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Clinical manifestation of acute, subacute and chronic low back pain in different age groups


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Background Low back pain is major health care problem causing tremendous economic cots. Methods Clinical manifestation of low back pain (LBP) was characterized in 35,446 patients. We focused on the comparison of the acute, subacute, and chronic LBP stage with regard to patients’ age, based on epidemiological and clinical questionnaires (e.g. painDETECT, pain disability index), pain intensity, pain descriptors, and functional impairment. Results We found that neuropathic components were most frequent in chronic LBP patients at the age of 51‐60 years. Elderly LBP patients showed a decrease in neuropathic and an increase of nociceptive pain. The most frequently reported pain descriptors were “pressure pain” and “pain attacks” through all stages of LBP, whereas “burning” and “prickling” were most frequent in the chronic stage. Patients after back surgery presented neuropathic pain symptoms most frequently and had the highest amount of pain medication intake. Conclusions Burning and prickling were revealed as possible indicators for LBP chronicity. Combined with pain attacks and pressure pain, these four pain descriptors might be a promising adjunct to pain intensity in terms of outcome parameters for future LBP studies. The decrease of neuropathic pain syndromes in the elderly might be explained by degenerative processes in main parts. The presented work provides important insights on LBP management in the acute, subacute, and chronic stage. This article is protected by copyright. All rights reserved.
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Clinical Manifestation of Acute, Subacute, and
Chronic Low Back Pain in Different Age
Groups: Low Back Pain in 35,446 Patients
Philipp H
ullemann, PhD*; Thomas Keller, DSc
; Maria Kabelitz, Dip
Janne Gierthm
uhlen, PhD*; Rainer Freynhagen, PhD
; Thomas T
olle, PhD
Julia Forstenpointner , MD*; Ralf Baron, PhD*
*Division of Neurological Pain Research and Therapy, Department of Neurology, University
Hospital Schleswig-Holstein, Kiel;
StatConsult GmbH, Magdeburg;
Centre of
Anaesthesiology, Intensive Care Medicine, Pain Medicine and Palliative Care Medicine,
Benidictus Hospital Tutzing and Department of Anaesthesiology, Technical University of
Munich, Munich;
Department of Neurology, Klinikum rechts der Isar, Technical University of
Munich, Munich, Germany
Background: Low back pain (LBP) is a major healthcare
problem causing tremendous economic costs.
Methods: Clinical manifestation of LBP was characterized in
35,446 patients. We focused on the comparison of the acute,
subacute, and chronic LBP stage with regard to patients’
ages, based on epidemiologic and clinical questionnaires (eg,
painDETECT Questionnaire, Pain Disability Index), pain inten-
sity, pain descriptors, and functional impairment.
Results: We found that neuropathic components were most
frequent in chronic LBP patients at the ages of 51 to 60 years.
Elderly LBP patients showed a decrease in neuropathic and an
increase in nociceptive pain. The most frequently reported
pain descriptors were “pressure pain” and “pain attacks”
through all stages of LBP, whereas “burning” and “prickling”
were most frequent in the chronic stage. Patients after back
surgery presented neuropathic pain symptoms most fre-
quently and had the highest amount of pain medication
Conclusions: Burning and prickling were revealed as possi-
ble indicators for LBP chronicity. Combined with pain attacks
and pressure pain, these 4 pain descriptors might be a
promising adjunct to pain intensity in terms of outcome
parameters for future LBP studies. The decrease of neuro-
pathic pain syndromes in the elderly might be explained by
degenerative processes. The presented work provides impor-
tant insights on LBP management in the acute, subacute, and
chronic stages. &
Key Words: painDETECT, neuropathic component, age,
low back pain, pain descriptors
Low back pain (LBP) is a global healthcare issue with a
high lifetime prevalence
and a high chronicity rate.
During the past decade, the prevalence of chronic low
back pain (cLBP) increased,
causing tremendous
economic costs
and representing the main reason
Address correspondence and reprint requests to: Philipp H
PhD, Division of Neurological Pain Research and Therapy, Department of
Neurology, University Clinic Schleswig-Holstein, Campus Kiel, Arnold-
Heller-Str. 3, Haus 41, 24105 Kiel, Germany. E-mail: p.huellemann@neur-
Submitted: December 21, 2017; Revised March 26, 2018;
Revision accepted: March 31, 2018
DOI. 10.1111/papr.12704
©2018 World Institute of Pain, 1530-7085/18/$15.00
Pain Practice, Volume , Issue , 2018 
for sick leave and early retirement.
Notably, the
neuropathic components of LBP are particularly respon-
sible for increased economic costs.
The pathogenesis of LBP is heterogeneous and cannot
be summarized into a single pathophysiological
Most clinical guidelines for the assessment of
LBP propose a classification into 3 groups: nonspecific
LBP, specific LBP (based on the “red flags” checklist),
and radiculopathy.
Other classifications are based on
pathophysiological mechanisms (ie, nociceptive vs.
neuropathic pain) rather than ethology.
Although, some progress has been made regarding
the management of LBP, specific treatment of defined
subgroups is still estimated to be insufficient.
patients report no, or insufficient, benefit from treat-
11% to 12% of LBP patients are disabled
because of LBP,
and 10% to 15% develop a cLBP
state, which hardly improves over time and consumes
most resources.
Only a few reports have addressed gender-specific
and sociodemographic variables as well as pain charac-
teristics in large cohorts of LBP patients, with respect to
the stage (acute, subacute, and chronic) of LBP.
present investigation aimed to assist future research and
clinical physicians to choose the most relevant param-
eters/questionnaires for optimal LBP management. The
objectives were:
1. To give an update on epidemiologic and sociode-
mographic data, based on datasets of more than
35,000 patients with LBP, and to investigate the
impact of these parameters on various aspects of
2. To assess differences in chronicity stages of LBP
(acute, subacute, and chronic).
3. To estimate the impact of neuropathic compo-
nents, psychological parameters, and functional-
ity in LBP in different age groups.
4. To assess the impact of age on the clinical
manifestation of LBP.
An epidemiologic questionnaire (see later section on
questionnaires) and 7 clinical questionnaires were pre-
sented to LBP patients (at least 18 years old) on a hand-
held computer (personal digital assistant [PDA]; Palm
Tungsten E operating on the platform OS 5.4). The
programming of the PDAs included automated plausi-
bility checks, and on a regular basis, anonymized and
encrypted data were transferred to a central database.
Missing values were not replaced.
The recruiting sites (offices of general practitioners,
rheumatologists, orthopedists, and pain specialists)
consisted of about 900 physician offices throughout
Germany, which were responsible for the correct
implementation of study procedures. The patients were
not reimbursed, and physicians did not receive financial
incentive for recruitment efforts, but they were free to
use their collected data for diagnostic support, docu-
mentation, or quality measurement.
The ethical committee of the University of D
dorf approved the study protocol. All protocols con-
formed to guidelines as set by the Declaration of
Definition of Low Back Pain and Pain Stage
The area of LBP was defined by the main area of pain.
The patient selected the main area on a mannequin,
which was presented on the PDA screen. Patients who
selected any upper body part above the lower back (eg,
head, neck, shoulders, arms, hands) were excluded from
According to their stage of LBP,
patients were
distributed into 3 groups for later analysis:
Acute LBP (< 6 weeks)
Subacute LBP (6 weeks to 3 months)
cLBP (> 3 months)
Assessment of Epidemiologic Parameters
The following variables were analyzed: age, gender,
body mass index, surgery (surgery because of back pain,
intervertebral disc surgery), sick leave from work
because of LBP, medication intake, and hospitalization.
Pain Intensity (Visual Analog Scale [VAS]). The pain
intensity indicates the patient’s current pain as well as
average and maximum pain within the preceding
4 weeks. Patients were asked to rate their subjective
pain perception on a VAS, scored from 0 (no pain) to
100 (maximum imaginable pain).
painDETECT Questionnaire (PD-Q). Freynhagen
et al.
validated the PD-Q for the screening of neuro-
pathic pain features in patients with back pain. In order
to differentiate between neuropathic and nociceptive
pain, 3 categories were introduced: a PD-Q score of 12
points indicates that a neuropathic component is
unlikely; 13 to 18 points means it is uncertain (ie, a
neuropathic pain component can be present); and 19
points means it is likely (ie, >90% probability of having
neuropathic pain components). The sensitivity and
specificity of a correct assignment were calculated at
84% each. The positive predictive value was calculated
to be 83%.
Since 2006 the questionnaire has been validated for
other cultures and languages,
as has the application
of an electronic version of the PD-Q.
In the present study, the sum score of each patient
group and the frequency of neuropathic pain symptoms
were analyzed.
Pain Disability Index (PDI). The PDI
assesses the
patient’s disability caused by pain on a scale from 0 (no
disability) to 70 (maximum disability). To facilitate a
better comparability, the PDI was graded according to
the disability status as follows: grade I, score of 0 to 13
(no relevant disability); grade II, score of 14 to 34 (mild
disability); grade III, score of 35 to 55 (moderate
disability); and grade IV, score of 56 to 70 (severe
Hannover Functional Questionnaire (FFbH-R). The
contains 12 questions, assessing the ability to
perform activities like lifting a heavy object, putting on
socks, or reaching for a shelf. The questionnaire has a
maximum score of 36 points (36 points =100% ability
to perform all 12 tasks in daily life; 0 points =0%
maximal impairment); 29 to 36 points (80% to 100%)
indicates normal functionality, 22 to 28 points (60% to
79%) moderate functionality, and less than 21 points
(<60%) relevant impairment.
Heidelberg Short Questionnaire (HKF-R-10). The
was validated to predict the risk for
developing cLBP, with a sensitivity of 75.3% and a
specificity of 78.6%. Additionally, the chronicity
stages were graded according to 6 categories. For
practicability reasons, categories C and D (no predic-
tion possible) were combined: Category A (0 to 2.5
points) =predicts no risk for chronicity, Category B
(3 to 8 points) =predicts no risk for chronicity in
70%, Category C+D (8.5 to 27.5 points) =no
prediction possible, Category E (28 to 36.5
points) =predicts risk for chronicity in 70%, and
Category F (37 points) =predicts high risk for
Patient Health Questionnaire (PHQ-D). The PHQ-D
assesses the severity of depression in depressive, panic,
and anxiety disorders on a scale from 0 to 27 (0 to
4=nonminimal; 5 to 9 =mild; 10 to 14 =moderate;
15 to 19 =moderately severe; and 20 to 27 =severe).
Generalized Anxiety Disorders (GAD-7). The GAD-
contains 7 items, and each item scores anxiety on a
scale from 0 to 3 (0 to 4 points =minimal; 5 to 9
points =minor; 10 to 14 points =moderate; and 15 to
21 points =major).
Statistical Analysis
The German painDETECT database contains 265,271
documented patient data sets. For the analysis, only
patients who met the inclusion criteria for LBP were
included, which consisted of a total of 35,446 patients
(1,420 acute, 1,732 subacute, and 32,294 chronic).
Patients with multiple pains were excluded (see later
subsection on analysis of LBP intensity). Derived data
sets were obtained via SAS programs containing proce-
dures for labeling, formatting, and calculating addi-
tional variables (SAS
9.2; SAS Institute Inc., Cary, NC,
For the calculation of categorical data, contingency
tables were applied, and acute, subacute, and chronic
stage subgroups were analyzed in relation to question-
naire items. The results of the contingency table were
presented as absolute and relative frequencies. In addi-
tion, gender-specific differences were assessed (Mann
Whitney U-test).
Ordinal variables (eg, age group, categories derived
from total scores of questionnaires) were correlated to
the subgroups representing different chronicity stages
(Mantel-Haenszel test). Further, the relation of catego-
rized nominal variables (eg, PD-Q symptoms) was
analyzed to differentiate between chronicity stages
(Armitage Trend test).
Pairwise comparisons of parameters evaluating sur-
gery, pain medication, hospitalization, and sick leave
between acute, subacute, and chronic patients, respec-
tively, were calculated by odds ratios (ORs; P<0.05).
Comparisons of continuous variables between pain
groups were calculated with analysis of variance (with
Bonferroni correction, where applicable). All statistical
Low Back Pain in 35,446 Patients 3
tests were performed as exploratory data analysis and
were not corrected for multiple testing.
In total, 133,832patients from the painDETECT database
(of 265,271 patients), were assigned to the category “back
pain” by their physician. Out of this cohort, 98,386
patients had to be excluded from analysisdue to additional
main pain above the lower back or radiating pain into
other body areas (such as the neck, shoulders, or arms). In
35,446 patients, the inclusion criteria for LBP were met,
and these patients were included in the data analysis.
Further subgrouping revealed that 1,420 patients (663
male, 757 female) suffered from acute LBP, 1,732 patients
(786 male, 946 female) suffered from subacute LBP, and
32,294 (13,116 male, 19,178 female) were categorized as
cLBP patients. Epidemiologic and sociodemographic
data, such as pain medication, sick leave, and back
surgery, are presented in Table 1.
Analysis of Low Back Pain Intensity
Analysis of Pain Intensity with Regard to Chronicity
Stage. The current and average pain intensity was
higher in chronic LBP compared to patients with acute
LBP. In contrast, maximum pain intensity was higher in
subacute patients than in acute patients, whereas no
difference between chronic and acute LBP patients was
found (see Table 1).
Age-Dependent Analysis of Pain Intensity. Chronic
patients were significantly older than acute and subacute
patients (P<0.001; see Table 1). An age-related anal-
ysis of patients <65 years of age vs. >65 years of age
indicated that the average pain intensity was higher in
elderly LBP patients in the acute (52.03 [21.01] vs.
58.46 [20.2]; P<0.0001), subacute (56.16 [19.14]
vs. 58.98 [20.48]; P=0.017), and chronic stages
(57.42 [18.89] vs. 58.08 [19.13]; P=0.0068).
Remarkably, in patients under the age of 65 years, the
average pain intensity increased from the acute towards
the chronic LBP group (acute vs. subacute and chronic,
P<0.0001; subacute vs. chronic, not significant [n.s.]).
In contrast, no difference between acute, subacute, and
chronic LBP patients was detected in patients >65 years
of age (P>0.1 for all comparisons; Figure 1).
Gender-Dependent Analysis of Pain Intensity and
Chronicity. Depending on the LBP chronicity stage,
gender-specific analysis revealed that men were up to
3.5 years younger compared to women (P<0.001; see
Table 1). Notably, women reported higher current,
average, and maximum pain intensity compared to
men (on average 3 to 4 VAS points during the acute
stage (P<0.001 for all comparisons); 1.5 to 4 VAS
points during the subacute stage (P<0.001 for current
and average pain intensity; n.s. for maximum pain
intensity); and 2 to 3 VAS points during the chronic
stage (P<0.001 for all comparisons).
Evaluation of Neuropathic Pain Components
PD-Q Score with Regard to Chronicity Stage. The
neuropathic pain score (PD-Q) was highest in chronic
LBP patients (13.2 [7.1]) in comparison to subacute
(11.6 [6.7]) and acute (10.7 [6.4]) patients
(P<0.0001 for all comparisons).
In the acute group of LBP patients, 65.8% (n=934)
scored unlikely, 21.1% (n=300) scored unclear, and
13.1% (n=186) scored likely for neuropathic pain
components. The corresponding frequencies in the
subacute group were 59.9% (n=1,037), 23.6%
(n=409), and 16.5% (n=286); in the chronic group
49.3% (n=15,919), 27.4% (n=8,864), and 23.3%
(n=7,511), respectively. Not surprisingly, the cLBP
group presented the highest percentage for neuropathic
pain components (P<0.0001).
Analysis of PD-Q descriptors revealed that attacks
and pressure were most frequently reported through all
stages of LBP, followed by burning and prickling, which
were reported more often in the chronic stage (Table 2),
whereas allodynia and thermal hyperalgesia were
reported less frequently. Numbness was reported more
often at the chronic stage but did not reach frequencies
in the range of the above-mentioned parameters.
The PD-Q sum score analysis was in line with PD-Q
frequencies and revealed an increasing score for all
symptoms from the acute to the subacute and chronic
pain stages, except for allodynia (P<0.0001 for burn-
ing, thermal hyperalgesia, and numbness; P<0.001 for
pressure; P<0.01 for prickling). The PD-Q sum scores
and PD-Q descriptors of acute, subacute, and chronic
LBP patients are presented in Figure 2 and Table 2.
Age-Dependent Analysis of PD-Q Score. Interestingly,
in subacute and chronic patients, the frequency of
neuropathic components increased until the age of
60 years. After the age of 60 years, neuropathic pain
components decreased in the subacute group (P<0.01)
and chronic group (P<0.0001), but not in the acute
group (see Figure 2).
Furthermore, the highest frequency of neuropathic
pain components was found in patients between 51 and
60 years of age at the subacute and chronic stages of
Gender-Dependent Analysis of PD-Q Score. Frequen-
cies of neuropathic pain components between male
Table 1. Epidemiologic Parameters and Pain Intensity
Acute LBP (n=1,420) Subacute LBP (n=1,732) Chronic LBP (n=32,294)
Odds Ratiosncol. % ncol. % ncol. %
Male 663 46.7 786 45.4 13,116 40.6
Female 757 53.3 946 54.6 19,178 59.4
Total 1,420 100.0 1,732 100.0 32,294 100.0
Pain medication
Male 326 (662) 49.2 464 (783) 59.3 8,750 (13,089) 66.9 Male vs. female: 0.511; P<0.0001
Acute vs. chronic: 0.828; P=0.0045
Acute vs. subacute: 0.448;P<0.0001
Subacute vs. chronic: 0.541; P<0.0001
Female 386 (757) 51.0 605 (944) 64.1 13,638 (19,144) 71.2
Total 712 (1,419) 50.2 1,069 (1,727) 61.9 22,388 (32,233) 69.5
Sick leave
Male 198 (536) 35.2 351 (624) 56.3 3,779 (9,187) 41.1 Female vs. male 0.819; P<0.0001
Acute vs. chronic 0.123; P<0.0001
Acute vs. subacute 0.807; P=0.2105
Subacute vs. chronic 6.534; P<0.0001
Female 147 (611) 24.1 289 (728) 39.7 3,305 (12,616) 26.2
Total 345 (1,174) 29.4 640 (1,352) 47.3 7,084 (21,803) 32.5
Male 87 (663) 13.1 134 (786) 17.0 6,359 (13,116) 48.5 Female vs. male 0.732; P<0.0001
Acute vs. chronic 0.122; P<0.0001
Acute vs. subacute 0.784; P=0.2460
Subacute vs. chronic 6.402; P<0.0001
Female 68 (757) 9.0 173 (946) 18.3 8,271 (19,178) 43.1
Total 155 (1,420) 10.9 307 (1,732) 17.7 14,630 (32,294) 45.3
Back surgery
Male 32 (617) 5.2 39 (732) 5.3 3,572 (12,072) 29.6 Female vs. male 1.220; P<0.0001
Acute vs. chronic 0.447; P<0.0001
Acute vs. subacute 0.621; P<0.0001
Subacute vs. chronic 1.388; P<0.0001
Female 28 (728) 3.8 49 (877) 5.6 4,533 (17,733) 25.6
Total 60 (1,345) 4.5 88 (1,609) 5.5 8,105 (29,805) 27.2
Intervertebral disc surgery
Male 24 (617) 3.9 31 (732) 4.2 2,678 (12,064) 22.2 Female vs. male 0.812; P<0.0001
Acute vs. chronic 0.145; P<0.0001
Acute vs. subacute 0.572; P<0.0001
Subacute vs. chronic 3.950; P<0.0001
Female 15 (728) 2.1 28 (877) 3.2 3,068 (17,724) 17.3
Total 39 (1,345) 2.9 59 (1,609) 3.7 5,746 (29,788) 19.3
nMean SD nMean SD nMean SD
Significance Level
Age (years)
Male 663 49.6 15.6 781 52.1 15.9 13,087 55.9 14.4 <0.001 (all comparisons
significant)Female 748 53.1 16.7 940 54.9 16.1 19,126 59.5 14.9
Total 1,411 51.5 16.3 1,721 53.6 16.0 32,213 58.0 14.8
Male 650 27.5 5.3 774 27.6 4.4 12,874 28.1 4.8 <0.001 (acute vs. subacute n.s.)
Female 734 26.6 5.7 926 26.9 6.1 18,819 27.8 5.9
Total 1,384 27.0 5.6 1,700 27.2 5.4 31,693 27.9 5.5
Current pain
Male 559 43.4 24.0 672 43.9 24.7 11,006 49.5 23.7 <0.001 (acute vs. subacute n.s.)
Female 616 47.3 25.6 795 47.3 24.3 15,688 51.0 23.9
Total 1,175 45.5 24.9 1,467 45.7 24.5 26,694 50.3 23.8
Average pain
Male 559 51.2 20.8 672 54.6 19.7 11,006 56.1 19.2 <0.001 (chronic vs. subacute n.s.)
Female 616 55.6 21.1 795 58.9 19.2 15,688 58.8 18.8
Total 1,175 53.5 21.0 1,467 57.0 19.5 26,694 57.7 19.0
Maximum pain
Male 559 76.0 19.9 672 79.2 18.7 11,006 77.2 18.1 <0.001 (acute vs. chronic n.s.)
Female 616 79.2 19.2 795 80.8 17.7 15,688 78.5 17.5
Total 1,175 77.7 19.6 1,467 80.1 18.2 26,694 77.9 17.8
Data are displayed as means and standard deviations. Frequency comparisons were calculated with odds ratios. The comparison of the sum scores between acute, subacute, and
chronic low back pain (LBP) patients is calculated in the last column (analysis of variance [ANOVA] with Bonferroni correction as post hoc test). Total patient numbers are presented
in parentheses.
col. %, column; BMI, body mass index; n.s., not significant.
Low Back Pain in 35,446 Patients 5
and female patients were comparable in all stages of
LBP (Figure 3). A gender-based evaluation of PD-Q
symptom distribution revealed that at the acute
stage, pressure was reported more frequently in
female patients (P=0.0034); at the subacute stage,
women reported thermal hyperalgesia (P=0.04) and
pressure (P<0.0001) more frequently; at the
chronic stage, male patients reported prickling
(P<0.0001), pain attacks (P=0.021), and numb-
ness (P<0.0001) more frequently, whereas women
reported more allodynia (P<0.0001), thermal
hyperalgesia (P<0.001), and pressure (P<0.0001)
(see Table 2).
Parameters Investigating Functionality (PDI, FFbH-R)
The disability index (PDI) of LBP patients increased
from the acute (31.8 [16.2]) to the subacute (33.5
[16.3]) and chronic (35.4 [15.1]) LBP stages
(P<0.0001 for all comparisons) (Table 3). Moderate
to severe disability was found most frequently in
cLBP patients. Corresponding to that, the functional-
ity score (FFbH-R) decreased accordingly from the
acute (62.2 [24.4]) towards the chronic (55.3
[22.8]) pain stage. The correlation analysis revealed
a significant correlation between PDI and FFbH-R
(r=0.65). Patients over the age of 60 years had
lower functionality scores in comparison to younger
patients (FFbH-R 63.12 [20.74] vs. 69.01 [19.56],
Parameters Assessing Chronicity, Depression, and
Anxiety Levels (HKF-R-10, PHQ-D, GAD)
Severity of chronicity (HKF-R-10) and depression
(PHQ-D) scores increased from acute (HKF-R-10,
39.2 [29.7]; PHQ-D, 7.4 [5.2]) to subacute (HKF-
R-10, 41.4 [27.7]; PHQ-D, 8.5 [5.4]) to chronic
(HKF-R-10, 52.5 [29.2]; PHQ-D, 9.2 [5.6]) LBP
patients (P<0.001). In contrast, the anxiety sum score
(GAD) remained unchanged through all stages of
disease (P>0.5).
Accordingly, the percentage of moderate-to-severe
and severe depression was highest in the chronic group
(P<0.001), whereas moderate-to-severe anxiety
remained unchanged (P=0.971). Patients over the age
of 60 years had lower anxiety and depression scores in
comparison to younger patients (GAD 6.05 [5.21] vs.
7.42 [5.6], P<0.0001; PHQ-D 9.07 [5.47] vs.
10.43 [5.96], P<0.0001).
Figure 1. Average pain intensity (VAS). The average pain intensities are shown for acute, subacute, and chronic LBP patients in relation
to different age groups. Values are shown with mean 95%confidence interval. Patient numbers are indicated in grey.
Correlation Analysis of Questionnaires’ Sum Scores
with Pain Intensity, Functionality, and Neuropathic
Pain Score
Pain intensity (current, average, and maximum) corre-
lated weakly to moderately with the disability index (PDI)
through all stages of LBP (r=0.44 to 0.53). Further
correlationanalysis revealed thatin theacutestage of LBP,
neuropathic pain components (PD-Q) correlated moder-
ately with current pain intensity (VAS) and disability
(PDI). In the chronic stage, there was no correlation
between PD-Q score and pain intensity (r=0.21 to 0.27
for current, average, and maximum pain intensity).
Table 2. Frequencies of Clinically Relevant painDETECT Questionnaire (PD-Q) Symptoms
PD-Q Symptoms Gender
(n=32,294) Acute vs.
Subacute vs.
Chronic (Trend Test) Male vs. Female (MannWhitney U-Test)ncol. % ncol. % ncol. %
Burning Male 90 13.6 114 14.5 3,006 22.9 < 0.0001 Acute: P=0.1233 Subacute: P=0.1539
Chronic: P=0.6346Female 125 16.5 161 17 4,352 22.7
All 215 15.1 275 15.9 7,358 22.8
Prickling Male 81 12.2 134 17 3,069 23.4 < 0.0001 Acute: P=0.4368 Subacute: P=0.4670
Chronic: P< 0.0001Female 103 13.6 149 15.8 4,009 20.9
All 184 13 283 16.3 7,078 21.9
Allodynia Male 24 3.6 38 4.8 812 6.2 < 0.0001 Acute: P=0.9571 Subacute: P=0.3210
Chronic: P< 0.0001Female 27 3.6 56 5.9 1,429 7.5
All 51 3.6 94 5.4 2,241 6.9
Attacks Male 175 26.4 211 26.8 4,073 31.1 0.0089 Acute: P=0.1998 Subacute: P=0.4047
Chronic: P= 0.0205Female 223 29.5 271 28.6 5,724 29.8
All 398 28 482 27.8 9,797 30.3
Thermal hyperalgesia Male 15 2.3 32 4.1 939 7.2 < 0.0001 Acute: P=0.1882 Subacute: P= 0.0443
Chronic: P= 0.0002Female 26 3.4 59 6.2 1,587 8.3
All 41 2.9 91 5.3 2,526 7.8
Numbness Male 67 10.1 87 11.1 2,137 16.3 < 0.0001 Acute: P=0.1264 Subacute: P=0.1284
Chronic: P< 0.0001Female 59 7.8 84 8.9 2,401 12.5
All 126 8.9 171 9.9 4,538 14.1
Pressure Male 104 15.7 123 15.6 2,804 21.4 < 0.0001 Acute: P= 0.0034 Subacute: P< 0.0001
Chronic: P< 0.0001Female 165 21.8 241 25.5 5,651 29.5
All 269 18.9 364 21 8,455 26.2
PD-Q scores of >3 (out of 5) were estimated to be clinically relevant. Frequencies above 20% are indicated in boldface.
col. %, column.
Figure 2. PainDETECT Questionnaire (PD-Q) score and PD-Q symptoms. PD-Q symptoms in relation to pain groups (acute, subacute, and
age groups are shown on the left side. In order to improve visualization, the 6-point PD-Q scale was reduced to a 4-point scale (strong,
very strong are not shown). The PD-Q sum score is presented on the right side (the scale was reduced from 38 to 20). Values are shown
with mean 95% confidence interval.
Low Back Pain in 35,446 Patients 7
Figure 3. PainDETECT Questionnaire (PD-Q) grading frequencies. The PD-Q grading frequencies are shown for acute, subacute, and
chronic patients of different age groups. Significance level (Mantel-Haenszel correlation): acute p=0.0079; subacute p=0.49; chronic
p<0.0001. Patient numbers are indicated in grey.
Low Back Pain Treatment
The highest percentage of back surgery and hospitaliza-
tion was detected at the chronic pain stage (27%). In
contrast, back surgery was rarely performed in patients
in the acute (5%) and subacute (6%) stages. Accord-
ingly, 50% of patients required pain medication at the
acute stage, 62% at the subacute stage, and 70% at the
chronic stage (see Table 1).
Gender-specific differences in surgical interventions,
pain medication intake, and hospitalization were esti-
mated as not being clinically relevant since the differ-
ences did not exceed 5% (OR 0.732 to 1.220), although
all comparisons were significant (P<0.001) due to the
high number of patients (see Table 1).
Notably, male patients were on sick leave more
frequently as compared to female patients through all
stages of back pain (ie, 11.1% to 16.6%; see Table 1).
Further, 47% of the patients in the subacute group were
on sick leave due to their back pain, in contrast to 29%
in the acute group and 33% in the chronic group.
Interestingly, patients who had undergone a previous
surgical intervention presented neuropathic pain com-
ponents more frequently, as indicated by increased PDQ
scores. Signs of neuropathic pain were present in 41.4%
of patients with previous surgery, compared to 26.1%
with no previous back surgery.
LBP is a very common pain syndrome with a tremen-
dous socio-economic impact. In the past, it was demon-
strated that LBP not only influences individual physical
and psychological constitutions, but that it also affects
various areas of life ranging from individual socio-
economic aspects to public healthcare issues. Therefore,
it is important to improve the understanding of pain
mechanisms with regard to different chronicity stages as
well as their impact on sociodemographic and epidemi-
ologic aspects.
Pain Descriptors and Pain Intensity in LBP
Neuropathic pain components are reported to be
major contributors to LBP chronicity.
The present
investigation confirms that neuropathic pain was
highest at the chronic stage. Further analysis of PD-
Q symptoms revealed that most relevant clinical
symptoms were pain attacks and pressure in all stages
of LBP, followed by burning and prickling, which
were found mainly in the chronic stage. This suggests
that future clinical trials investigating LBP may
include these symptoms as promising outcome param-
eters in addition to pain intensity. In contrast,
allodynia, thermal hyperalgesia, and numbness seem
to be negligible.
Notably, there was no correlation between PD-Q
score and pain intensity in the cLBP stage regarding
average, current, and maximum pain on the VAS,
indicating that both pain intensity and PD-Q score need
to be assessed in order to retrieve a complete data set.
Anxiety, Depression, and Sick Leave in LBP
Hong et al.
reported increased frequencies of depres-
sion and anxiety in cLBP patients. In contrast to this,
anxiety scores (GAD) did not differ through pain stages,
whereas depression (PHQ-D) showed significantly
higher scores in cLBP. This result implicates that anxiety
does not change during the chronicity process; therefore,
anxiety might have less impact on pain chronicity than
previously assumed.
Patients in the subacute group were on sick-leave
most frequently (ie, 47%), which makes this group the
focus of socio-economic considerations. Directing more
medical attention to this group might help reduce
chronicity and the high rate of sick leaves, and therefore
reduce economic costs.
Impact of Age on LBP Intensity and Neuropathic Pain
Patients over 65 years of age reported higher pain
intensities than patients under 65 through all stages of
LBP, which is in line with the findings of Lautenbacher
et al.,
who reported a reduced tolerance to moderate
and severe pain in the elderly.
Chronic LBP patients between 51 and 60 years of age
reported neuropathic pain components most frequently,
whereas neuropathic components decreased in patients
over 60 years of age. This decreased frequency of
neuropathic components may be explained by degener-
ative processes in the intervertebral disc tissue prevent-
ing further nerve compression.
This finding is in
contrast to previous work showing a reduced efficacy of
descending inhibitory controls in the elderly,
was interpreted as possibly contributing to a higher
frequency of neuropathic pain in the elderly.
The literature lacks information about the frequency
of neuropathic pain components in elderly LBP patients.
Low Back Pain in 35,446 Patients 9
Only 1 recent study examining a rather small number of
cLBP patients found that “neuropathic pain was signif-
icantly reduced with age,” without providing any
specific explanation for the reduction of neuropathic
pain in the elderly.
Furthermore, older age appeared to
be a protective factor for persistent neuropathic pain
after inguinal herniorrhaphy,
although this finding
was not discussed either. Dziechciaz et al.
that nociceptive symptoms appear more frequently in
the elderly population (such as osteoporosis,
osteoarthritis, rheumatoid arthritis, or degeneration or
instability of the spine), which might reduce the
proportion of neuropathic LBP.
It is not surprising that younger LBP patients
presented lower frequencies of neuropathic pain com-
ponents since patients 51 to 60 years of age have almost
reached the end of their working lives, when interver-
tebral disc herniation and protrusion are reported most
frequently even in pain-free subjects.
Depression and anxiety decreased in individuals over
60 years of age, which is contrary to the reported increase
in pain intensity. The fact that patients under 60 years of
age have higher depression and anxiety scores might be
explained by psychosocial factors (eg, negative implica-
tions in their work lives due to repetitive sick leave).
LBP Treatment
The majority of LBP is estimated to be of nonspecific
origin, and such patients do not benefit from surgical
However, 27% of cLBP patients under-
went back surgery and 19% underwent intervertebral
disc surgery. This high number of surgical interventions
is alarming, since only 7% to 10% of LBP patients suffer
from specific LBP syndromes.
The majority of patients
improve by conservative treatment.
Our data imply
that only the frequencies of back surgery in the acute and
subacute stage were in line with the reported frequency
of specific LBP syndromes.
Thus, general practitioners, pain specialists, and
surgeons are required to double-check whether the
indication for back surgery is justified in chronic pain
Table 3. Functionality and Pain Disability
Grade Gender
All Acute vs.
Subacute vs.
Chronic (Mantel-
Male vs. Female
(MannWhitney U-Test)ncol. % ncol. % ncol. %
FFbH-R grading
Normal functionality
(80% to 100%)
Male 150 28.4 159 25.9 2,131 19.7 P< 0.0001 Acute: P=0.2826
Subacute: P< 0.0001
Chronic: P< 0.0001
Female 147 24.7 123 16.1 1,854 11.8
All 297 26.4 282 20.5 3,985 15
Reduced funtionality
(60% to 79%)
Male 79 14.9 107 17.5 1,655 15.3
Female 97 16.3 132 17.3 2,177 13.9
All 176 15.6 239 17.4 3,832 14.5
Relevant impairment
Male 300 56.7 347 56.6 7,056 65.1
Female 352 59.1 507 66.5 11,646 74.3
All 652 58 854 62.1 18,702 70.5
Total Male 529 100 613 100 10,842 100
Female 596 100 762 100 15,677 100
All 1,125 100 1,375 100 26,519 100
PDI grading
No relevant disability Male 67 16.7 57 11.6 719 8.7 P< 0.0001 Acute: P=0.6825
Subacute: P=0.5747
Chronic: P=0.7465
Female 68 14.8 84 14.1 1,023 8.6
All 135 15.7 141 13 1,742 8.6
Mild Male 157 39.2 197 40.2 3,170 38.2
Female 186 40.5 228 38.3 4,660 39
All 343 39.9 425 39.1 7,830 38.7
Moderate Male 141 35.2 189 38.6 3,618 43.6
Female 163 35.5 229 38.4 5,045 42.2
All 304 35.3 418 38.5 8,663 42.8
Severe Male 36 9 47 9.6 794 9.6
Female 42 9.2 55 9.2 1,213 10.2
All 78 9.1 102 9.4 2,007 9.9
Total Male 401 100 490 100 8,301 100
Female 459 100 596 100 11,941 100
All 860 100 1,086 100 20,242 100
Frequencies and grading of the Hannover Functional Questionnaire (FFbH-R) and the Pain Disability Index (PDI) are given here.
col. %, column. Bold letters indicate significant P-values.
10 H
patients, especially since our data suggest surgical
intervention might be a disposing factor for developing
neuropathic LBP, requiring an increased amount of pain
killer intake (this finding should nevertheless be con-
firmed in a longitudinal study).
The ICD-10-based diagnosis was available only in
approximately 10% of patients, which does not repre-
sent the actual sample size. Moreover, the authors
acknowledge that there was a selection bias, since most
patients with successful conservative treatment or suc-
cessful surgery without ongoing pain would not have
consulted their physicians for further pain treatment.
The PD-Q pain descriptors pressure, attacks, prickling,
and burning were identified as the most frequent neuro-
pathic symptoms of cLBP in a large cohort of patients.
Apart from pain intensity, these descriptors might form
promising outcome parameters for future LBP trials.
Chronic LBP patients had the highest pain intensity,
depression, and anxiety scores and presented the worst
physical function, which might be explained by the
increased frequency of neuropathic components. The
subacute LBP group had the highest frequency of sick
leave, indicating that LBP should be treated early and
sufficiently in order to prevent high socio-economic
costs and pain chronicity.
The age-dependent analysis showed an increase of
pain intensity from the acute to the chronic stage in
patients under 60 years of age, whereas patients over 60
showed higher average pain intensities through all stages
of LBP without change in intensity between the acute,
subacute, and chronic groups.
Neuropathic pain components were most frequent in
patients 51 to 60 years of age. After the age of 60 years,
neuropathic components declined with further aging,
possibly due to degenerating processes. Patients who
underwent back surgery showed the highest frequency
of neuropathic pain and presented the highest amount of
pain medication intake, underlining the necessity of
further optimization of surgical indications.
We thank the patients who agreed to participate in
this study. All co-authors contributed to revising the
manuscript and approved the final version for publi-
This research was made possible by the support of Pfizer
Germany and Pfizer Europe.
P.H. has received speaking fees from Pfizer and Gen-
zyme and travel reimbursement from Gr
unenthal. T.K.
was a contract statistical consultant of Statconsult
GmbH, Germany; this company received payments
from at Pfizer Pharma GmbH, Germany. M.K. declared
no conflicts of interest. J.G. has received speaker fees
and travel support from Pfizer and Gr
unenthal, and
consultancy fees from Glenmark Pharmaceuticals and
bioCSL. R.F. has received consultancy and speaker fees
in the past 12 months from Astellas, Develco, Eli Lilly,
unenthal, Merck, Mitsubishi Tanabe Pharma, and
Pfizer. T.R.T. has received research support from Pfizer.
He is a member of the IMI Europain collaboration, and
industry members of this are: AstraZeneca, Pfizer,
Esteve, UCB-Pharma, Sanofi Aventis, Gr
unenthal, Eli
Lilly, Boehringer Ingelheim, and the German Federal
Ministry of Education and Research (BMBF): German
Research Net-work on Neuropathic Pain. He has
received speaking fees from Pfizer, Gr
unenthal, Mundi-
pharma, Lilly, Boehringer Ingelheim, and Astellas. J.F.
has received personal fees and nonfinancial support
from Gr
unenthal, personal fees from Sanofi Genzyme,
and personal fees from Bayer outside the submitted
work. R.B. has received grants from Pfizer, Genzyme
GmbH, Gr
unenthal GmbH, and Mundipharma. He is a
member of EU Project No. 633491: DOLORisk and a
member of the IMI Europain collaboration, and indus-
try members of this are: AstraZeneca, Pfizer, Esteve,
UCB-Pharma, Sanofi Aventis, Gr
unenthal GmbH, Eli
Lilly, Boehringer Ingelheim Pharma GmbH & Co. KG,
and the German Federal Ministry of Education and
Research (BMBF). He is also a member of the
ERA_NET NEURON/IM-PAIN Project (01EW1503),
German Research Network on Neuropathic Pain
(01EM0903), NoPain system biology (0316177C), and
German Research Foundation (DFG). He has received
personal fees from Pfizer, Genzyme GmbH, Gr
GmbH, Mundipharma, Sanofi Pasteur, Medtronic Inc.,
Neuromodulation, Eisai Co. Ltd., Lilly GmbH, Boeh-
ringer Ingelheim Pharma GmbH & Co. KG, Astellas,
Low Back Pain in 35,446 Patients 11
Desitin, Teva Pharma, Bayer-Schering, MSD GmbH,
Seqirus, Allergan, Novartis, Bristol-Myers Squibb, Bio-
genidec, AstraZeneca, Merck, Abbvie, Daiichi Sankyo,
Glenmark Pharmaceuticals, Teva Pharma, Genentech,
Galapagos NV, Kyowa Kirin GmbH, Vertex Pharma-
ceuticals Inc., Biotest AG, and TAD Pharma GmbH
outside the submitted work.
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Low Back Pain in 35,446 Patients 13
... Comparing the stage of LBP, normal functionality declines (acute LBP 26.4%, subacute 20.5%, and chronic 15%) as well as those without pain disability (acute 15.7%, subacute 13%, and chronic 8.6%). 8 The resulting weakness and pain affects work performance, limits mobility, impacts deployment health, and ultimately leads to disability and early discharge of otherwise healthy service members. To mitigate this progression, treatment during the subacute phase is ideal to prevent recurrence and chronicity through effective interventions. ...
Introduction Low back pain (LBP) is a major cause of visits to ambulatory care, missed duty time, and disability discharge. The subacute phase of LBP presents an opportune time to prevent chronicity and lessen recurrence. The goal of this randomized controlled trial (RCT) was to determine the relative effectiveness of neuromuscular electrical stimulation (NMES) training and a progressive exercise program (PEP) on improving physical performance, pain, and torso strength in U.S. service members with subacute LBP, compared to standard primary care management (PCM) alone. Methods This is an Institutional Review Board–approved protocol for an RCT conducted with active duty military personnel (n = 128) at Fort Campbell, Kentucky, between April 2018 and March 2020. Participants were randomized to receive NMES (n = 43), PEP (n = 42), or PCM (n = 43) for 9 weeks. Outcome measures of physical performance (sit-ups, push-ups, walking, and torso endurance), torso muscle strength (flexion and extension), and pain were assessed at baseline and after 3, 6, and 9 weeks. Analysis was intent-to-treat using linear mixed effects models. A sensitivity analysis was performed to address the protocol deviations that occurred in response to coronavirus disease 2019 pandemic, which required rescheduling 17 in-person study visits to home assessments at 9-week testing. Results Evidence was found for group differences in physical performance for sit-ups and push-ups, with NMES showing greater improvement than PCM. The two groups showed similar improvements in torso muscle strength, although the NMES groups may show better improvement during early treatment. No group differences in pain levels were observed during the intervention, and all groups improved during the course of the study period. The amount of NMES muscle stimulation was directly related to the level of improvement, which was not the case for the hours reported for PEP exercise. Conclusion In an active duty population with subacute LBP, integrating NMES strength training into the rehabilitation therapy may offer a modest benefit for increasing sit-ups and push-ups and improving torso strength.
... Di Amerika Serikat, nyeri pinggang bawah merupakan kondisi kedua terbanyak yang menyebabkan kunjungan pasien berobat ke dokter dengan biaya pengobatan akibat kondisi ini mencapai 100 juta dolar per tahunnya. Nyeri pinggang bawah dapat disebabkan oleh kondisi yang mengenai berbagai struktur yang terdapat pada tulang belakang seperti otot, facet, sendi, diskus, serta saraf (3)(4)(5). Etiologi dari nyeri pinggang bawah dapat berupa infeksi, kondisi degeneratif, neoplasma, trauma, gangguan kongenital, penyakit metabolik, dan autoimunitas (6,7). Sesuai dengan onsetnya, nyeri pinggang bawah dapat dikategorikan menjadi nyeri pinggang bawah akut, subakut dan kronis, di mana nyeri pinggang bawah akut merupakan nyeri <6 minggu, nyeri subakut dirasakan 6 minggu -3 bulan, dan dikatakan kronis apabila sudah berlangsung >3 bulan.4 ...
Full-text available
Low back pain is the most common symptom found in the primary health care and is the number one cause of disability throughout worldwide. It is estimated that around 60 – 80% the world population will experience back pain during their lifespan. There are three different source of pain in the spine: axial-lumbosacral, radicular and reffered pain. All of these source brings different clinical presentations. Low back pain could be classified as acute, subacute and chronic low back pain. The pain could be nociceptive or neuropathic, the most common symptoms reported are “pressure pain” and “pain attack”. The physician should be aware of “red flags” symptoms that lead into more serious condition beside back pain and, therefore the patient has to be investigated to further examination whenever these symptoms present. The management of low back pain consist of severe modalities, both therapeutic and rehabilitative procedure. Oftentimes, the management needed multidisciplinary approach. It is important to general practitioners to identify and treat low back pain appropriately to reduce the burden of the disease and to prevent the disabilties caused by this condition.
... 2. Subacute: Lasting between 4 and 12 weeks. 3. Chronic: Persists for ≥12 weeks [2]. ...
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Objectives: Disability related to chronic low back pain (LBP) is a complex and multidimensional phenomenon all over the world. The prevalence of backache in middle age and elderly is up to 84%. This study aims to evaluate the associations of X-ray features of lumbar disk degeneration with severity of disability among patients with mechanical LBP. Patients and Methods: A cross-sectional study was conducted on a total of 300 patients with chronic mechanical LBP. Severity of disability was measured using Modified Oswestry Disability Index and intensity of backache was assessed using numeric rating scale (0–10). X-ray features of lumbar disc degeneration according to Lane classification and spondylolisthesis were assessed in lateral recumbent lumbar X-rays. Results: The mean age of our sample was 52.45±7.87 and 71.7% of involved patients were women. Most patients were recorded as overweight or obese. The findings of disk space narrowing were mild in 65.7%, moderate in 28.7%, and severe in 5.6%, where the presence of osteophytes were small in 76.9%, moderate in 20.5%, and large in 2.6%. Regarding disability, two-third of cases were focused on minimal disability, followed by moderate, severe, and crippled as (26%), (6%), and (2%), respectively. There was highly significant association between women and pain radiation to legs (p=0.004). Obesity and overweight had meaningless effects on all markers. Conclusions: The severity of disability was significantly more in women, high intensity of lower back pain, presence of pain radiating to legs, moderate/severe disk space narrowing on X-ray, and disk degenerative disease score on X-ray, while age, presence of osteophytes and spondylolisthesis, body mass index, and pain duration were not associated with severity of disability.
... Some studies have divided the stages of the low back pain based on self-report pain intensity into chronic, acute, and subacute. However, they have not evaluated the relationship between muscle strength and stages of low back pain [35][36][37]. In the RaNCD cohort study, pain intensity was not assessed, and we were unable to perform this classification. ...
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Background Musculoskeletal disorders can reduce the quality of life and work capacity. The study assessed handgrip strength (HGS) in relation to low back pain and arthralgia in Kurdish men. Methods This cross-sectional study was conducted using data from Ravansar non-communicable diseases (RaNCD) cohort study on 2164 men aged 35–65 years. HGS was measured using a hand-held hydraulic handgrip dynamometer. Low back pain, arthralgia, and joint stiffness were evaluated by the RaNCD cohort study physician using a standard questionnaire. Results The results showed that 21.39 and 24.58% of studied participants had low back pain and arthralgia, respectively. Among the participants with low back pain, 14.5% had back stiffness, and among those with arthralgia, 12.8% had joint stiffness. The mean of HGS in participants with arthralgia and back & joint stiffness was significantly less than those without these disorders ( P < 0.001, P = 0.05, and P = 0.005, respectively). Multiple-adjusted OR and 95% confidence intervals (CI) for arthralgia and back and joint stiffness across muscle strength showed the HGS increase to be associated with a lower risk of arthralgia and back &joint stiffness, but not low back pain. Conclusions Higher HGS was associated with a lower risk of arthralgia and back & joint stiffness. However, there was no association between HGS and low back pain. Exercise and adherence to proper nutrition are suggested to enhance muscle strength in order to reduce musculoskeletal pain.
... Some studies have divided the stages of the low back pain based on self-report pain intensity into chronic, acute, and subacute. However, they have not evaluated the relationship between muscle strength and stages of low back pain [35][36][37]. In the RaNCD cohort study, pain intensity was not assessed, and we were unable to perform this classi cation. ...
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Background: Musculoskeletal disorders can reduce the quality of life and work capacity. The study assessed handgrip strength (HGS) in relation to low back pain and arthralgia in Kurdish men. Methods: This cross-sectional study was conducted using data from Ravansar non-communicable diseases (RaNCD) cohort study on 2164 men aged 35-65 years. HGS was measured using a hand-held hydraulic handgrip dynamometer. Low back pain, arthralgia, and joint stiffness were evaluated by the RaNCD cohort study physician using a standard questionnaire. Results: The results showed that 21.39% and 24.58% of studied participants had low back pain and arthralgia, respectively. Among the participants with low back pain, 14.5% had back stiffness, and among those with arthralgia, 12.8% had joint stiffness. The mean of HGS in participants with arthralgia and back & joint stiffness was significantly less than those without these disorders (P<0.001, P=0.05, and P= 0.005, respectively). Multiple-adjusted OR and 95% confidence intervals (CI) for arthralgia and back and joint stiffness across muscle strength showed the HGS increase to be associated with a lower risk of arthralgia and back &joint stiffness, but not low back pain. Conclusions: Higher HGS was associated with a lower risk of arthralgia and back & joint stiffness. However, there was no association between HGS and low back pain. Exercise and adherence to proper nutrition are suggested to enhance muscle strength in order to reduce musculoskeletal pain.
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Purpose: To explore the evidence of the internal structure validity of the Roland-Morris Disability Questionnaire in older adults with low back pain. Methods: This was a cross-sectional study of psychometric testing involving 528 older adults with low back pain. Internal structure validity was explored by exploratory factor analysis and semi-confirmatory factor analysis. Reliability was verified using Kuder-Richardson Formula 20, Cronbach's alpha, and McDonald's omega. Replicability was observed by the generalized H index. Results: Roland-Morris Disability Questionnaire displayed two factors that assess "functional capacity" and "mobility". Eight items were excluded for presenting cross-loading (2 and 10), inadequate loading factors and communalities (18, 24, 13, and 12), or did not relate to the latent construct (15 and 22). Semi-confirmatory factor analysis indicated that the questionnaire had a good fitness model [X2 = 153.698 (p = 0.00001); RMSEA = 0.037; RMSR = 0.06; WRMR = 0.04; NNFI = 0.987; GFI = 0.979; AGFI = 0.971]. Reliability was acceptable (KR-20 = 0.79; Cronbach's alpha = 0.86; McDonald's Omega = 0.85), but replicability was poor in both factors (G-H factor 1 = 0.816-0.655; G-H factor 2 = 0.889-0.775). Conclusions: The most appropriate version of the Roland-Morris Disability Questionnaire to apply to older adults with low back pain has 16 items and assesses functional capacity and mobility. IMPLICATIONS FOR REHABILITATIONThe RMDQ-16 is the most appropriate version of the RMDQ to use in older adults with LBP;The RMDQ-16 is bidimensional and assesses "functional capacity" and "mobility";The poor replicability of the RMDQ-16 indicates that it will probably not be stable across studies, but it can be useful in a clinical setting.
Objectives: Low Back Pain (LBP) is prevalent in most people of working age. The morbidity it causes cannot be taken lightly, as is its economic burden. Physiotherapy has long been prescribed to LBP patients, but treatment outcome measurements, along with the factors influencing it, have not been widely evaluated. In this study, we aim to assess the correlation between patient’s expectation and LBP physical therapy outcome. Methods: This was a cross sectional study conducted at physical rehabilitation outpatient clinic in September-December 2019. Participants were patients with LBP who were treated with physical therapy. One series of physical therapy consists of 5 sessions of modality only or modality with exercise therapy; one patient underwent 2 sessions per week. Oswestry disability index (ODI) score was used to evaluate treatment outcome and Stanford Expectation of Treatment Scale score was used to evaluate patient’s expectation. Data was collected twice, before and after 1 series of therapy. Results: There were 91 participants included in this study, most of whom were female. Most patients reported a significant decrease in ODI score, irrespective of the LBP chronicity or nutritional status. However, patients who received a combination of physical exercises and modalities reported lower after therapy ODI than those who only received modalities (p=0.009). No correlation was found between positive (p=0.567) or negative (p=0.910) expectations with ODI improvement. Conclusion: Our study did not find any correlation between positive or negative expectations towards ODI score improvement. Keywords: Low back pain; Physical therapy; Treatment outcome; Patient expectation; ODI score
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Identification of predictive neuroimaging markers of pain intensity changes is a crucial issue to better understand macroscopic neural mechanisms of pain. Although a single connection between the medial prefrontal cortex and nucleus accumbens has been suggested as a powerful marker, how the complex interactions on a large-scale brain network can serve as the markers is underexplored. Here, we aimed to identify a set of functional connections predictive of longitudinal changes in pain intensity using large-scale brain networks. We re-analyzed previously published resting-state functional magnetic resonance imaging data of 49 subacute back pain (SBP) patients. We built a network-level model that predicts changes in pain intensity over one year by combining independent component analysis and a penalized regression framework. Connections involving top-down pain modulation, multisensory integration, and mesocorticolimbic circuits were identified as predictive markers for pain intensity changes. Pearson’s correlations between actual and predicted pain scores were r = 0.33–0.72, and group classification results between SBP patients with persisting pain and recovering patients, in terms of area under the curve (AUC), were 0.89/0.75/0.75 for visits four/three/two, thus outperforming the previous work (AUC 0.83/0.73/0.67). This study identified functional connections important for longitudinal changes in pain intensity in SBP patients, providing provisional markers to predict future pain using large-scale brain networks.
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Background Pain localization is one of the hallmarks for the choice of first-line treatment in neuropathic pain. This literature review has been conducted to provide an overview of the current knowledge regarding the etiology and pathophysiology of localized neuropathic pain (LNP), its assessment and the existing topical pharmacological treatments. Materials and methods Literature review was performed using Medline from 2010 to December 2016, and all studies involving LNP and treatments were examined. A multidisciplinary expert panel of five pain specialists in this article reports a consensus on topical approaches that may be recommended to alleviate LNP and on their advantages in clinical practice. Results Successive international recommendations have included topical 5% lidocaine and 8% capsaicin for LNP treatment. The expert panel considers that these compounds can be a first-line treatment for LNP, especially in elderly patients and patients with comorbidities and polypharmacy. Regulatory LNP indications should cover the whole range of LNP and not be restricted to specific etiologies or sites. Precautions for the use of plasters must be followed cautiously. Conclusion Although there is a real need for more randomized controlled trials for both drugs, publications clearly demonstrate excellent risk/benefit ratios, safety, tolerance and continued efficacy throughout long-term treatment. A major advantage of both plasters is that they have proven efficacy and may reduce the risk of adverse events such as cognitive impairment, confusion, somnolence, dizziness and constipation that are often associated with systemic neuropathic pain treatment and reduce the quality of life. Topical modalities also may be used in combination with other drugs and analgesics with limited drug–drug interactions.
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Diffuse Noxious Inhibitory Controls (DNIC) utilize descending inhibitory controls through poorly understood brainstem pathways. The human counterpart, conditioned pain modulation (CPM), is reduced in patients with neuropathy aligned with animal data showing a loss of descending inhibitory noradrenaline (NA) controls together with a gain of 5HT3 receptor-mediated facilitations after neuropathy.We investigated the pharmacological basis of DNIC and whether it can be restored after neuropathy. Deep dorsal horn neurons were activated by von Frey filaments applied to the hind paw and DNIC was induced by a pinch applied to the ear in isoflurane-anaesthetized animals. Spinal nerve ligation (SNL) was the model of neuropathy. DNIC was present in control rats but abolished after neuropathy. Alpha-2 adrenoceptor mechanisms underlie DNIC since the antagonists, yohimbine and atipamezole, markedly attenuated this descending inhibition. We restored DNIC in SNL animals by blocking 5HT3 descending facilitations with the antagonist ondansetron or by enhancing NA modulation through the use of reboxetine (a NA reuptake inhibitor, NRI) or tapentadol (mu opioid receptor agonist (MOR) and NRI). Additionally ondansetron enhanced DNIC in normal animals. DNIC are reduced following peripheral nerve injury illustrating the central impact of neuropathy leading to an imbalance in descending excitations and inhibitions. Underlying noradrenergic mechanisms explain the relationship between CPM and the use of tapentadol and duloxetine (a serotonin-NRI) in patients. We suggest pharmacological strategies through manipulation of the monoamine system could be used to enhance DNIC in patients by blocking descending facilitations with ondansetron or enhancing NA inhibitions, so possibly reducing chronic pain.
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Preliminary study. To assess the association of neuropathic pain with chronic low back pain (LBP) and the effect of pregabalin on neuropathic pain in the elderly. Of those with chronic LBP, 37% were predominantly presenting with neuropathic pain in young adults. Pregabalin is effective for pain in patients with diabetic neuropathy and peripheral neuralgia. No study has reported on the effects of pregabalin for chronic LBP in elderly patients yet. Pregabalin was administered to 32 patients (age, ≥65 years) with chronic LBP for 4 weeks. Pain and activities of daily living were assessed using the Neuropathic Pain Screening Questionnaire (NePSQ), the pain DETECT questionnaire, visual analog scale, the Japanese Orthopedic Association score, the short form of the McGill Pain Questionnaire and the Roland Morris Disability Questionnaire. Modic change and spinal canal stenosis were investigated using magnetic resonance imaging. Altogether, 43.3% of patients had neuropathic pain according to the NePSQ and 15.6% patients had pain according to the pain DETECT. The efficacy rate of pregabalin was 73.3%. A significant effect was observed in patients with neuropathic pain after 4 weeks of administration. Neuropathic pain was slightly less frequently associated with chronic LBP in the elderly. Pregabalin was effective in reducing pain in patients with chronic LBP accompanied with neuropathic pain. Lumbar spinal stenosis and lower limb symptoms were observed in patients with neuropathic pain. We recommend the use of pregabalin for patients after evaluating a screening score, clinical symptoms and magnetic resonance imaging studies.
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A greater incidence of persistent pain after inguinal herniorrhaphy is suspected with the open mesh procedure than with laparoscopy (transabdominal preperitoneal), but the involvement of neuropathy needs to be clarified. We examined the cumulative incidence of neuropathic persistent pain, defined as self-report of pain at the surgical site with neuropathic aspects, within 6 months after surgery in 2 prospective subcohorts of a multicentre study. We compared open mesh with laparoscopy using different analysis, including a propensity-matched analysis with the propensity score built from a multivariable analysis using a generalized linear model. Considering the full patient sample (242 open mesh v. 126 laparoscopy), the raw odds ratio for neuropathic persistent pain after inguinal herniorrhaphy was 4.3. It reached 6.8 with the propensity-matched analysis conducted on pooled subgroups of 194 patients undergoing open mesh and 125 undergoing laparoscopy (95% confidence interval 1.5-30.4, p = 0.012). A risk factor analysis of these pooled subgroups revealed that history of peripheral neuropathy was an independent risk factor for persistent neuropathic pain, while older age was protective. We found a greater risk of persistent pain with open mesh than with laparoscopy that may be explained by direct or indirect lesion of nerve terminations. Strategies to identify and preserve nerve terminations with the open mesh procedure are needed.
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Study Design Literature review. Objective Since the 1970s, spine surgeons have commonly required 6 weeks of failed conservative treatment prior to considering surgical intervention for various spinal pathologies. It is unclear, however, if this standard has been validated in the literature. The authors review the natural history, outcomes, and cost-effectiveness studies relating to the current standard of 6 weeks of nonoperative care prior to surgery for patients with spinal pathologies. Methods A systematic Medline search from 1953 to 2013 was performed to identify natural history, outcomes, and cost-effectiveness studies relating to the optimal period of conservative management prior to surgical intervention for both cervical and lumbar radiculopathy. Demographic information, operative indications, and clinical outcomes are reviewed for each study. Results A total of 5,719 studies were identified; of these, 13 studies were selected for inclusion. Natural history studies demonstrated that 88% of patients with cervical radiculopathy and 70% of patients with lumbar radiculopathy showed improvement within 4 weeks following onset of symptoms. Outcomes and cost-effectiveness studies supported surgical intervention within 8 weeks of symptom onset for both cervical and lumbar radiculopathy. Conclusions There are limited studies supporting any optimal duration of conservative treatment prior to surgery for cervical and lumbar radiculopathy. Therefore, evidence-based conclusions cannot be made. Based on the available literature, we suggest that an optimal timing for surgery following cervical radiculopathy is within 8 weeks of onset of symptoms. A shorter period of 4 weeks may be appropriate based on natural history studies. Additionally, we found that optimal timing for surgery following lumbar radiculopathy is between 4 and 8 weeks. A prospective study is needed to explicitly identify the optimal duration of conservative therapy prior to surgery so that costs may be reduced and patient outcomes improved.
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Background Chronic low back pain (CLBP) has a significant effect on quality of life and imposes a great economical burden on society. In a number of studies, validated questionnaires had been given to CLBP patients to determine their health-associated quality of life, sleep disturbance, and psychological status. However, such outcome studies had not been performed previously in Korea. Methods We used self-report questionnaires to compare CLBP patients with an age- and sex-matched healthy control group. Between September 2012 and August 2013, we enrolled 47 patients who had CLBP for more than 3 months (group P) and 44 healthy age- and sex-matched controls (group C), who completed the following self-report questionnaires: 36-Item Short Form Health Survey (SF-36), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Oswestry Disability Index (ODI), and Pittsburgh Sleep Quality Index (PSQI). Results The scores from the ODI, BDI, and BAI were significantly higher in group P than in group C. The SF-36 scores were significantly lower in group P than in group C, suggesting lower quality of life in group P. The incidence of depression and anxiety was significantly higher in group P than in group C. However, neither the PSQI score nor the incidence of sleep disturbance was significantly different between the groups. Conclusions Patients with CLBP showed considerable functional disability and significant impairment of psychological status with a low quality of life. Hence, it is important to evaluate CLBP patients to provide adequate psychological support.
Demographic changes, with substantial increase in life expectancy, ask for solid knowledge about how pain perception might be altered by aging. Although psychophysical studies on age-related changes in pain perception have been conducted over more than 70 years, meta-analyses are still missing. The present meta-analysis aimed to quantify evidence on age-related changes in pain perception, indexed by pain thresholds and pain tolerance thresholds in young and older healthy adults. After searching PubMed, Google Scholar and PsycINFO using state-of-art screening (PRISMA-criteria), 31 studies on pain threshold and 9 studies assessing pain tolerance threshold were identified. Pain threshold increases with age, which is indicated by a large effect size. This age-related change increases the wider the age-gap between groups; and is especially prominent when heat is used and when stimuli are applied to the head. In contrast, pain tolerance thresholds did not show substantial age-related changes. Thus, after many years of investigating age-related changes in pain perception, we only have firm evidence that aging reduces pain sensitivity for lower pain intensities.
Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected, For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician, When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical. examination usually provide clues to the rare but potentially serious causes of low back pain, as well as identify patients at risk for prolonged recovery, Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation, For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.
Objective: For interlaminar cervical epidural steroid injections (CESI) the lateral fluoroscopic view (LAT) is often considered to improve needle localization. However, the contralateral-oblique view (CLO) is a useful alternative with potential advantages to improve identification of cervical anatomy and needle depth assessment. The authors explored the attitudes and perceptions of pain medicine fellows currently training in two ACGME-accredited pain medicine fellowship programs regarding the use of these two types of fluoroscopic views. Methods: The survey was conducted online following a request by e-mail. Of a total of 20 fellows who were contacted, there were 17 respondents who had experience with both techniques, and they were included for analysis. Results: The response rate for participation was 95%. Whereas 70.6% respondents reported they were very certain about the assessment of anatomy with the CLO view, only 17.6% felt very certain with the LAT view. Compared with learning to perform interlaminar CESI using the LAT view only, the majority of fellows thought that using the CLO technique was easier to learn (P < 0.01) and offered better visualization of contrast dye spread pattern to confirm the cervical epidural space (P = 0.013). All respondents perceived that the likelihood of interlaminar CESI complications would be lower with CLO technique. Overall, 82.4% of respondents considered CLO visualization as a preferred technique for interlaminar CESI. Respondents stated that the likelihood of using the CLO technique as an independent physician was significantly higher than using only the LAT technique (P < 0.001), particularly for patients who are obese and have short necks. Conclusions: For interlaminar CESI, using the CLO is perceived to provide better definition of anatomy and yet is easier to learn. Trainees may become more confident in performing interlaminar CESI with the CLO. We encourage all fellowship programs to include the CLO technique for interlaminar CESI as part of the training.