou et al., 2013). ...
... Our results are in line with those of other studies pointing to worse clinical outcomes in patients with selfreported LBP with pain running down the leg, in general [27] and, more specifically, in the elderly living in the community [4]. Studies carried out in working populations (patients < 60 years) consulting their general practitioner in the UK, have shown that pain location matters and that the presence of radiating leg pain is of poor prognosis in terms of impact on HRQoL with significant decrements in EQ-5D scores [25,26]. ...
Article
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PurposeThe present study aims at investigating the effects of low back pain (LBP), i.e., type of symptoms, activity limitations, frequency, duration, and severity on health-related quality of life (HRQoL) in a sample of 707 community-dwelling men and women aged ≥ 65 years living in Switzerland. Methods The study is part of a larger survey conducted in Switzerland on a sample of older adults selected randomly from population records, stratified by age and sex. The Standardized Back Pain Definition was used to investigate LBP, and HRQoL was assessed by means of the EQ-5D, including Health Utility Index (HUI) measures. ResultsFor more than half of the sufferers, pain was chronic, occurred most days or every day and induced activity limitations. One-third of the sufferers reported sciatica symptoms. Individuals reporting every day pain, severe pain and more than 3 years since the last episode without pain lost nearly 10 points of HRQoL. Amongst the dimension of HRQoL, Mobility was the most affected by LBP. Conclusions These results provide further insight into the impact of qualitative aspects of LBP and in particular the importance of radiating leg pain and pain frequency and duration. While LBP-related activity limitations had little impact on both self-rated overall health and HUI, radiating leg pain and pain frequency and duration were associated with significantly decreased scores on both dimensions.
... Although the prognosis of radiculopathy is favourable for many, the presence of leg pain, compared to LBP alone, adversely affects symptom severity, disability, absence from work and outcome (Konstantinou et al., 2013). For up to 30% of people, significant on-going symptoms continue beyond a year (Koes et al., 2007). ...
Article
Background: Clinical guidelines recommend that investigations, such as magnetic resonance imaging, are offered only when likely to change management. Meanwhile, the optimal process of diagnosing radiculopathy remains uncertain and, in clinical practice, differences of opinion can occur between patient and clinician regarding the perceived importance of investigations. Objectives: To explore peoples' experiences of investigations and the effect of concordance between clinical presentation and investigation findings. Methods: In this qualitative study, 14 participants who had recently undergone investigations for a clinical presentation of radiculopathy were purposively recruited from an NHS, Primary Care Service in the United Kingdom. Based on the principles of interpretative phenomenological analysis, individual, semi-structured interviews were recorded and transcribed verbatim. Data were managed using a framework approach and analysed thematically. Findings: Although people reported wanting investigations to understand the cause of symptoms and inform management, access to them was reported to be difficult and protracted. When investigations revealed potentially relevant findings, people experienced relief, validation, empowerment and decisive decision-making. Disappointment emerged, however, regarding treatment options and waiting times, and long-term prognosis. When investigations failed to identify relevant findings, people were unable to make sense of their symptoms, relinquish their search to identify the cause, or to move forward in their management. Conclusions: This study provides the first reported in-depth interpretation of peoples' experience of undergoing investigations specifically for radiculopathy. Important implications have been identified for: investigation referral criteria; shared-decision-making; information sharing and managing expectations and disappointment. CLINICALTRIALS. Gov reference: UOS-2307-CR.
Article
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Purpose Conservative management of lumbar radiculopathy (LR) is the first treatment option. To date, systematic reviews and clinical practice guidelines have not considered the most appropriate timing of management. This study aimed to establish consensus on effective conservative treatment modalities across different stages (i.e., acute, sub-acute, or chronic) of LR. Materials and methods Through an iterative multistage Delphi process, experts rated agreement with proposed treatment modalities across stages of LR and could suggest additional treatment modalities. The agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Results Fourteen panelists produced a consensus list of effective treatment modalities across stages of LR. Acute stage management should focus on providing patients with information about the condition including pain education, individualized physical activity, and directional preference exercises, supported with NSAIDs. In the sub-acute stage, strength training and neurodynamic mobilization could be added and transforaminal/epidural injections considered. In the chronic stage, spinal manipulative therapy, specific exercise, and function-specific physical training should be combined with individualized vocational, ergonomic and postural advice. Conclusions Experts agree effectiveness of interventions differs through the evolution of LR. • IMPLICATIONS FOR REHABILITATION • To date clinical guideline for conservative management of lumbar radiculopathy do not consider the evolution of the condition. • Acute stage management of lumbar radiculopathy should focus on providing information about the condition and support individualized physical activity with pain medication. • Sub-acute management should add neurodynamic mobilization to strength training, while transforaminal and/or epidural injections could be considered. • Chronic stage management should consider spinal manipulative therapy and focus on restoring personalized functional capacity.
Chapter
Mining practices have evolved over a period of time and so have the new health hazard exposures. Today the physical heavy work is greatly reduced since most of the jobs are either partially or fully mechanized. Therefore, a considerable amount of time of a skilled mine worker is spent operating machinery and driving vehicles for increased productivity. This technological advent, often coupled with a neglect of ergonomic considerations, brings with it a different set of impacts on miners involved in operating earthmoving machinery. Commonly visible at first as monotony associated fatigue, this is often neglected as it assumes symptoms of body pain, chiefly neck, shoulder and low back pain; to later manifest as musculoskeletal disorders (MSD) over a prolonged period of time. Research has established the presence of a host of risk factors related to such postural injuries and the pain associated with it. While age, duration of employment, and usage of machinery, etc. are the primary causes; nevertheless, the transmission of vibration and postural anomalies coupled with repetitive and strenuous bending and twisting movements routinely observed in these operators, play an equally important role. However, a clear cut demarcation of these causative factors and the extent of their involvement can only be ascertained by a questionnaire that is objective as well as in sync with the aims of any such envisaged study. An attempt has been made to present a critical review of postural injuries of earthmoving machinery and locomotive operators in mines in this article, wherein we have included findings of our previous study carried out on the Side Discharge Loader (SDL) operators in coal mines as well as similar studies published elsewhere. The combined results of these studies indicate that postural injuries constitute a serious health hazard, and should be considered on par with other occupational health hazards to mine workers.KeywordsErgonomicsPostural injuriesEarth moving machinerySDLMSDMines
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Background: Chronic Sciatica is a disabling condition causing considerable medical, social and financial implications. Currently, there is no recognised long-term effective treatment to alleviate sciatica. Acupuncture has been widely used for treating chronic pains with persistent analgesic effects. We aim to evaluate the efficacy and safety of acupuncture for chronic sciatica with follow-up in 52 weeks. Methods and analysis: This is a multicenter randomised sham-controlled trial. A total of 216 patients with chronic sciatica will be enrolled and randomly assigned to the acupuncture or sham acupuncture group. There will be 10 treatment sessions applied in 4 weeks with frequency decreased over time. Patients will complete follow-ups during 52 weeks. The primary outcomes are changes in leg pain intensity and disability from baseline to week 4. Secondary outcomes include back pain intensity, frequency and bothersomeness, quality of life, and global perceived effect. Adverse events will be recorded in detail. Ethics and dissemination: Ethical approval of this trial was granted from the ethics committee of Beijing University of Chinese Medicine and all study centres (No. 2020BZYLL0803). Written informed consent will be obtained from enrolled patients. Trial results will be disseminated in peer-reviewed publications. Trial registration number: ChiCTR2100044585 (Chinese Clinical Trial Registry, http://www.chictr.org.cn, registered on 24 March 2021); preresults.
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A psychological consequence of chronic pain may be an inappropriately limited future time perspective (FTP) for middle-aged and older adults. FTP is defined as one’s perception of time as limited or expansive. Potentially meaningful measures, like pain temporal pattern, are often ignored in the chronic pain literature. The present study uses secondary data to assess the association between pain temporal pattern and FTP, and the moderating effect of pain duration. Among 140 individuals with chronic pain, there was no significant association between pain pattern and FTP. However, both pain-related activity interference and pain duration were associated with FTP where greater interference predicted more limited FTP ('b' = –0.16, 'p' = .03) and longer pain duration contributed to more expansive FTP ('b' = 0.001, 'p' = .03). The temporal pattern x pain duration interaction terms were non-significant. We discuss implications, limitations, and future directions of these findings.
Article
Background Study results vary on whether depressive symptoms are associated with worse prognosis for low back pain (LBP). We assessed the association between depressive symptoms or depression and health outcomes in persons with LBP.Methods We searched MEDLINE, Embase, CINAHL, and PsycINFO from inception to June 2020. Eligible studies were cohort and case-control studies assessing the association between depressive symptoms (questionnaires) or depression (diagnoses) and health outcomes in persons aged ≥16 years with LBP in the absence of major pathology. Reviewers independently screened articles, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. We classified exploratory versus confirmatory studies based on phases of prognostic factor investigation. We conducted random-effects meta-analyses and descriptive synthesis where appropriate.ResultsOf 13,221 citations screened, we included 62 studies (63,326 participants; 61 exploratory studies, 1 confirmatory study). For acute LBP, depressive symptoms were associated with self-reported disability (descriptive synthesis: 6 studies), worse recovery (descriptive synthesis: 5 studies), and slower traffic injury–related claim closure (1 study), but not pain or work-related outcomes. Depressive symptoms were associated with greater primary healthcare utilization for acute LBP (1 confirmatory study). For chronic LBP, depressive symptoms were associated with higher pain intensity (descriptive synthesis: 9 studies; meta-analysis: 3 studies, 2902 participants, β=0.11, 95% confidence interval (CI) 0.05–0.17), disability (descriptive synthesis: 6 studies; meta-analysis: 5 studies, 3549 participants, β=0.16, 95% CI 0.04–0.29), and worse recovery (descriptive synthesis: 2 studies; meta-analysis: 2 studies, 13,263 participants, relative risk (RR)=0.91, 95% CI 0.88–0.95), but not incident chronic widespread pain (1 study).DiscussionDepressive symptoms may be associated with self-reported disability and worse recovery in persons with acute and chronic LBP, and greater primary healthcare utilization for acute LBP. Our review provides high-quality prognostic factor information for LBP. Healthcare delivery that addresses depressive symptoms may improve disability and recovery in persons with LBP. Confirmatory studies are needed to assess the association between depressive symptoms and health outcomes in persons with LBP.Protocol RegistrationPROSPERO database (CRD42019130047)
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The management of patients with lumbosacral radicular pain (LRP) is of primary importance to healthcare professionals. This study aimed to: identify international clinical practice guidelines on LRP, assess their methodological quality, and summarize their diagnostic and therapeutic recommendations. A systematic search was performed (August 2019) in MEDLINE, PEDro, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence (NICE), New Zealand Guidelines Group (NZGG), International Guideline Library, Guideline central, and Google Scholar. Guidelines presenting recommendations on diagnosis and/or treatment of adult patients with LRP were included. Two independent reviewers selected eligible guidelines, evaluated quality with Appraisal of Guidelines Research & Evaluation (AGREE) II, and extracted recommendations. Recommendations were classified into ‘should do’, ‘could do’, ‘do not do’, or ‘uncertain’; their consistency was labelled as ‘consistent’, ‘common’, or ‘inconsistent’. Twenty-three guidelines of varying quality (AGREE II overall assessment ranging from 17% to 92%) were included. Consistent recommendations regarding diagnosis are (‘should do’): Straight leg raise (SLR) test, crossed SLR test, mapping pain distribution, gait assessment, congruence of signs and symptoms. Routine use of imaging is consistently not recommended. The following therapeutic options are consistently recommended (‘should do’): educational care, physical activity, discectomy under specific circumstances (e.g., failure of conservative treatment). Referral to a specialist is recommended when conservative therapy fails or when steppage gait is present. These recommendations provide a clear overview of the management options in patients with LRP.
Article
Background: An increasing number of lumbar spine conditions are treated surgically. Such intervention, however, is commonly thought to be more effective in addressing leg pain than low back pain. Patient expectations may also contribute to self-reported surgical outcomes. Questions/Purposes: We sought to compare the expectations of patients in 2 groups undergoing lumbar spine surgery: those with predominantly low back pain and those with predominantly leg pain. We also sought to evaluate how these expectations were fulfilled for each group. Methods: We carried out a retrospective analysis of prospectively collected data from a prior study in which patients scheduled for lumbar spine surgery at a single institution completed validated surveys preoperatively and at 2 years postoperatively, including a 20-item survey on expectations for lumbar spine surgery. The patients were enrolled in the study between February 2010 and August 2012, and were divided into 2 cohorts: a “Back > Leg” group that consisted of patients with back pain that was isolated or greater than leg pain, and a “Leg ≥ Back” group that consisted of patients with leg pain that equaled or exceeded back pain. The primary analysis compared composite expectation scores (range, 0–100) between groups. Results: A total of 366 patients were deemed eligible for the study; of these, 162 patients were allocated to the Back > Leg group and 204 patients were allocated to the Leg ≥ Back group. Patients in the Leg ≥ Back group had a greater mean preoperative expectation score compared with those in the Back > Leg group. Multivariate analysis demonstrated that higher preoperative expectations were associated with leg pain symptoms after controlling for disease diagnosis. Both groups reported similar proportions of fulfilled expectations. Conclusion: Patients with predominantly leg pain hold greater preoperative expectations for lumbar spine surgery than do patients with predominantly back pain. That these patient groups reported similar fulfillment of their expectations at 2 years postoperatively illustrates the greater clinical outcomes achieved among patients who presented with predominantly leg pain.
Article
Background: The frequency with which sensory disturbances occur in patients with radicular leg pain and disc herniation is not well known, and the efficacy of tests to identify such changes are not firmly established. The presence of sensory disturbances is a key sign of nerve root involvement and may contribute to the diagnosis of a lumbar disc herniation, identify patients for referral to spinal imaging and surgery, and improve disease classification. Questions/purposes: In this study, we sought: (1) to determine the frequency with which abnormal sensory findings occur in patients with lumbar disc herniation-related radicular pain, using a standard neurological sensory examination; (2) to determine what particular standard sensory test or combination of tests is most effective in establishing sensory dysfunction; and (3) to determine whether a more detailed in-depth sensory examination results in more patients being identified as having abnormal sensory findings. Methods: Between October 2013 and April 2016, 115 patients aged 18 to 65 years referred to secondary health care with radicular leg pain and disc herniation were considered potentially eligible for inclusion in the study. Based on these inclusion criteria, 79% (91) were found eligible. Ten percent (11) were excluded because of other illness that interfered with the study purpose, 3% (3) because of cauda equina syndrome, 2% (2) because of spinal stenosis, 2% (2) because of prior surgery at the same disc level, and 2% (2) because of poor Norwegian language skills. Three percent (4) of the patients did not want to participate in the study. Of the 91 eligible patients, 56% (51) consented to undergo a comprehensive clinical examination and were used for analysis here. The sample for the purposes of the present study was predetermined at 50. These patients were first examined by a standard procedure, including sensory assessment of light touch, pinprick, vibration, and warmth and cold over the back and legs. Second, an in-depth semiquantitative sensory testing procedure was performed in the main pain area to assess sensory dysfunction and improve the detection of potential positive sensory signs, or sensory gain of function more precisely. Sensory loss was defined as sensations experienced as distinctly reduced in the painful side compared with the contralateral reference side. In contrast, sensory gain was defined as sensations experienced as abnormally strong, unpleasant, or painful and distinctly stronger than the contralateral side. Ambiguous test results were coded as a normal response to avoid inflating the findings. The proportions of abnormal findings were calculated for each sensory modality and for all combinations of the standard examination tests. Results: The standard examination identified at least one abnormal finding in 88% (45 of 51) of patients. Sensory loss was present in 80% (41), while sensory gain was present in 35% (18). The combination of pinprick and light touch identified all patients who were classified as having abnormal findings by the full standard examination. The semiquantitative procedure identified an additional three patients with an abnormal finding. Conclusion: We suggest that the combination of pinprick and light touch assessment is an adequate minimal approach for diagnostic and classification purposes in patients with lumbar radicular pain. Level of evidence: Level I, diagnostic study.
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Background Sciatica has a substantial impact on individuals and society. Stratified care has been shown to lead to better outcomes among patients with non-specific low back pain, but it has not been tested for sciatica. We aimed to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care. Methods We did a two-parallel arm, pragmatic, randomised controlled trial across three centres in the UK (North Staffordshire, North Shropshire/Wales, and Cheshire). Eligible patients were aged 18 years or older, had a clinical diagnosis of sciatica, access to a mobile phone or landline number, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery. Patients were recruited from general practices and randomly assigned (1:1) by a remote web-based service to stratified care or usual care, stratified by centre and stratification group allocation. In the stratified care arm, a combination of prognostic and clinical criteria associated with referral to spinal specialist services were used to allocate patients to one of three groups for matched care pathways. Group 1 was offered brief advice and support in up to two physiotherapy sessions; group 2 was offered up to six physiotherapy sessions; and group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomisation. The primary outcome was self-reported time to first resolution of sciatica symptoms, defined as “completely recovered” or “much better” on a 6-point ordinal scale, collected via text messages or telephone calls. Analyses were by intention to treat. Health-care costs and cost-effectiveness were also assessed. This trial is registered on the ISRCTN registry, ISRCTN75449581. Findings Between May 28, 2015, and July 18, 2017, 476 patients from 42 general practices around three UK centres were randomly assigned to stratified care or usual care (238 in each arm). For the primary outcome, the overall response rate was 89% (9467 of 10 601 text messages sent; 4688 [88%] of 5310 in the stratified care arm and 4779 [90%] of 5291 in the usual care arm). Median time to symptom resolution was 10 weeks (95% CI 6·4–13·6) in the stratified care arm and 12 weeks (9·4–14·6) in the usual care arm, with the survival analysis showing no significant difference between the arms (hazard ratio 1·14 [95% CI 0·89–1·46]). Stratified care was not cost-effective compared to usual care. Interpretation The stratified care model for patients with sciatica consulting in primary care was not better than usual care for either clinical or health economic outcomes. These results do not support a transition to this stratified care model for patients with sciatica. Funding National Institute for Health Research.
Article
Background: Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. Objectives: To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. Search methods: We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. Selection criteria: We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. Data collection and analysis: Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. Main results: We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. Authors' conclusions: This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.
Article
Aim: The aim of this paper is to analyze hospital admission and associated factors following presentation to healthcare facilities for low back pain (LBP) in Ethiopia. Methods: A population-based cross-sectional study was conducted between June and November 2018 in South-west Shewa zone of Oromia regional state. Data were collected by face-to-face interviews of adults (≥18 years) with self-reported LBP using a newly developed and validated instrument. All the statistical analyses of (n = 543) individuals with a 1-year history of presentation to healthcare facilities for LBP were performed using R version 3.5.1. The log-binomial regression model was fitted and prevalence ratios with 95% confidence intervals (CIs) were calculated to identify factors associated with hospitalization and the significance level was considered at the P value of ≤ .05. Results: The proportion of hospital admissions following presentation to healthcare facilities for LBP was 14.4%, 95% CI 11.4-17.3, with an average length of stay (LOS) 7.4 days, 95% CI 6.4-8.8. The admission rate was 18.5%, 95% CI 13.4-23.3 in females and 11.4%, 95% CI 8.0-15.1 in males. Multiple factors, such as gender, age, living conditions, residential environment, alcohol consumption status, intensity of pain, and presence of additional spinal pain, were found to be independently associated with hospitalization for LBP. Conclusions: The burden on the individuals and the Ethiopian healthcare system as a result of LBP is evident by the rate of hospital admissions. Further evidence on LBP case referral procedures is needed to allow health policy makers to develop appropriate management strategies capable of dealing with the increasing epidemiology of LBP.
Article
Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding. Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome. Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome. Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.
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Introduction Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. A Delphi study will therefore be conducted to obtain an expert-derived consensus list of clinical indicators to identify a neuropathic component to LBLP. Methods/analysis Included participants will be considered experts within the field as measured against a predefined eligibility criterion. Through an iterative multistage process, participants will rate their agreement with a list of clinical indicators and suggest any missing clinical indicators during each round. Agreement will be measured using a 5-point Likert scale. Descriptive statistics will be used to measure agreement; median, IQR and percentage of agreement. A priori consensus criteria will be defined for each round. Data analysis at the end of round three will enable a list of clinical indicators to be derived. Ethics and dissemination Ethical approval was gained from the University of Birmingham (ERN_19-1142). On completion of the study, findings will be disseminated in a peer-reviewed journal and presented at relevant conferences.
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Background: The prevalence of low back pain with radiculopathy in general population varies from 9.9% to 25%, which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc. Transforaminal epidural injection of a mixture of long-acting anaesthetic (bupivacaine) and particulate steroids (depomedrol) has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications. Methods: To analyze the effectiveness of transforaminal epidural steroid injection (TFESI) in the treatment of low back pain with radiculopathy, a retrospective case series evaluating the records of patients that received TFESI (1 mL 0.5% bupivacaine +1 ml/40 mg depomedrol) under C-arm guidance from January 2015 to December 2018 (3 years) at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), their lumbo-sacral MRI and the pre-procedure, 1-week and 3-month numeric pain rating scale, were analyzed. Successful treatment (reduction of pain scale by more than 50% of baseline at 3 months) in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared. Results: Out of 67 patients that received TFESI, 35 (52.23%) could be followed up. The mean age was 55.8 ± 14.39 years and 51.3% were females. 68.57% had L5 and 20% had S1 radiculopathy. Bony recess stenosis was seen in the aged 40% and PIVD was the cause of radiculopathy in 60%. The median duration of radicular pain prior to intervention was 3 months. TFESI was effective as the mean numeric pain scale before injection was 8.97 ± 1.32 which reduced to 3.91 ± 3.23 (paired t test p value < 0.001) at 1 week post injection and 3.23 ± 3.34 (paired t test p value < 0.001) at 3 months post injection. Twenty-six of the 35 patients (75.29%) had more than 50% pain relief compared to baseline at 3 months and were satisfied. Nine patients continued to have pain; however, only one required a surgical intervention. The effectiveness of TFESI was not significantly different in different ages (Fisher's exact test p value 0.182) and in different anatomic levels (Fisher's exact test p value 0.241). Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD, though it was not statistically significant (Fischer's exact test p value 0.688). There were no adverse events recorded. Conclusion: TFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.
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Objective: Chronic low back pain has been observed to decrease movement coordination. However, it is unclear whether the existing alteration of inter-hemispheric synchrony of intrinsic activity in patients with chronic low back-related leg pain (cLBLP). The present study aims to investigate the alteration of homotopic connectivity and its clinical association with the cLBLP patients. Participants and methods: A cohort of cLBLP patients (n=25) and well-matched healthy controls (HCs) (n=27) were recruited and underwent MRI scanning and a battery of clinical tests. The voxel-mirrored homotopic connectivity (VMHC) was used to analyze the interhemispheric coordination in the typical (0.01-0.1 Hz) as well as five specific (slow-6 to slow-2) frequency bands and associated with clinical index in cLBLP patients. Results: We observed that cLBLP patients with lower homotopic connectivity than HCs in the inferior temporal gyrus, the superior temporal gyrus, the basal ganglia, the middle frontal gyrus, and the medial prefrontal cortex in the typical and five specific frequency bands, respectively. In the typical and five specific frequency bands, significant positive correlations were observed between the VMHC values of medial prefrontal cortex and the visual analogue scale scores, while the VMHC values of basal ganglia negative correlated with the values of two-point tactile discrimination (2PD) test for the right hand in cLBLP patients, etc. Further receiver operating characteristic curve analysis revealed that VMHC in the above regions with decreased could be used to differentiate the cerebral functional plasticity of cLBLP from healthy individuals with high sensitivity and specificity. Conclusion: Our results imply that multiscale frequency-related interhemispheric disconnectivity may underlie the central pathogenesis of functional coordination in patients with cLBLP.
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Background: Sciatica is a painful condition managed by a stepped care approach for most patients. Currently, there are no decision-making tools to guide matching care pathways for patients with sciatica without evidence of serious pathology, early in their presentation. This study sought to develop an algorithm to subgroup primary care patients with sciatica, for initial decision-making for matched care pathways, including fast-track referral to investigations and specialist spinal opinion. Methods: This was an analysis of existing data from a UK NHS cohort study of patients consulting in primary care with sciatica (n = 429). Factors potentially associated with referral to specialist services, were identified from the literature and clinical opinion. Percentage of patients fast-tracked to specialists, sensitivity, specificity, positive and negative predictive values for identifying this subgroup, were calculated. Results: The algorithm allocates patients to 1 of 3 groups, combining information about four clinical characteristics, and risk of poor prognosis (low, medium or high risk) in terms of pain-related persistent disability. Patients at low risk of poor prognosis, irrespective of clinical characteristics, are allocated to group 1. Patients at medium risk of poor prognosis who have all four clinical characteristics, and patients at high risk of poor prognosis with any three of the clinical characteristics, are allocated to group 3. The remainder are allocated to group 2. Sensitivity, specificity and positive predictive value of the algorithm for patient allocation to fast-track group 3, were 51, 73 and 22% respectively. Conclusion: We developed an algorithm to support clinical decisions regarding early referral for primary care patients with sciatica. Limitations of this study include the low positive predictive value and use of data from one cohort only. On-going research is investigating whether the use of this algorithm and the linked care pathways, leads to faster resolution of sciatica symptoms.
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Background: There is limited research on the economic burden of low back-related leg pain, including sciatica. The aim of this study was to describe healthcare resource utilisation and factors associated with cost and health outcomes in primary care patients consulting with symptoms of low back-related leg pain including sciatica. Methods: This study is a prospective cohort of 609 adults visiting their family doctor with low back-related leg pain, with or without sciatica in a United Kingdom (UK) Setting. Participants completed questionnaires, underwent clinical assessments, received an MRI scan, and were followed-up for 12-months. The economic analysis outcome was the quality-adjusted life year (QALY) calculated from the EQ-5D-3 L data obtained at baseline, 4 and 12-months. Costs were measured based on patient self-reported information on resource use due to back-related leg pain and results are presented from a UK National Health Service (NHS) and Societal perspective. Factors associated with costs and outcomes were obtained using a generalised linear model. Results: Base-case results showed improved health outcomes over 12-months for the whole cohort and slightly higher QALYs for patients in the sciatica group. NHS resource use was highest for physiotherapy and GP visits, and work-related productivity loss highest from a societal perspective. The sciatica group was associated with significantly higher work-related productivity costs. Cost was significantly associated with factors such as self-rated general health and care received as part of the study, while quality of life was significantly predicted by self-rated general health, and pain intensity, depression, and disability scores. Conclusions: Our results contribute to understanding the economics of low back- related leg pain and sciatica and may provide guidance for future actions on cost reduction and health care improvement strategies. Trial registration: 13/09/2011 Retrospectively registered; ISRCTN62880786 .
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Background There is increasing interest in the role of pro-inflammatory cytokines in the pathogenesis of sciatica and whether these could be potential targets for treatment. We sought to investigate serum biomarker levels in patients with low back-related leg pain, including sciatica. Methods Primary care consulters aged > 18 with low back-related leg pain were recruited to a cohort study (ATLAS). Participants underwent a standardised clinical assessment, lumbar spine MRI and a subsample (n = 119) had samples taken for biomarker analysis. Participants were classified having: a) clinically confirmed sciatica or referred leg pain, and then subdivided into those with (or without) MRI confirmed nerve root compression due to disc prolapse. Seventeen key cytokines, chemokines and matrix metalloproteinases (MMPs) implicated in sciatica pathogenesis including TNFα and IL-6, were assayed in duplicate using commercial multiplex detection kits and measured using a Luminex suspension array system. Median biomarker levels were compared between the groups using a Mann Whitney U test. Multivariate logistic regression analysis was used to investigate the association between clinical measures and biomarker levels adjusted for possible confounders such as age, sex, and symptom duration. Results No difference was found in the serum level of any of the 17 biomarkers tested in patients with (n = 93) or without (n = 26) clinically confirmed sciatica, nor between those with (n = 44) or without (n = 49) sciatica and MRI confirmed nerve root compression. Conclusion In this cohort, no significant differences in serum levels of TNFα, IL-6 or any other biomarkers were seen between patients with sciatica and those with back pain with referred leg pain. These results suggest that in patients with low back-related leg pain, serum markers associated with inflammation do not discriminate between patients with or without clinically confirmed sciatica or between those with or without evidence of nerve root compression on MRI.
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Study design: Longitudinal cohort. Objectives: The Hospital Anxiety and Depression Scale (HADS) was developed to provide clinicians a reliable, valid, and practical tool to identify and quantify the anxiety and depression in medical patients. Several studies have shown that patients with chronic low back pain may have subclinical depression and impairments in mental health and that these in turn may lead to less than optimal results after lumbar spine surgery. The purpose of this study is to determine if there are associations between preoperative HADS and differences in pre- and postoperative health-related quality-of-life (HRQOLs) scores after spine surgery. Methods: From a single center, a consecutive series of patients completed the HADS, Oswestry Disability Index (ODI), Short Form-36 (SF-36), EuroQOL-5D (EQ-5D), and Visual Analog Scale (VAS) for back and leg pain. Except for HADS, the patients completed the same HRQOLs 1 year after surgery. Results: Of 308 eligible cases, 208 (68%) had follow-up data available and were included in the analysis. Patients in the HADS-Anxiety (HADS-A) Abnormal category had the worst preoperative HRQOLs but had the greatest improvement in 1-year postoperative scores. Except for VAS Leg Pain, preoperative HRQOLs were better in patients in the HADS-Depressed (HADS-D) Normal category. Patients in the HADS-D Abnormal category had statistically significantly greater improvement in 1-year postoperative EQ-5D and ODI scores when compared with the other cohorts. Conclusion: Worse HADS-A and HADS-D scores are associated with worse preoperative HRQOL scores in patients with lumbar degenerative disorders scheduled for spine surgery. However, similar improvements in HRQOLs can be expected 1 year postoperative regardless of the patients' HADS scores.
Article
Objectives: To evaluate the clinical effect of sciatic neural mobilization in combination with the treatment of surrounding structures for sciatica patients. Secondly, we were also interested in identifying possible baseline characteristics that may be associated with improvements in pain and disability for sciatica patients. Methods: Twenty-eight patients with a clinical diagnosis of sciatica were treated with neural mobilization, joint mobilization and soft tissue techniques. Pain intensity and lumbar disability were assessed at baseline and after treatment using a Numerical Rating Scale (0–10) and the Oswestry Disability Index (0–100), respectively. The pre- and post-intervention data were compared. The research protocol was registered under the number NCT03663842. Results: Participants attended an average of 16 (SD±5.6) treatment sessions over an average of 12 weeks. Decrease in pain scores (before median = 8, after median = 2; p < 0.001) and improvement in lumbar disability scores (before median = 33.3%, after median = 15.6%; p < 0.001) were observed. A multiple linear regression analysis showed that duration of pain and age of the patient predicted the disability improvement: F (2, 24) = 4.084, p < 0.030, R² = 0.254. Discussion: Patients with sciatica may benefit from neural mobilization in combination with manual therapy for pain and lumbar disability. Longer pain duration and younger age had a negative influence on lumbar disability improvement.
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Increasing evidence has suggested that central plasticity plays a crucial role in the development and maintenance of (chronic) nonspecific low back pain. However, it is unclear how local or short-distance functional interactions contribute to persisting low back-related leg pain (LBLP) due to a specific condition (i.e., lumbar disc herniation). In particular, the multiscale nature of local connectivity properties in various brain regions is still unclear. Here, we used voxelwise Kendall's coefficient of concordance (KCC) and coherence (Cohe) regional homogeneity (ReHo) in the typical (0.01–0.1 Hz) and five specific frequency (slow-6 to slow-2) bands to analyze individual whole-brain resting-state functional magnetic resonance imaging scans in 25 persistent LBLP patients (duration: 36.7 ± 9.6 months) and 26 healthy control subjects. Between-group differences demonstrated significant alterations in the KCC- and Cohe- ReHo of the right cerebellum posterior lobe, brainstem, left medial prefrontal cortex and bilateral precuneus in LBLP patients in the typical and five specific frequency bands, respectively, along with interactions between disease status and the five specific frequency bands in several regions of the pain matrix and the default-mode network (P <.01, Gaussian random field theory correction). The altered ReHo in the five specific frequency bands was correlated with the duration of pain and two-point discrimination, which were assessed using partial correlational analysis. These results linked the course of disease to the local connectivity properties in specific frequency bands in persisting LBLP. In future studies exploring local connectome association in pain conditions, integrated frequency bands and analytical methods should be considered.
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Background: Low back pain is a common musculoskeletal disorder that can incur high financial burden. A significant proportion of this burden may be incurred from referrals to health services and subsequent healthcare usages. Patients’ overall experience of pain and its related life interferences may also have some relevance to this usage. Objective: This study aimed to examine the referral practices and subsequent health service utilization of patients with LBP within a tertiary specialist clinic setting. A secondary objective was to explore potential associations between primary independent variables of pain and life interferences with health service utilization. Methods: Participants were patients with low back pain, who completed a set of self-reported low back pain measures. These included measures for pain intensity, pain interference, disability and quality of life. The participants’ back pain-related referral and health service utilization in the subsequent 12 months were recorded. Results: A total of 282 patients completed the full measures. Of these, 59.9% were referred for physiotherapy, 26.3% for diagnostic imaging and 9.2% for interventional procedures. Compared to patients who were referred from tertiary care, those from primary care had lower pain intensity (p=0.001), pain interference (p=0.002), disability (p=0.001), but better physical and mental quality of life (p
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Objective The clinical presentation and outcome of patients with back and leg pain in primary care are heterogeneous and may be better understood by identification of homogeneous and clinically meaningful subgroups. Subgroups of patients with different back pain trajectories have been identified, but little is known about the trajectories for patients with back‐related leg pain. This study sought to identify distinct leg pain trajectories, and baseline characteristics associated with membership of each group, in primary care patients. Methods Monthly data on leg pain intensity were collected over 12 months for 609 patients participating in a prospective cohort study of adult patients seeking healthcare for low back and leg pain including sciatica, of any duration and severity, from their general practitioner. Growth mixture modelling was used to identify clusters of patients with distinct leg pain trajectories. Trajectories were characterised using baseline demographic and clinical examination data. Multinomial logistic regression was used to predict latent class‐membership with a range of covariates. Results Four clusters were identified: (1) improving mild pain (58%), (2) persistent moderate pain (26%), (3) persistent severe pain (13%), and (4) improving severe pain (3%). Clusters showed statistically significant differences with a number of baseline characteristics. Conclusion Four trajectories of leg pain were identified. Clusters 1, 2 and 3 were generally comparable to back pain trajectories, while cluster 4, with major improvement in pain, is infrequently identified. Awareness of such distinct patient groups improves understanding of the course of leg pain and may provide a basis of classification for intervention. This article is protected by copyright. All rights reserved.
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Introduction Lumbosacral radicular syndrome is often caused by a disc herniation. The standard surgical technique to remove a disc herniation is open microdiscectomy. An alternative technique is percutaneous transforaminal endoscopic discectomy (PTED), which is less invasive. In the Netherlands, PTED is not currently considered as standard care, and therefore not reimbursed within public health insurance. A pragmatic, multicentre, non-inferiority, randomised controlled trial has been designed to determine the effectiveness and cost-effectiveness of PTED versus open microdiscectomy for the treatment of lumbar disc herniation. Method and analysis In total, 682 patients between 18 and 70 years of age with >10 weeks of radiating pain or with >6 weeks of excessive radiating pain are to be recruited from participating centres. Patients must have an indication for surgery based on an MRI demonstrating compression of the nerve root from a lumbar disc herniation. Patients are to be randomised to PTED or open microdiscectomy. The primary outcome is self-reported leg pain measured by the 0–100 mm Visual Analogue Scale. Secondary outcomes include self-reported health and functional status, back pain, self-perceived recovery and a physical examination. Outcomes will be measured the day following surgery, at 2, 4 and 6 weeks, and at 3, 6, 9, 12 and 24 months. Physical examination will be performed at 6 weeks, and 3 and 12 months. An economic evaluation will be performed from a societal perspective and cost questionnaires will be used (eg, EQ-5D-5L). The data will be analysed longitudinally; the non-inferiority margin for the primary outcome is 5. Bootstrapping techniques will be used for the economic evaluation. Ethics and dissemination This study has received approval of the Medical Ethical Committee of the VU Medical Centre Amsterdam: NL50951.029.14. The results will be published in an international peer-reviewed scientific journal. Trial registration number NCT02602093 ; Pre-results, recruiting stage.
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Background context: Evidence is lacking on the prognosis and prognostic factors for back-related leg pain and sciatica in patients seeing their primary care physicians. This could guide timely appropriate treatment and referral decisions. Purpose: To describe prognosis and prognostic factors in primary care patients with low back-related leg pain, and sciatica. Study design: Prospective cohort study PATIENT SAMPLE: Adults visiting their family doctor with back-related leg pain in the United Kingdom. Outcome measures: Information was collected on pain, function, psychological and clinical variables. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire). Methods: Participants completed questionnaires, underwent clinical assessments, received an MRI scan, and were followed-up 12-months later. Mixed-effects logistic regression evaluated the prognostic value of six a-priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination and imaging variables). A combined model including variables from all models examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest. Results: 609 patients were included. At 12-months, 55% improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (OR 0.41; CI 0.19 to 0.90), higher identity score (OR 0.70; CI 0.53 to 0.93) and patient's belief that the problem will last a long time (OR 0.27; CI 0.13 to 0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup. Conclusions: This study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12-months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.
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A prospective observational study was conducted in 524 lumbar intervertebral disc herniation (LDH) inpatients to report the long-term effects of complementary and alternative medicine (CAM) treatment. Participants received integrative CAM treatment during hospitalization, from June 2012 to May 2013, and long-term outcomes were assessed from July to August 2016. Numerical rating scales (NRSs) of back and leg pain, the Oswestry disability index (ODI), satisfaction, surgery, recurrence, and current care status were investigated. Baseline characteristics were analyzed to determine factors that predicted long-term satisfaction. A total of 367 patients were available for follow-up. The long-term change in NRS of back and leg pain and ODI was 3.53 (95% CI, 3.22, 3.83), 2.72 (2.34, 3.11), and 32.89 (30.21, 35.57), respectively, showing that improvements were well sustained. Regarding satisfaction, 86.11% responded that they were “slightly improved” or better. Range of lumbar flexion ≤ 60° and both legs’ pain at admission were significant predictors of “much improved” or better satisfaction in the long term. Overall, LDH patients who received CAM treatment maintained favorable states in the long term. However, as an uncontrolled observational study, further studies with placebo and/or active controls are warranted. Trial Registration . This trial is registered with ClinicalTrials.gov NCT02257723 (date of registration: October 2, 2014).
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Background Heterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the ‘comparator variables’). Methods This was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above. Results The two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants’ recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%–6.9% for pain intensity and from 6.8%–20.3% for disability, and highest at the 2 weeks follow-up. Conclusions Latent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients. Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1708-9) contains supplementary material, which is available to authorized users.
Article
This systematic review synthesizes literature describing prevalence, characteristics, and prognosis of low back-related leg pain (LBLP) patients with neuropathic pain in primary care and/or similar settings. Inclusion and exclusion criteria were developed and used by independent reviewers to screen citations for eligibility. The initial search yielded 24,948 citations; after screening 12 studies were included. Neuropathic pain was identified using case ascertainment tools (n = 5), clinical history with examination (n = 4), and using LBLP samples assumed neuropathic (n = 3). Neuropathic pain prevalence varied from 19% to 80%. There was consistent evidence for higher back-related disability (n = 3), poorer health-related quality of life (n = 2), and some evidence for more severe depression (n = 2), anxiety (n = 3), and pain intensity (n = 4) in patients with neuropathic pain. Results were less consistent when cases were identified through clinical history with examination than those identified using case ascertainment tools. Prognosis (n = 1) of LBLP patients with neuropathic pain was worse compared with those without, in all outcomes (leg pain intensity, leg and back-related disability, self-reported general health) except back pain intensity. No studies described prognostic factors. This systematic review highlights the evidence gap in neuropathic pain in LBLP in primary care, especially with respect to prognosis. Perspective: Patients with LBLP may have neuropathic pain. This systematic review emphasizes the paucity of evidence describing the characteristics and prognosis of neuropathic pain in this patient population. Future research investigating prognosis of these patients with neuropathic pain is likely to contribute to better understanding and management.
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We prospectively studied outcomes for 179 patients with low back pain. Predictors of future function, employment, and medical utilization were drawn from 21 clinical, demographic, and psychosocial variables using multivariate techniques. Education, previous episodes, and whether the patient "always feels sick" were independently associated with most outcome measures, but prescribed therapy and physical findings were not. These 3 items created a scale defining subgroups with 3-fold differences in outcomes (e.g., 35% functionally improved in the worst group vs 93% in the best, p less than 0.001). Data from a national survey supported the importance of education and self-rated health as correlates of back related disability.
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To assess the health status of patients with 11 common illnesses--asthma, diabetes, arthritis, back pain, sciatica, hypertension, angina, anxiety, depression, and heart attack and stroke. Face to face interview using a structured questionnaire which contained the Short Form 36 questionnaire (SF-36) and questions on lifestyle, health service utilisation, and self reported conditions treated by physicians. Patients' homes, in West Glamorgan, Wales. Twelve hundred adults, aged 20-89 years, were randomly selected from the register of the family health services authority. The eight scales within the SF-36 health profile. The response rate was 82%. Each illness had a distinctive profile; patients with anxiety or depression reported the worst health experience in role limitations because of emotional problems and mental health, while patients with back pain, arthritis, or sciatica registered the three highest negative scores in bodily pain and role limitations due to physical problems. For all disease groups, the general health perceptions of those with the disease was significantly worse than those without it (p < 0.01). The SF-36 allows comparison of the health status of patients suffering from different conditions. Data such as these can be used to inform better purchasing decisions on how resources might be more effectively deployed and as a bench mark to monitor the effects of multiple health care interventions by conducting serial surveys.
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In this study we estimated the costs of back pain to society in The Netherlands in 1991 to be 1.7% of the GNP. The results also show that musculoskeletal diseases are the fifth most expensive disease category regarding hospital care, and the most expensive regarding work absenteeism and disablement. One-third of the hospital care costs and one-half of the costs of absenteeism and disablement due to musculoskeletal disease were due to back pain. The total direct medical costs of back pain were estimated at US$367.6 million. The total costs of hospital care due to back pain constituted the largest part of the direct medical costs and were estimated at US$200 million. The mean costs of hospital care for back pain per case were US$3856 for an inpatient and US$199 for an outpatient. The total indirect costs of back pain for the entire labour force in The Netherlands in 1991 were estimated at US$4.6 billion; US$3.1 billion was due to absenteeism and US$1.5 billion to disablement. The mean costs per case of absenteeism and disablement due to back pain were US$4622 and US$9493, respectively. The indirect costs constituted 93% of the total costs of back pain, the direct medical costs contributed only 7%. It is therefore concluded that back pain is not only a major medical problem but also a major economical problem.
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In their clinical review Koes et al use the entirely non-evidence-based term “sciatica.”1 From the Greek, it literally means hip pain. In English, the Oxford English Dictionary gives precedent to a quote from Shakespeare's Timon of …
Article
Purpose : Disability following acute occupational low back pain (OLBP) represents a significant and preventable health outcome, yet confusion about prognostic factors have limited the development of effective, targeted interventions for those at greatest risk. The purpose of this study was to synthesize findings from available studies of prognostic factors for OLBP disability in a clinically-relevant framework. Method : A systematic search of the MEDLINE database was conducted to identify empirical studies assessing the value of various prognostic factors to predict extended disability after an acute episode of OLBP. Relevant studies were screened based on a number of inclusionary criteria. Prognostic factors were catalogued, summarized, and evaluated based on agreement across studies, and clinical recommendations were developed based on the evidence. Results : Of 361 studies of OLBP disability found, 22 met specific criteria for inclusion. Significant prognostic factors included low workplace support, pe...
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Fifteen rabbits with antigen (bovine serum albumin) induced arthritis had antibodies to collagens type I, II and III detected weekly by passive hemagglutination. Antitype I collagen antibodies were detected in 80% of the animals in the 3rd week of arthritis; antitypes II and III were found less frequently. No anticollagen antibody was detected after the 6th week of arthritis. Although the appearance of these antibodies was clearly related to the induction of arthritis, results indicate that humoral immunity to collagen is unable to initiate or contribute to the perpetuation of synovitis in this experimental model. Antibodies to collagen are probably an epiphenomenon of articular damage in the antigen induced arthritis of the rabbit.
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The intensity of work recovery in LBP has been studied using the National Health Register. Nine hundred forty men, 40-47 years old, were selected randomly from the census register of the city of Göteborg, Sweden. Sickness absence data were obtained from the Health Register, in which all sickness absence from age 16 is recorded. The rate of return to work decreases as expected with an increase in absence period. Different rates were found for different diagnoses, however, with low return intensities in patients with sciatica compared with those with back pain, ie, return to work was slower in patients with sciatica. Men with manual work had a significantly longer average sickness absence than white-collar workers. The intensity of work recovery was lower in blue-collar workers during the first 20 days of absence, while the reverse was true after 20 days of sickness absence, ie, the white-collar workers who were absent more than 20 days had a slower rate of recovery than blue-collar workers who had been absent for 20 days. Data as presented here can be used to study the effect of intervention (for example, manual therapy) on the natural course of work recovery. It also can be used, as above, to study differences in sickness absence patterns between different diagnoses and work groups.
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A prospective survey of patients seeking primary care for low back pain. Clinical and psychosocial data, available at presentation, were explored for predictors of outcome at 1 year. To determine the relative value of clinical and psychosocial variables for early identification of patients with a poor prognosis. Current treatment strategies for low back pain have failed to stem the rising levels of disability. Psychosocial factors have been shown to be important determinants of response to therapy in chronic patients, but the contribution from similar data in acute or subchronic patients has not been comprehensively investigated. Two hundred fifty-two patients with low back pain, presenting to primary care, underwent a structured clinical interview and completed a battery of psychosocial instruments. Follow-up was done by mail at 1 year; outcome was measured using a back pain disability questionnaire. Predictive relationships were sought between the data at presentation and disability at follow-up. Most patients showed improved disability and pain scores, although more than half had persisting symptoms. Eighteen percent showed significant psychological distress at presentation. Multiple regression analysis showed the level of persisting disability to depend principally on measures in the psychosocial domain; for acute cases outcome is also dependent on the absence or presence of a previous history of low back trouble. Discriminant models successfully allocated typically 76% of cases to recovered/not-recovered groups, largely on the basis of psychosocial factors evident at presentation. Early identification of psychosocial problems is important in understanding, and hopefully preventing, the progression to chronicity in low back trouble.
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The efficacy of a physical therapy outpatient program with multiple interventions to treat low back pain in subjects receiving workers' compensation was examined. The primary purpose of the study was to describe the level of disability, physical impairment, and rate of return to work for compensated patients. One hundred thirty-eight patients (84 male, 54 female), aged 17 to 63 years (mean = 38, SD = 10), were evaluated prospectively. Subjects were assessed initially (INA) and were reevaluated 1 month later (1MO) and again at the time of discharge (DC). The Oswestry disability score, fingertip-to-floor distance during forward bending, maximal isometric lift, and work status were described as outcomes. Subjects were grouped based on compliance, chronicity, and leg symptoms. Each disability/impairment outcome was analyzed with paired t tests (INA versus 1MO and INA versus DC). The frequency of subjects returning to work across groups was evaluated with a chi-square analysis corrected for unequal group sizes. Overall, there was improvement in each dependent measure at 1MO and DC compared with the INA. Subjects with high compliance had a 10% reduction in mean disability at 1MO and a 12% reduction in mean disability at DC compared with the INA. The low-compliance group, in contrast, showed less than a 5% reduction in mean disability at both the 1MO and DC assessments compared with the INA. The magnitude of improvement in disability status, forward bending, and maximal lift was approximately two to three times greater for subjects with acute symptoms compared with those with chronic symptoms. The increase in mean forward bending for subjects without leg symptoms was over twice as large as the increase in forward bending for subjects with leg symptoms. Seventy-five percent of the subjects followed at DC (30 out of 40) were released to work in some capacity. There was no association between compliance or presence of leg symptoms and work status at DC. Eighty percent of the subjects with acute symptoms, however, were working at the time of DC compared with 44% of those with chronic symptoms. Compliance, chronicity, and leg symptoms are all factors that can affect the outcome of physical therapy. The positive outcomes for subjects who complied with therapy suggest that a physical therapy program with multiple interventions may decrease disability and impairment.
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To study the natural history of acute sciatica, 208 patients with obvious symptoms and signs of a lumbar radiculopathy (L5 and S1) were examined within 14 days of onset. A concomitant double-blind investigation of the effect of the nonsteroidal anti-inflammatory drug piroxicam was performed. The results measured by visual analog scale and Roland's functional tests showed a satisfactory improvement throughout the 4 weeks of observation. The piroxicam-treated group had same results as the control group. Based on questionnaires at months 3 and 12 approximately 30% of the patients still complained about back trouble and 19.5% were out of work after 1 year. Four patients underwent surgery during this period.
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A cross-sectional study on patients with chronic low back pain to compare relationships between subjective disability and pain intensity, pain duration, pain location, and work-related factors. One hundred and seven outpatients with low back pain, with or without radiation to the legs, of at least 3 months' duration, were administered a comprehensive back patient questionnaire. The questionnaire included the Pain Disability Index (PDI) for the assessment of overall perceived disability and assessments of pain intensity, duration, and location and two pretested short-form work questionnaires. None of the patients had undergone a back operation. Tertiary care center. There was evidence of significant interrelationships between the PDI and pain intensity (low back pain, r = 0.53, p < 0.001; leg pain, r = 0.32, p < 0.01; and buttock pain, r = 0.36, p < 0.01), pain location (significantly higher scores with distal pain radiation), and work-related factors (a work load sum score of r = 0.31, p < 0.01; significantly higher scores in patients on sick leave). The results suggest that subjective disability in patients with chronic low back pain overlaps with both pain and work-related factors. The observations support the multidimensionality of low back disability.
Article
This study involved 342 patients hospitalized because of severe, persistent sciatica suggestive of a lumbar intervertebral disc herniation. After standard clinical evaluation, EMG and myelography, 220 patients underwent lumbar discectomy. The remaining 122 patients were treated conservatively. Follow-up examinations were arranged after 1, 5 and 13 years. The study focused on the rehabilitation outcome in general and differences in outcome between the two treatment groups. Several indicators showed a rather poor outcome for sciatica patients during the 13-year follow-up period. In the operated group 16% had been re-operated because of lumbar disc herniation. True recurrence of herniation (same level and side) occurred in 8%. In the conservatively treated group 14% had undergone spinal surgery. Nearly 70% of the patients still reported sciatica. Self-assessed levels of low back pain were "no change/worse" for 19% in the operated group and for 44% in the conservatively treated group. In both the study groups, nearly 40% of the subjects had retired on disability pensions.
Article
A prospective cohort study of patients seen in primary care for low back pain. A new measure of back pain outcomes is used to describe the status of back problems at various intervals after visits to primary care physicians and to identify subsets of patients with worse prognoses. Most previous studies of the prognosis of back pain in primary care have failed to provide clinically useful information. Baseline data were collected from 219 patients making an initial visit for an episode of low back pain to a primary care clinic. A measure of how patients reported they would feel if they had their current back symptoms for the rest of their lives ("Symptom Satisfaction") was used to distinguish good from poor outcomes. Patient outcomes were assessed 1, 3, 7, and 52 weeks after the index visit. Only 67% of patients reported good outcomes after 7 weeks, and only 71% were satisfied with their condition 1 year later. After controlling for the effects of other variables measured during the initial physician visit, only younger age, depression, and pain below the knee were significant predictors of poor outcome at 7 weeks, and only pain below the knee and depression were significant predictors at 1 year. The proportion of primary care patients with back pain who have poor outcomes appears to be higher than generally recognized. Ways of improving how primary care responds to patients with persisting pain should be investigated.
Article
This cross-sectional study compares the Oswestry and Roland-Morris disability scales in two groups of patients with low back pain of different clinical and electromyographic severity. To evaluate the correlation between functional disability and diagnoses. There is an increasing need for functional disability measurements to be applied to the evaluation of therapy and outcome in patients experiencing low back pain. Two very different groups of patients with low back pain completed the Oswestry and Roland-Morris self-administrated functional disability questionnaires. One group included patients presenting with an episode of mechanical low back pain with no clinical radiculopathy. The other group consisted of patients with low back pain and clinical and electromyographic evidence of radiculopathy. Patients diagnosed with low back pain who exhibited signs of radiculopathy on electromyography had a mean score of 49.1 +/- 17.1 on the Oswestry disability questionnaire; a mean score of 33.0 +/- 14.7 was found for patients who experienced "simple" low back sprain (with no radiculopathy). This difference was statistically significant (P < 0.0001). On the Roland-Morris questionnaire, the mean score obtained by the group of patients with radiculopathy was 59.1 +/- 21.8 compared with 45.4 +/- 19.4 for those with no radiculopathy. This difference was also statistically significant (P < 0.0001). Moreover, there exists a moderate correlation between both functional scales within each group of patients: 0.72 (P < 0.0001) in the group with radiculopathy and 0.66 (P < 0.0001) among those without radiculopathy. The authors conclude that both functional disability scales accurately discriminated between these two groups of patients with low back pain of very different clinical and electromyographic severity.
Article
Cross-sectional data were analyzed from the Veterans Health Study, an observational study of patients receiving ambulatory care. To develop a method of stratifying patients with low back pain by combining patient reports of radiating leg pain with the results of straight leg raising tests. Four hundred thirty-four participants with low back pain were identified through patient reports of ever having had low back pain, of low back pain that began more than 3 months ago, and of a health-care visit for low back pain in the past year. Four hundred twenty-eight patients with low back pain were included in the current analysis. Participants were mailed a health-related quality of life questionnaire and had an interview that included a low back pain questionnaire and a straight leg raising test. Patients' reports of radiating leg pain and results of the straight leg raising tests were combined into four hierarchical groups. This stratification was evaluated in relation to responses to the health-related quality of life questionnaire, localized low back pain, disability, and use of medical services. The intensity of localized low back pain and disability increased from Group 1 (low back pain alone) to Group 4 (pain below knee with positive straight leg raising test result), whereas health-related quality of life decreased. Group 4 patients were 5.1 times more likely than were Group 1 patients to use medications for low back pain (95% confidence interval 1.2, 22.9), 6.8 times more likely to have a spinal magnetic resonance study (95% confidence interval, 2.7, 17.2), and 3.9 times more likely to have surgery (95% confidence interval, 1.3, 11.4). The method of measuring correlation performs well in identifying patients with different levels of localized low back pain intensity, health-related quality of life, and use of services. It may be useful in studies of health outcomes, in clinical trials, and in predicting demands on health care resources.
Article
Low back pain (LBP) is one of the most frequent reasons patients seek consultations in primary care, and it is a major cause of disability. Our research examines the natural history of LBP and the prediction of chronicity in the context of patients presenting to family medicine clinics. We performed a prospective cohort study of new episodes of LBP within the framework of a national family practice research network. The setting was 28 primary care family practice clinics located throughout Israel. Of 238 eligible subjects, 219 (92%) completed the study. During the 2-month study period, 2 subjects were referred to the emergency department and discharged, and 2 others were hospitalized. Forty-five percent did not require bed rest, and 38% of the employed were not absent from work. Seventy-one percent showed improvement in functional status; however, only 37% noted complete pain relief. Clinical and demographic data usually did not predict LBP-episode outcomes. The strongest predictors of chronicity were depression, history of job change due to LBP in the past, history of back contusion, lack of social support, family delegitimization of patient's pain, dissatisfaction with first office visit, family history of LBP or other chronic pain, coping style, and unemployment. The cohort patients displayed a relatively benign natural history of LBP, matched by benign clinical behavior from their physicians. In Israeli primary health care, acute LBP is infrequently associated with hospitalization or prolonged work absenteeism. Although most patients have functional improvement, pain often lingers. Almost all predictors of chronicity are psychosocial.
Article
We have developed a simple procedure for assigning persistent low back pain patients to one of four mutually exclusive, hierarchically organized classes. The procedure relies on the spatial distribution of a patient's pain and the results of straight leg raise tests to make the assignment. We have applied the procedure to a large group of patients who sought treatment for persistent LBP at several university affiliated tertiary care clinics, and found that the resulting four classes of patients were significantly different from one another in their presentation, and in the way they were evaluated and treated by physicians. We concluded that the procedure may have practical research and clinical applications.
Article
Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain. This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome. Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome. Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study. Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.
Article
Disability following acute occupational low back pain (OLBP) represents a significant and preventable health outcome, yet confusion about prognostic factors have limited the development of effective, targeted interventions for those at greatest risk. The purpose of this study was to synthesize findings from available studies of prognostic factors for OLBP disability in a clinically-relevant framework. A systematic search of the MEDLINE database was conducted to identify empirical studies assessing the value of various prognostic factors to predict extended disability after an acute episode of OLBP. Relevant studies were screened based on a number of inclusionary criteria. Prognostic factors were catalogued, summarized, and evaluated based on agreement across studies, and clinical recommendations were developed based on the evidence. Of 361 studies of OLBP disability found, 22 met specific criteria for inclusion. Significant prognostic factors included low workplace support, personal stress, shorter job tenure, prior episodes, heavier occupations with no modified duty, delayed reporting, severity of pain and functional impact, radicular findings and extreme symptom report. Physicians can decrease OLBP disability by using standardized questionnaires, improving communication with patients and employers, specifying return to work accommodations, and employing behavioural approaches to pain and disability management. Future studies should evaluate interventions guided by prognosis.
Article
A prospective cohort study was conducted on workers claiming earnings-related compensation for low back pain. Information obtained at the time of the initial claim was linked to compensation status (still claiming or not claiming) 3 months later. To identify individual, psychosocial, and workplace risk factors associated with the transition from acute to chronic occupational back pain. Despite the magnitude of the economic and social costs associated with chronic occupational back pain, few prospective studies have investigated risk factors identifiable in the acute stage. At the time of the initial compensation claim, a self-administered questionnaire was used to gather information on a wide range of risk factors. Then 3 months later, chronicity was determined from claimants' computerized records. The findings showed that 3 months after the initial assessment, 204 of the recruited 854 claimants (23.9%) still were receiving compensation payments. A combined multiple regression model of individual, psychosocial, and workplace risk factors demonstrated that severe leg pain (odds ratio [OR], 1.9), obesity (OR, 1.7), all three Oswestry Disability Index categories above minimal disability (OR, 3.1-4), a General Health Questionnaire score of at least 6 (OR, 1.9), unavailability of light duties on return to work (OR, 1.7), and a job requirement of lifting for three fourths of the day or more all were significant, independent determinants of chronicity (P < 0.05). Simple self-report measures of individual, psychosocial, and workplace factors administered when earnings-related compensation for back pain is claimed initially can identify individuals with increased odds for development of chronic occupational disability.
Article
In this prospective study, a cohort of 2077 workers free of sciatic pain and another cohort of 327 workers with severe sciatic pain were followed up for 1 year. To evaluate the effects of different risk factors on the incidence and persistence of sciatic pain. Sciatic pain seems to differ from other types of low back pain in terms of etiology, occurrence, and prognosis. Yet only a few studies of sciatic pain exist. The role of individual characteristics, occupational loading, and participation in different sports has rarely been assessed in a study with a prospective design among a working population. The subjects of this study, Finnish forest industry workers, replied to a modified version of the Nordic Questionnaire at the baseline of this study and after 1 year. The effects of the predictors on the 1-year incidence and persistence of sciatic pain were studied with multivariable logistic regression modeling. Greater age, mental stress, smoking of long duration, and work-related twisting of the trunk increased the risk of incidental sciatic pain. Joggers had a lower risk for incidental sciatic pain, but a higher risk for persistent symptoms. Walking was positively associated with the risk of incidental pain. Greater age, mental stress, former smoking, jogging, and poor job satisfaction increased the risk for persistent severe sciatic pain. The findings from this study suggest that mental stress and smoking are independent risk factors for incidental sciatic pain. Overall physical exercise and most of the sports activities, except jogging and walking, had no effect on sciatic pain. Physical workload factors seemed to be more involved in the onset of sciatic pain, whereas psychosocial factors were related to the persistence of symptoms.
Article
The objective of this study was to determine the prevalence of lower back pain and associated leg pain/numbness in postmenopausal Caucasian women and the relationship of these symptoms to health status and function. A convenience sample of 573 white women enrolled in the Observational Study of the Women's Health Initiative (WHI) in Pittsburgh completed a questionnaire on low back pain (LBP) and leg pain (LP) and its impact on their daily activity. For data analysis, this information was merged with that obtained under the standard WHI protocol. Almost half of the women (49%) reported having had LBP during the previous month: 8% had LBP only, while 41% had both LBP and LP. In 9% of women, the leg and back symptoms were alleviated by sitting. Among women with LBP during the previous month, those who also had leg pain were five times more likely to have had functional limitations, two to four times more likely to have consulted a clinician or taken medications, and more likely to have had prior spinal surgery or hospitalization than the women with no LP. Based on the Short Form-36, women with LBP/LP had significantly lower scores for physical function, physical role, and bodily pain than women with no LBP or with LBP alone. Low back pain that radiates into the hip, buttock, or leg is relatively common in postmenopausal Caucasian women living in the community and is associated with decreased physical health status and with physical limitations.
Article
The prevalence of sciatica in Western society and its economic and functional impact make it an important problem to understand for treatment. Such understanding will impact greatly both medical management and decisions regarding activity, which could affect the perceived disability and financial dependence of a patient. This knowledge could be used to direct primary prevention, patient education, and future research efforts in back pain. The article also discusses that such strategies could improve health, decrease disability, and rein in costs.
Article
Inception cohort study. To examine the clinical course of acute low back pain and to evaluate prognostic factors for nonrecovery. Few studies have explored clinical course and prognostic factors in patients who consult primary care for their first time because of an episode of low back pain of <3 weeks duration. A total of 123 patients with acute low back pain <3 weeks consulting primary care for the first time were included, and 120 completed 3 months follow-up. Baseline assessments included sociodemographic characteristics, back pain history and current status, psychological questionnaires and clinical examination. Main outcome measures were pain intensity, disability by Roland Morris Disability Questionnaire, and recovery of disability. Potential prognostic factors for recovery or not were analyzed by multivariate logistic regression. At 4 weeks and 3 months 76% of the patients had recovered. Mean pain intensity and mean disability scores dropped 58% and 68%, respectively, of initial levels during the 3 months. The proportion with sickness absence was 8% at 4 weeks and 6% at 3 months. Several sociodemographic, clinical, and psychological factors were of prognostic value. Compared with their respective reference categories, age above 45 years (odds ratio 4.4, 95% confidence interval 1.4-14.0), smoking (3.0, 1.1-8.5), two or more neurological signs (4.6, 1.4-14.9), a score of >or=90 on the psychosocial screening (3.1, 1.0-9.4), and high levels of distress (4.1, 1.3-12.8) were the best prognostic factors of nonrecovery at 3 months. During a period of 3 months, 24% of the patients had not recovered. Psychological factors and neurological signs were strongly associated with nonrecovery at 3 months. In addition to the traditional examination of neurological symptoms and signs, psychological factors should be considered already at the initial visit of an episode of low back pain.
Article
Low back pain is a major burden to society. Many people will experience an episode of low back pain during their life. Some people develop chronic low back pain, which can be very disabling. Low back pain is associated with high direct and indirect costs. Recent epidemiological data suggest that there is a need to revise our views regarding the course of low back pain. Low back pain is not simply either acute or chronic but fluctuates over time with frequent recurrences or exacerbations. Also, low back pain may frequently be part of a widespread pain problem instead of being isolated, regional pain. Although epidemiological studies have identified many individual, psychosocial and occupational risk factors for the onset of low back pain, their independent prognostic value is usually low. Similarly, a number of factors have now been identified that may increase the risk of chronic disability but no single factor seems to have a strong impact. Consequently, it is still unclear what the most efficient strategy is for primary and secondary prevention. In general, multi-modal preventative approaches seem better able to reflect the clinical reality than single-modal interventions.
Article
The aims of this study were to investigate the possible prognostic value of disk-related magnetic resonance imaging (MRI) findings in relation to recovery at 14 months in patients with severe sciatica, and whether improvement of disk herniation and/or nerve root compromise is concurrent with recovery. All patients included in this prospective observational study of patients with sciatica receiving active conservative treatment were scanned at baseline and at 14 months' follow-up. Definite recovery at follow-up was defined as an absence of sciatic leg pain and a Roland Morris disability score of 3 or less. Potential predictors of interest were disk-related MRI findings in the lumbar spine. Bi- and multivariate logistic regression analyses were used to identify any predictors of recovery. Age, sex, and treatment were included in the analyses as possible confounding/modifying factors. According to the definitions used, 53% of 154 patients recovered; 63% of men (n = 84) and 40% of women (n = 70). In the multivariate analyses, broad-based protrusions, extrusions, and male sex were found to be predictive of a positive outcome. Sex was identified as a true confounder in that the prevalence of disk-related MRI findings was different for men and women, and they had different recovery rates. Improvement of disk herniations and nerve root compromise over time did not coincide with definite recovery. In patients with sciatica receiving active conservative treatment, broad-based protrusions and extrusions at baseline were positive predictors of definite recovery at 14 months. However, at 14 months the MRI-defined improvement of disk herniations and nerve root compromise was not correlated with definite recovery.
The epidemiology of spinal disorders The Adult Spine: Principles and Practice. Philadelphia: Lippincott-Raven
  • Gbj Andersson
  • Jw Frymoyer
  • Tb Ducker
  • Nm Hadler
Andersson GBJ. The epidemiology of spinal disorders. In: Frymoyer JW, Ducker TB, Hadler NM, et al, eds. The Adult Spine: Principles and Practice. Philadelphia: Lippincott-Raven; 1997:93–150.
Standards Advisory Group Report on Back Pain
  • Csag Clinical
Clinical CSAG. Standards Advisory Group Report on Back Pain. London: HMSO; 1994.