Aage Indahl

Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.

Study Design. Single blind randomized study. Objectives. To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Summary of Background Data. To the authors’ best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician. Patients and Methods. Sixty-four patients aged 25–60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4–L5 and/or L5–S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index. Results. At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (−6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rateaccording to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%. Conclusion. The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion.

Good prognosis for low back pain when left untampered. A randomized clinical trial.

Objective. This randomized clinical trial was designed to determine the effect of treating low back pain as a benign, self limiting condition by light normal activity. Methods. Patients on sickness leave from work for more than 8 weeks were randomized into two groups: intervention (n = 463) and control (n = 512). Those in the intervention group were examined, provided information, and given instruction. Outcome was measured by return or failure to return to work (still on sickness leave). Results. Survival analysis showed a highly significant (P = 0.000) reduction in sickness leave in the intervention group as compared with the control group. At 200 days 60% were still on sickness leave in the control group vs. 30% in the intervention group. A multivariate analysis with age, sex, and treatment as cofactors showed that sex had no effect on length of sickness leave and that treatment retained its effect when adjusting for differences in age composition. Conclusion. This study indicates that low back pain treated as a benign, self limiting condition recommended to light mobilization gives superior results as compared to treatment within a conventional medical system.

Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study.

Abstract The effectiveness of lumbar fusion for chronic low back pain after surgery for disc herniation has not been evaluated in a randomized controlled trial. The aim of the present study was to compare the effectiveness of lumbar fusion with posterior transpedicular screws and cognitive intervention and exercises. Sixty patients aged 25–60 years with low back pain lasting longer than 1 year after previous surgery for disc herniation were randomly allocated to the two treatment groups. Experienced back surgeons performed transpedicular fusion. Cognitive intervention consisted of a lecture intended to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The primary outcome measure was the Oswestry Disability Index (ODI). Outcome data were analyzed on an intention‐to‐treat basis. Ninety‐seven percent of the patients, including seven of eight patients who had either not attended treatment (n = 5) or changed groups (n = 2), completed 1‐year follow‐up. ODI was significantly improved from 47 to 38 after fusion and from 45 to 32 after cognitive intervention and exercises. The mean difference between treatments after adjustment for gender was −7.3 (95% CI −17.3 to 2.7, p = 0.15). The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group. For patients with chronic low back pain after previous surgery for disc herniation, lumbar fusion failed to show any benefit over cognitive intervention and exercises.

Electromyographic response of the porcine multifidus musculature after nerve stimulation.

Study Design In this study, a porcine model was used to study whether a nerve reaction in the anulus fibrosus of a lumbar disc or in a facet joint capsule could cause a muscular response in the multifidus musculature. Objectives To determine if there is an interrelationship between the intervertebral disc and facet joint innervation and the multifidus musculature as a possible pain mechanism. Summary of Background Data The innervation of the anulus fibrosus of the intervertebral disc and the capsule of the facet joint is well described in the literature, although the functions of these nerves are poorly understood. An interrelationship between this innervation and the paraspinal musculature has not been previously described. Methods Fifteen adult pigs were used to measure the electromyographic response in the multifidus musculature to electrical stimulation of the lateral region of the disc anulus and the facet joint capsule in the L1-L2 motion segment. Motor unit action potentials were recorded using three sets of bipolar needle electrodes placed into the deepest fascicles of the multifidus, bilateral to the L2, L3, and L4 spinous processes. The effect of lidocaine injection into the facet joint and subperiosteal muscle detachment on the electromyographic response were studied. Results Stimulation of the disc anulus fibrosus induced reactions in the multifidus on multiple levels and on the contralateral side, whereas stimulation of the facet joint capsule induced reactions predominantly on the same side and segmental level as the stimulation. Introduction of lidocaine into the facet joint resulted in a significantly reduced electromyographic response to either stimulation, with the most drastic reduction seen when stimulation, with the most drastic reduction seen when stimulating the facet joint capsule. Subperiosteal detachment of the paraspinal muscles prevented any muscular response. Conclusions Stimulation of the disc and the facet joint capsule produced contractions in multifidus fascicles. The clinical implications are that there may be interactive responses between injured or diseased structures, i.e., disc or facet joints, and the paraspinal musculature. Activation of the multifidus muscles may have a stabilizing effect, constraining the motion of the lumbar spine. Longstanding muscular contraction may produce ischemic conditions and may be a potential source of pain.

Exploration of physicians' recommendations for activities in chronic low back pain.

Study Design. A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients. Objectives. To explore physicians’ recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations. Summary of Background Data. Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients’ lives, little is known about the factors that shape recommendations. Methods. Mailed surveys included questions inquiring about the physicians’ demographics, training, and experience in low back pain, the Health Care Providers’ Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test–retest reliability was assessed with a second mailing of the questionnaire to all initial responders. Results. Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Mostphysicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians’ pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients’ clinical symptoms. Conclusions. Physicians’ recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients’ clinical symptoms.

Sensorimotor control of the spine

The spinal viscoelastic structures including disk, capsule and ligaments were reviewed with special focus on their sensory motor functions. Afferent capable of monitoring proprioceptive and kinesthetic information are abundant in the disc, capsule and ligament. Electrical stimulation of the lumbar afferents in the discs, capsules and ligaments seem to elicit reflex contraction of the multifidus and also longissimus muscles. The muscular excitation is pronounced in the level of excitation and with weaker radiation 1 to 2 levels above and below. Similarly, mechanical stimulation of the spinal viscoelastic tissues excites the muscles with higher excitation intensity when more than one tissue (ligaments and discs for example) is stimulated. Overall, it seems that spinal structures are well suited to monitor sensory information as well as to control spinal muscles and probably also provide kinesthetic perception to the sensory cortex.

A randomized double-blind controlled trial of intra-annular radiofrequency thermal disc therapy--a 12-month follow-up.

ABSTRACT The discTRODE™ probe applies radiofrequency (RF) current, heating the annulus to treat chronic discogenic low back pain. Randomized controlled studies have not been published. We assessed the long‐term effect and safety aspects of percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) with the discTRODE™ probe in a prospective parallel, randomized and gender stratified, double‐blind placebo‐controlled study. Twenty selected patients with chronic low back pain and a positive one‐level pressure‐controlled provocation discography were randomized to either intra‐annular PIRFT or intra‐annular sham treatment. A blinded interim analysis was performed when 20 patients had been followed for six months. The 6‐month analysis did not reveal any trend towards overall effect or difference between active and sham treatment for the primary endpoint: change in pain intensity (0–10). The inclusion of patients was therefore discontinued. After 12 months the overall reduction from baseline pain had reached statistical significance, but there was no significant difference between the groups. The functional outcome measures (Oswestry Disability Index, and SF 36 subscales and the relative change in pain) appeared more promising, but did not reach statistical significance when compared with sham treatment. Two actively treated and two sham‐treated patients reported increased pain levels, and in both groups a higher number was unemployed after 12 months. The study did not find evidence for a benefit of PIRFT, although it cannot rule out a moderate effect. Considering the high number, reporting increased pain in our study, we would not recommend intra‐annular thermal therapy with the discTRODE™ probe.

Sacroiliac joint involvement in activation of the porcine spinal and gluteal musculature.

In the search for causes of low back pain, the sacroiliac joint has gained renewed interest as a possible pain generator. There is reason to believe that the sacroiliac joint plays a regulatory role involving reflex muscle activation, which controls trunk mobility and stability, as well as locomotion. The aim of this experimental study was to determine whether stimulation of nerves in the sacroiliac joint and joint capsule could elicit contractions in porcine gluteal or lumbar spinal muscles. Via a lateral retroperitoneal approach and using hypodermic needles, bipolar stimulating wire electrodes were inserted into the ventral area of the sacroiliac joint and directly under the surface of the capsular membrane, in 10 adolescent pigs (45 kg). This procedure was performed bilaterally, thus establishing two bilateral stimulation sites in the joints. Six electromyographic electrodes were unilaterally inserted into the following muscles: multifidus, gluteus medius, gluteus maximus, and quadratus lumborum. On stimulation within the ventral area of the joint, predominant responses occurred in both the gluteus maximus and quadratus lumborum muscles. However, when stimulating the capsule, the greatest muscular responses were detected in the multifidus muscles. This study addressed the possible regulatory function of the sacroiliac joint, namely, its involvement in activation of the spinal and gluteal muscles, which help control locomotion and body posture, as well as provide stability on the segmental level in the lumbar spine.

The physician as disability advisor for patients with musculoskeletal complaints

Study Design. Literature review. Objectives. To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area. Summary of Background Data. While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients’ general health, employment, and financial well-being. Methods. Medical literature search. Results. Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients’ desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients’ requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians. Conclusions. Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.

Low back pain media campaign: No effect on sickness behaviour

OBJECTIVE To evaluate the effect of a media campaign on popular beliefs about LBP, and eventual changes in sick leave, imaging examinations, and surgery. METHODS Quasi-experimental telephone survey of 1500 randomly chosen people before, during, and after a media campaign in two Norwegian counties, with residents of an adjacent county as the control group. Data on sickness absence, surgery rates for disc herniation and imaging examinations on LBP in the area were collected at the same intervals. RESULTS The campaign led to a small but statistically significant shift in beliefs about LBP in the general public. In particular, beliefs about the use of X-rays, and the importance of remaining active and at work, seemed to have changed in response to the campaign messages. However, this change in attitude and understanding of the condition did not lead to any corresponding change in sickness behaviour. CONCLUSIONS Although the media campaign seemed to somewhat improve beliefs about LBP in the general public, the magnitude of this was too small to produce any significant change in behaviour. PRACTICE IMPLICATIONS A media campaign on LBP should not be limited to small areas and low-budget. A much larger investment is needed for a media campaign to have sufficient impact on publics beliefs on LBP to lead to altered sickness behaviour.