Performance Testing of Low Back Pain Patients

This study was designed to evaluate if physical performance tests were reliable and valid in low back pain patients. Using a sample of 44 LBP patients and 48 pain-free subjects, the authors compared the two groups as they performed in multiple tests—such as the "Lumbar Flexion," "Five-Minute Walk," "Sorensen fatigue test," and "Repeated Sit-to-Stand." As well, the subjects took self-report tests to express their perceived levels of pain and disability, as a means of comparison to the physical functioning and endurance tests.

The authors found the battery of tests reliable. Another benefit of these tests is that since they are easily administered, good reliability can be found in a clinical context. And after testing and retesting subjects, scores still were stable—which indicates a patient only has to perform the task/test once, and a reliable score will emerge.

The authors found a moderate correlation between the physical performance tests and the self-report pain questionnaires:

"Further, although physical performance and self-report of disability were moderately correlated, the correlation between disability and lumbar flexion was trivial. This shows that physical performance measures are much better indicators of a patient�s ability to function than the frequently used impairment measure of spinal range of motion. Low back pain is a problem of activity intolerance; therefore, clinical assessments should be activity based."

The authors conclude that the battery of tests are useful indicators of disability. A strong correlation between the self-reports of disability and the tests confirmed an association between a patient�s perception of their disability and their actual physical performance.

Simmonds MJ, Olson SL, Jones S, et al. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine 1998; 23(22):2412-2421.

Pre-Work Screenings and Low Back Injuries

This study set out to assess if pre-work screening methods with hospital employees reduced the low back injury rate, lost workdays, and medical costs. The screening was intended to match an employee's physical capabilities with the physical demands of a job. The screening consisted of assessing posture, flexibility, strength, and range of motion. Additionally, the session included instruction on lifting techniques and body mechanics.

Over 10 ^1/2 years, 1457 pre-work screening were performed. In that time 177 back sprains and strains occurred. When comparing the rate of back injuries between the screened and unscreened personnel, no significant differences occurred. But, the amount of lost work days and medical costs decreased significantly among the screened employees:

"These findings suggest that though the rate of back sprain or strain injuries do not decrease, the severity of those injuries do decrease significantly over time. Also, the use of the prework functional screen offers the employer the highest degree of protection against rising lost work days and incurred medical costs that occur as the result of back sprain or strain injuries."

�The authors conclude that preventive measures and pre-work screenings will aid an employer in reducing its various costs and help identify the individuals who are not able to perform the physical demands of the job they are being hired for.

Nassau D. The effects of prework functional screening on lowering an employer's injury rate, medical costs and lost work days. Spine 1999;24(3): 269-274.

Prognosis of Low Back Pain in General Practice

This study attempted to identify what factors determined the duration of low back pain (LBP) episodes and recurrence rate in a group of 269 general practice patients. The authors studied a number of variables in their investigation: the duration of LBP before the patient consulted a physician; the type of onset of back pain (sudden or gradual); severity of back pain at initial visit; whether or not the patient had a history of back surgery; whether the patient received physical therapy for LBP symptoms; and the degree of disability from the LBP. The patients were followed for one year after the initial assessment. The study found:

• "The median time to recovery from the index episode was 7 weeks...70% of patients still had low back pain after 4 weeks, 48% after 8 weeks, 35% after 12 weeks, and at the end of the follow-up year 10% of the patients still had low back pain."
• Recovery from LBP was complicated by four factors:

1. A longer history of back pain before the initial visit to a physician.
2. The presence of sciatica.
3. "Maximal lumbal flexion" as determined by Schobers test.
4. Receiving physical therapy. "The results of the present study indicate that patients receiving physical therapy during the first 5 weeks after the initial visit also will take longer to recover from low back pain than those not receiving physical therapy." The study found that "the time to recovery was approximately 4 weeks longer for patients who received physical therapy than for patients who did not receive physical therapy."

The only factor that appeared to influence the rate of relapse was disability as measured by reports of daily functioning. The researchers found that the severity of pain and psychosocial factors were not associated with the patients time to recover. However, other aspects in the patients' history—such as back surgery or chronic LBP—did emerge as risk factors for recurring LBP.

van den Hoogen HJM, Koes BW, Deville W, van Eijk JTM, Bouter LM. The prognosis of low back pain in general practice. Spine 1997;22(13):1515-1521.

Stay-Active Care Versus Manual Therapy + Stay-Active Care

It is well known that staying active is an important way to quickly recover from an episode of low back pain. Other studies have shown that chiropractic care is also effective at helping patients with back pain.

This current study was conducted over a 10-week period in Sweden, and it looked at the effectiveness of traditional stay-active treatment for lower back pain, versus that of stay active-care combined with manual therapy that included stretching and manipulation.

160 study subjects aged 20 to 55 years of age, employed, and with lower back pain of 3 months duration or less and no other significant medical conditions or complications entered the clinical trial. Subjects were randomly assigned to one of two groups, with 45% assigned to the reference (stay-active care) group, and 55% assigned to the experimental (stay-active care + manual therapy) group.

Stay-active treatment was given by 2 orthopedic surgeons and 8 physiotherapists to the reference group. This treatment consisted of:

• Patient education to encourage taking part in physical activities to stay fit.
• Prescribing sick leaves as short as possible, with medications prescribed when indicated.
• Offering muscle stretching and matching home exercises (41% received stretching).

The experimental group (stay-active therapy + manual care) received treatment from 2 GPs and 9 physiotherapists who had previously received 12 days of training in administering manual therapy. They used the stay-active approach noted above, and added manual therapy to their treatment, which included:

• Muscular Energy Technique (MET) diagnostic items included in the physical exam.
• Mobilization for pelvic dysfunction, with a lock maneuver administered gently according to MET procedure.
• Treatment with specific mobilization or lumbar thrust techniques based on exam results.

Steroid injections were allowed in 50% of the patients based on specific findings, with soft tissue stretching after parasacrococcygeal injections (injections to the base of the spine near the rectum). Auto-traction was used when indicated for cases of herniated disc.

Outcomes for both pain and 15 disability variables were measured using visual analog scales that rated pain or disability from none (0 mm) to maximum (100 mm). 12 of the disability items formed the Disability Rating Index, which measured such items as the ability to lift heavy items, to do heavy or light physical work, ability to participate in sports, to run, to get up from a sitting position, to dress (without help), to bend over a sink, to carry a bag, to climb stairs, to make a bed, to walk outdoors. The other 3 disability variables measured the ability to lie still, and to drive or ride in a car. The questionnaire also asked about medications taken.

A baseline measurement was obtained when patients entered the study, and outcomes were measured at 5 weeks and 10 weeks after treatment started. Treatment staff was blinded to the outcomes during the study period.

At the beginning of the study, the baseline results were the same for both groups. Pain scores decreased significantly with treatment over time for both groups. But because the experimental group had a slightly greater degree of baseline pain, when adjustments for herniations, age and sex were made, the experimental group experienced a faster rate in the decrease of pain during the last week of the study. The use of pain medication and nonsteroidal anti-inflammatory medications decreased at a similar rate in both groups over the period of the study.

At baseline, the experimental group tended to have slightly higher initial disability scores for all 15 variables than the reference group. By 5 and 10 weeks, the experimental group tended to have lower scores on all disability variables, and to have experienced a faster rate of improvement in the Disability Rating index, than the reference group.

Stay-active care combined with manual therapy provided greater pain relief during the last week of treatment and improved disability scores at 5 and 10 weeks, when compared with stay-active care alone. These study results are consistent with previous studies that have shown the higher effectiveness of manual treatment when compared with stay-active care treatment. The study authors theorize that this effectiveness is due to extension of the muscle spindles resetting input into the proprioreceptive system within the lower back, although the true mechanism is still unknown and needs further study.

The improved results with manual therapy would indicate that it should become a more generally used treatment option in the treatment of lower back pain than stay-active care alone.

Grunnesjo MI, Bogefeldt JP, Svardsudd KF, Blomberg SIE. A randomized controlled clinical trial of stay-active care versus manual therapy in addition to stay-active care: functional variables and pain. Journal of Manipulative and Physiological Therapeutics 2004;27:431-441.

Referral Patterns in Low Back Pain Patients

This study examined how 98 cases of new onset, uncomplicated low back pain was generally handled in patients with workers' compensation claims.

Over half of the cases were initially seen in emergency rooms or urgent-care facilities. The authors hypothesize that this is due to patient preference, or an employer's desire for employee to receive prompt care, or limited availability of low-cost, easy-access centers for work-related injuries. 24% of these patients then had their follow-up care in the same urgent care centers. This is an extremely inefficient and expensive way to treat the onset and course of low back pain.

The authors seemed surprised that just a few patients were seen on intake by a "occupational medicine" (OM) specialist. "The main provider of care was again most likely to be a primary care physician (47%), followed by non-OM specialists (23%) and OM specialists in 13% of the cases. Of the original 98 patients, 52% were referred to a specialist. Of the 35 referrals to surgeons only 2 did have surgical intervention. The authors estimated the median number of visits to all providers was five.

The authors conclude that the handling of uncomplicated low back pain cases was ultimately not cost effective:

"As noted, many of the utilization and referral practices described herein can reasonably be expected to increase the costs of managing such LBP claims, and in multiple published reports, they have not been shown to demonstrably increase efficacy of treatment."

The entire study was focused not on the effectiveness of a particular type of treatment and did not study outcome. The focus was on costs and "system efficiency." This is not surprising, as the study was funded in part by the Liberty Mutual Insurance Company and a center that that have as part of Harvard University.

Tacci J, Webster B, Hashemi L, Christiani D. Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims. Journal of Occupational and Environmental Medicine 1998;40(11):958-963.

Controlling Lumbar Flexion to Reduce Low Back Pain

This study attempted to reduce patients' nonspecific low back pain without medication, manipulation, or surgery. They tested the prolonged effects of controlling lumbar flexion (forward bending) movement in the morning.

The authors emphasized to the subjects that the first two hours after rising were the most important—they should not bend, sit, or squat—and to attempt to keep a straight back during that time of the day. Squatting or kneeling was permissible for the remainder of the day, but bending was to be avoided.

The authors compared the results to a control group. The control group was advised to perform six commonly prescribed exercises, such as pelvic tilt, hamstring stretch, and side leg raise, which have been found ineffective in reducing low back pain.

Subjects in both groups were asked to keep a daily dairy that answered the following questions:

1. How would you rate your back pain today on a 0 to 10 scale in which 0 is "no pain" and 10 is "pain as bad as it could be"?
2. Did back pain prevent you form performing your usual work activities today (work, school, or housework)? Yes or No?
3. Did back pain prevent you from participating in any recreational, social, or family activities today? Yes or No?
4. Did you take any medication today (including over-the-counter medication)? Yes or no? If so, what kind?

Each week participants mailed in their responses. The questions were designed to measure pain intensity, disability, impairment, and medication usage.

The study began with 116 subjects, but due to the demanding regimen many participants dropped out; when they entered phase two, 85 subjects were involved. The treatment group had 24 subjects, and the control group had 36 patients.

Thirty�five percent of the subjects in the treatment group reduced their pain by 50% after six months of flexion control. The following chart shows the percentage decrease the patients experienced.

Overall the findings were successful, and patients who continued for six additional months reduced pain further. One additional benefit of the exercise was that it was effective for both men and women and for patients older (46-60) and younger (30-45). Also:

�"Perhaps somewhat surprising, but also encouraging, is the finding that subjects with high psychological overlay benefited as much as those with low psychological overlay, and subjects with leg pain benefited as much as those without leg pain. The only subjects who did not benefit as well were those who performed heavy physical work."

Snook SH, Webster BS, McGorry RW, et al. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine 1998;23(23):2601-2607.