Alan Breen

Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care

Maurits van Tulder (chairman) Epidemiologist (NL) Annette Becker General practitioner (GER) Trudy Bekkering Physiotherapist (NL) Alan Breen Chiropractor (UK) Tim Carter Occupational physician (UK) Maria Teresa Gil del Real Epidemiologist (ESP) Allen Hutchinson Public Health Physician (UK) Bart Koes Epidemiologist (NL) Peter Kryger-Baggesen Chiropractor (DK) Even Laerum General practitioner (NO) Antti Malmivaara Rehabilitation physician (FIN) Alf Nachemson Orthopaedic surgeon (SWE) Wolfgang Niehus Orthopaedic / anesthesiologist (Aus) Etienne Roux Rheumatologist (SUI) Sylvie Rozenberg Rheumatologist (FR)

An objective spinal motion imaging assessment (OSMIA): reliability, accuracy and exposure data

BackgroundMinimally-invasive measurement of continuous inter-vertebral motion in clinical settings is difficult to achieve. This paper describes the reliability, validity and radiation exposure levels in a new Objective Spinal Motion Imaging Assessment system (OSMIA) based on low-dose fluoroscopy and image processing.MethodsFluoroscopic sequences in coronal and sagittal planes were obtained from 2 calibration models using dry lumbar vertebrae, plus the lumbar spines of 30 asymptomatic volunteers. Calibration model 1 (mobile) was screened upright, in 7 inter-vertebral positions. The volunteers and calibration model 2 (fixed) were screened on a motorised table comprising 2 horizontal sections, one of which moved through 80 degrees. Model 2 was screened during motion 5 times and the L2-S1 levels of the volunteers twice. Images were digitised at 5fps.Inter-vertebral motion from model 1 was compared to its pre-settings to investigate accuracy. For volunteers and model 2, the first digitised image in each sequence was marked with templates. Vertebrae were tracked throughout the motion using automated frame-to-frame registration. For each frame, vertebral angles were subtracted giving inter-vertebral motion graphs. Volunteer data were acquired twice on the same day and analysed by two blinded observers. The root-mean-square (RMS) differences between paired data were used as the measure of reliability.ResultsRMS difference between reference and computed inter-vertebral angles in model 1 was 0.32 degrees for side-bending and 0.52 degrees for flexion-extension. For model 2, X-ray positioning contributed more to the variance of range measurement than did automated registration. For volunteer image sequences, RMS inter-observer variation in intervertebral motion range in the coronal plane was 1.86 degreesand intra-subject biological variation was between 2.75 degrees and 2.91 degrees. RMS inter-observer variation in the sagittal plane was 1.94 degrees. Radiation dosages in each view were below the levels recommended for a plain film.ConclusionOSMIA can measure inter-vertebral angular motion patterns in routine clinical settings if modern image intensifier systems are used. It requires skilful radiography to achieve optimal positioning and dose limitation. Reliability in individual subjects can be judged from the variance of their averaged inter-vertebral angles and by observing automated image registration.

A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement.

Introduction The Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement is a consensus statement aimed at improving the quality of prospective investigations into the transition from early stages of low back pain (LBP) to persistent problems. The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection. The MMICS Statement is primarily aimed at researchers who want to investigate prognosis in LBP, and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems. One approach to preventing acute new episodes of LBP (up to 3 weeks from onset) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability. Targeting interventions at those at highest risk could reduce the population burden of chronic LBP. A wide range of baseline parameters have been associated with poor outcome in inception cohort studies (1–6). Few existing studies have been of sufficient size and methodologic rigor to produce conclusive findings. Even in methodologically robust studies, baseline factors only account for a small proportion of the variance in outcome (7), typically around 30%. Systematic reviews of the literature could not pool data because studies used different measurements (1–3). Despite some information on physical, psychosocial, and work-related risk factors, it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP. How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003. A steering group for the collaboration was appointed, and 8 national team leaders volunteered to recruit teams of national experts. Three additional team leaders were recruited by the steering group (Australia, France, and Germany). Independent experts were invited to advise on the quality of the MMICS process. The MMICS steering group, located in the UK, met regularly and included expert researchers in clinical and outcome factors in back pain (AB), work-related issues in back pain (AKB), psychosocial aspects of back pain (TP and RS), and general practice aspects of back pain (MU). The MMICS Statement set out to include 1) a minimal but comprehensive number of predictor factors based on current evidence and theory; 2) appropriate measurement instruments for agreed predictor factors based on their clinometric properties, availability, and practical characteristics; and 3) a minimum set of followup measures, including recommendations about measurement and timing.

On behalf of the COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3 European Guidelines for the management of acute nonspecific low back pain in primary care.

Maurits van Tulder (chairman) Epidemiologist (NL) Annette Becker General practitioner (GER) Trudy Bekkering Physiotherapist (NL) Alan Breen Chiropractor (UK) Tim Carter Occupational physician (UK) Maria Teresa Gil del Real Epidemiologist (ESP) Allen Hutchinson Public Health Physician (UK) Bart Koes Epidemiologist (NL) Peter Kryger-Baggesen Chiropractor (DK) Even Laerum General practitioner (NO) Antti Malmivaara Rehabilitation physician (FIN) Alf Nachemson Orthopaedic surgeon (SWE) Wolfgang Niehus Orthopaedic / anesthesiologist (Aus) Etienne Roux Rheumatologist (SUI) Sylvie Rozenberg Rheumatologist (FR)

“You feel so hopeless”: A qualitative study of GP management of acute back pain

Background Biopsychosocial management of non‐specific back pain in general practice has been problematical, with frequent inappropriate referral for imaging and secondary care interventions and lack of self‐confidence in the ability to provide evidence‐based care.

Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache.

BACKGROUND The clinical significance of the ponticulus posticus is far from clear. It has been associated with headaches, Barré-Lieou syndrome, photophobia, and migraine. However, little epidemiologic evidence for this exists. OBJECTIVE This study investigated the relationship of ponticulus posticus on x-ray studies and headache symptoms in a series of chiropractic patients. METHODS Eight hundred ninety-five patients who visited a chiropractic clinic for the first time and whose conditions required cervical spine x-ray examinations were studied. Complaints were categorized as migraine with aura, migraine without aura, cervicogenic headache, neck pain only, and other conditions. The presence or absence of the ponticulus posticus (whether partial or complete) was determined by means of a lateral cervical film and noted as a positive or negative finding. The data were analyzed by frequency analysis and Pearsons chi 2 test. RESULTS Forty-six percent of the sample were men and the predominant complaint was neck pain (33%). Most patients were in the fourth decade of life. The frequencies of the other complaints were migraine with aura (7%), migraine without aura (4%), cervicogenic headache (22%), other conditions (33%). An 18% prevalence of ponticulus posticus was found. This finding was significantly associated with migraine without aura (chi 2 = 4.97; P = .03) and not with any other conditions. CONCLUSION In a chiropractic patient population that required cervical x-ray examinations, a significant association was found between ponticulus posticus and migraine without aura, with an odds ratio of 2.19:1 in favor of this complaint being present with the osseous anomaly. The mechanism for this remains obscure but may be related to ischemic compression of the vertebral artery or by dural tension at the craniocervical junction.

Persistent back pain — why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists

Aims (a) To investigate how widespread is the use of long term treatment without improvement amongst clinicians treating individuals with low back pain. (b) To study the beliefs behind the reasons why chiropractors, osteopaths and physiotherapists continue to treat people whose low back pain appears not to be improving.

Adverse effects of spinal manipulation.

Summary Guidelines on acute back pain recommend spinal manipulation, but some commentators express concern that the adverse effects are under-reported. Eleven chiropractors distributed questionnaires to 108 consecutive new patients aged >18 years, enquiring about adverse effects one hour, one day and two days after spinal manipulation. The forms were to be completed anonymously. 80 questionnaires (74%) were returned, 68 suitable for analysis. 28 patients reported adverse effects at one hour after treatment, the most common of which were extra pain (14) and radiating pain (9). 8 had reactions beginning the morning after. No serious adverse effects were reported. The adverse reactions, recorded in 53% of respondents, are those to be expected from a treatment that entails initial discomfort. They need to be set against the long-term benefits of spinal manipulation.

A digital videofluoroscopic technique for spine kinematics

The kinematic behaviour of the vertebral segments under the influence of spinal injury and other mechanical problems is difficult to quantify in patients. This paper describes the use of a calibration model and human subjects to investigate the accuracy of a method for determining lumbar intervertebral rotations using images digitized from an image intensifier. The main influences were found to be observer error in marking co-ordinates, scaling of the image presented by the computers monitor, distortion caused by out-of-plane images and loss of image quality as a result of scattered radiation from the soft tissues. The technique may be valuable in the light of its efficiency and low X-ray exposure to patients.

Spine kineamtics: a digital videofluoroscopic technique

Abstract It is notoriously difficult to quantify the kinematic behaviour of vertebral segments in the assessment and localization of mechanical disorders of the spine. This paper describes the use of an image processor and an X-ray machine with image intensifier for the measurement of lumbar spine angular rotation and instantaneuous centres of rotation in the coronal plane. The system was calibrated against a model under realistic conditions employing multiplanar motion and X-ray scatter.