Andrew J. Haig

Pain-related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain.

ObjectivesThe purpose of this study was to examine the relationship between pain-related fear, lumbar flexion, and dynamic EMG activity among persons with chronic musculoskeletal low back pain. It was hypothesized that pain-related fear would be significantly related to decreased lumbar flexion and specific patterns of EMG activity during flexion and extension. Study DesignData was obtained from subjects who, on a single day, completed self-report measures of pain and pain-related fear, and were interviewed to determine demographic and pain information. Subjects then underwent a dynamic EMG evaluation for which they were asked to stand, then bend forward as far as possible, stay fully flexed, and return to standing. Lumbar EMG and angle of flexion were recorded during this time. A flexion-relaxation ratio (FRR) was computed by comparing maximal EMG while flexing to the average EMG in full flexion. SubjectsSeventy-six persons with chronic musculoskeletal low back pain. ResultsZero-order correlations indicated that pain-related fear was significantly related to reduced lumber flexion (r = −0.55), maximum EMG during flexion (r = −0.38) and extension (r = −0.51), and the FRR (r = −0.40). When controlling for pain and demographic factors, pain-related fear continued to be related to reduced lumbar flexion. Using a path-analytic model to examine whether angle of flexion mediated the relationship between fear and EMG activity, the models examining maximal EMG during flexion and extension supported the notion that pain-related fear influences these measures indirectly through its association with decreased range of motion. Conversely, pain-related fear was independently related to higher average EMG in full flexion, while angle of flexion was not significantly related. Pain-related fear was directly related to a smaller FRR, as well as indirectly through angle of flexion. ConclusionsPain-related fear is significantly associated with reduced lumbar flexion, greater EMG in full flexion, and a smaller FRR. The relationship between pain-related fear and EMG during flexion and extension appears to be mediated by reduced lumbar flexion. These results suggest that pain-related fear is directly associated with musculoskeletal abnormalities observed among persons with chronic low back pain, as well as indirectly through limited lumbar flexion. These musculoskeletal abnormalities as well as limited movement may be involved in the development and maintenance of chronic low back pain. In addition, changes in musculoskeletal functioning and flexion associated with pain-related fear may warrant greater attention as part of treatment.

Activity Avoidance and Function in Persons with Chronic Back Pain

This study examined the relative contribution of two aspects of pain-related fear to functional disability among 133 persons with chronic pain, predominantly chronic back pain: 1) beliefs that pain represents damage or significant harm to the body and 2) beliefs that activities that cause pain should be avoided. Pain-related fear was assessed using the Tampa Scale for Kinesiophobia, Version 2 (TSK-2). Factor analysis in the present study replicated the two-factor solution found in a previous investigation, representing the two dimensions of pain-related fear noted above. Activity avoidance was significantly associated with the percent of maximum expected weight lifted from floor to waist and waist to shoulder during Progressive Isoinertial Lifting Evaluation (PILE). Fear of damage or harm to the body was only significantly related to the floor to waist lift. When controlling for demographic, physiologic, and other psychological variables, only activity avoidance continued to significantly predict performance on both lifts of the PILE. Although it has been proposed that deconditioning may mediate the relationship between activity avoidance and disability, this was not supported in the present investigation. The results highlight the importance of pain-related fear, particularly activity avoidance, in the assessment of functional activity among persons with chronic pain.

The Spurling test and cervical radiculopathy.

Study Design. A cross-sectional study design was used. Objective. To determine the sensitivity and specificity of the Spurling test for cervical radiculopathy. Summary of Background Data. The Spurling test is an accepted physical examination test, but there is little data on its sensitivity or specificity. Methods. From 1988 to 1993, 255 consecutive patients were referred for electrodiagnosis of upper extremity nerve disorders. A Spurling test administered before other testing was performed. The Spurling test was scored as positive if it caused pain or tingling that started in the shoulder and radiated distally to the elbow. After the electrodiagnostic examination, a score was given to each diagnosis in the differential diagnosis according to the likelihood of its presence. To determine the odds ratio, sensitivity, and specificity, &khgr;2 analysis was used. Also, the percentage of subjects with positive results from the Spurling test was calculated for several nerve disease diagnoses. Results. The Spurling test had a sensitivity of 6/20 (30%) and a specificity of 160/172 (93%). The results were positive in 16.6% of the normal group, in 3.4% of the group with nerve disorders other than a radiculopathy, in 25% of the group with an abnormality not consistent with any specific diagnosis group, in 37.5% of the group with possible radiculopathy, and in 40% of the group with certain radiculopathy. Conclusions. The Spurling test is not very sensitive, but it is specific for cervical radiculopathy diagnosed by electromyography. Therefore, it is not useful as a screening test, but it is clinically useful in helping to confirm a cervical radiculopathy.

Electromyographic and Magnetic Resonance Imaging to Predict Lumbar Stenosis, Low-Back Pain, and No Back Symptoms

BACKGROUND Magnetic resonance imaging is commonly used to diagnose lumbar spinal stenosis. Some persons without symptoms have a small lumbar spinal canal. Electrodiagnosis has been used to diagnose spinal stenosis for over sixty years, but we are aware of no masked, controlled trials of the use of electrodiagnosis for that purpose. This study was performed to evaluate the relationships of magnetic resonance imaging measures and electrodiagnostic data with the clinical syndrome of spinal stenosis. METHODS One hundred and fifty persons between the ages of fifty-five and eighty years old, including asymptomatic volunteers and persons referred for lumbar magnetic resonance imaging, underwent clinical examination, electrodiagnosis, and magnetic resonance imaging. Subjects were excluded if they had neuromuscular disease, sacral cancer, or inadequate test results, which left 126 subjects for the final analysis. The final cohort was divided into three groups--no back pain, mechanical back pain, and clinical spinal stenosis--on the basis of the impression of the examining physician, for whom the results of the magnetic resonance imaging and electrodiagnostic testing were masked. A spine surgeon also reviewed both the imaging and clinical examination data. RESULTS The examining physicians diagnosis of clinical spinal stenosis was significantly related to the neurological findings on examination (p < 0.05) and to the spine surgeons diagnosis (p < 0.001). The diagnosis of clinical spinal stenosis was also significantly related to the presence of fibrillations on electrodiagnostic testing (p < or = 0.003), the minimum anteroposterior diameter of the spinal canal on the magnetic resonance images (p = 0.016), and the average of the two smallest spinal canal diameters (p = 0.008) on the images. Measurements on magnetic resonance imaging did not differentiate subjects with clinical spinal stenosis from controls better than chance, whereas paraspinal mapping electrodiagnosis scores did. CONCLUSIONS This prospective, controlled, masked study of electrodiagnosis and magnetic resonance imaging for older subjects showed that imaging does not differentiate symptomatic from asymptomatic persons, whereas electrodiagnosis does. We believe that radiographic findings alone are insufficient to justify treatment for spinal stenosis.

A comparison of the relationship between depression, perceived disability, and physical performance in persons with chronic pain

This study examined the relationships between self‐report of depressive symptoms, perceived disability, and physical performance among 267 persons with chronic pain. Prior research has reported a relationship between depression and disability using self‐report measures. However, self‐report instruments may be prone to biases associated with depression as depressed persons with pain may have an exaggerated negative view of their level of function. In addition, we examined whether the relationship between depression and functional activity was mediated by physiologic effort (as measured by heart rate). The results indicated that self‐report of depressive symptoms (using the Center for Epidemiological Studies‐Depression Scale (CES‐D)) was significantly correlated with self‐report of disability on the Quebec Back Pain Disability Scale (QBPDS) and physical performance on the Progressive Isoinertial Lifting Evaluation (PILE). Regression analyses revealed that depression assessed by the CES‐D significantly contributed to the prediction of QBPDS scores and PILE performance even when controlling for age, gender, site of pain, and pain intensity. The magnitude of the relationships between depression and self‐report and functional activity were similar, suggesting that a self‐report bias associated with depression is not responsible for an observed relationship between depression and disability. Physiologic effort partially mediated the relationship between depression and physical performance. The findings further highlight the importance of depression in the experience of chronic pain.

The sensitivity and specificity of electrodiagnostic testing for the clinical syndrome of lumbar spinal stenosis

Study Design. Prospective, masked, double controlled diagnostic trial. Objectives. To determine the sensitivity and specificity of electrodiagnostic consultation (EDX) for the clinical syndrome of lumbar spinal stenosis. Summary of Background Data. EDX has been used for more than 50 years to diagnose spinal disorders but has not met the new standards of evidence-based medicine. Methods. A total of 150 subjects (asymptomatic volunteers and patients with MRIs suggesting back pain or spinal stenosis; 55–80 years of age) underwent physiatrist history and physical examination, MRI, and review of this data by a neurosurgeon, with each clinician masked to any outside information, leading to a unanimous consensus on diagnosis in 55. After masked EDX testing, 7 subjects with undiagnosed neuromuscular disease were discovered. EDX findings were related to “clinical gold standard” diagnoses in 48 persons. Results. Paraspinal mapping EMG score of >4 had 100% specificity and 30% sensitivity for stenosis compared with either the back pain or asymptomatic groups (each, P < 0.04). A composite limb and paraspinal fibrillation score had a sensitivity of 47.8% and specificity of 87.5% (P = 0.008), and H-wave sensitivity was 36.4, specificity 91.3 (P = 0.026) for stenosis versus all controls. Conclusions. This first masked study in the 60-year history of needle electromyography also introduces anatomically validated needle placement, quantified and reproducible examination of the paraspinal muscles, and dual control populations to EDX research in spinal disorders. EDX has statistically significant, clinically meaningful specificity for spinal stenosis and detects neuromuscular diseases that may masquerade as stenosis.

A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain

Objective:This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating chronic low back pain and disability. Methods:A single blind, randomized, controlled trial was employed. Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning. In addition, patients received manual therapy or sham manual therapy. Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily. Results:Seventy-two out of 100 patients completed the study. Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction (P = 0.04 and P = 0.05, respectively), indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received. When controlling for pretreatment scores, patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain. No change in perceived disability was observed, with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment. Discussion:Manual therapy with specific adjuvant exercise appears to be beneficial in treating chronic low back pain. Despite changes in pain, perceived function did not improve. It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability. Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population.

Spinal canal size and clinical symptoms among persons diagnosed with lumbar spinal stenosis

ObjectiveClinical symptoms associated with lumbar spinal stenosis (LSS) are believed to be due to neurogenic claudication caused by narrowing of the central and lateral spinal canals. However, there is a paucity of published data on these relationships. The purpose of the present study was to examine the relationship between clinical symptoms associated with LSS and osseous anterior-posterior (AP) spinal canal diameter as measured on axial magnetic resonance imaging. DesignCross-sectional study conducted at a University Spine Program. Fifty persons with a clinical diagnosis of LSS were administered measures of clinical pain and perceived function. Walking distance in the laboratory and community was also assessed. Participants also underwent magnetic resonance imaging of the spine. ResultsUsing recommended upper limits from the literature, patients with smaller canals reported greater perceived disability, but no other group differences emerged. In the entire sample, AP spinal canal diameter was not significantly associated with any of the clinical symptom measures examined. Body mass index was found to be significantly related to walking distance, but not perceived function or pain. ConclusionsAP spinal canal diameter is not predictive of clinical symptoms associated with LSS. The findings also suggest that body mass may play a significant role in functional limitations observed in this population.

Impairment, activity, participation, life satisfaction, and survival in persons with locked-in syndrome for over a decade: follow-up on a previously reported cohort.

Objective:To determine the long-term outcome of patients with stable locked-in syndrome. Setting:The community. Design:Retrospective phone survey. This study was further follow-up on a previously reported cohort. Participants:Twenty-nine persons with locked-in syndrome were included in an initial cohort 11 years prior to the current study. Records or contact with family showed that 16 were deceased. Telephone interviews were made with 1 living patient and the caregivers of 11 others. Public records documented survival of 1 nonrespondent. Outcome measures:Survival, codified responses regarding functional activities, social activities, and satisfaction with life. Results:Five-, 10-, and 20-year survival were 83%, 83%, and 40%, respectively. Ten subjects had not been hospitalized in the previous year. Eight lived with family. Little change in impairment occurred, but care was simplified. Improvements in communication related to technology, including computer and Internet access. Eleven left home at least monthly. Caregivers reported seven expressed satisfaction with life; five were occasionally depressed. No deaths could be attributed to euthanasia and no survivor had a “no code” status. One patient wished to die, seven had never considered euthanasia, six had considered and rejected it. Conclusions:Persons with initially stable locked-in syndrome can have prolonged survival, can live in the community if there is enough support, and have some measure of quality of life.

Spinal Cord Injury Management and Rehabilitation: Highlights and Shortcomings From the 2005 Earthquake in Pakistan

Recent natural disasters have highlighted the lack of planning for rehabilitation and disability management in emergencies. A review of our experience with spinal cord injury (SCI) after the Pakistan earthquake of 2005, plus a review of other literature about SCI after natural disasters, shows that large numbers of people will incur SCIs in such disasters. The epidemiology of SCI after earthquakes has not been well studied and may vary with location, severity of the disaster, available resources, the expertise of the health care providers, and cultural issues. A lack of preparedness means that evacuation protocols, clinician training, dedicated acute management and rehabilitation facilities, specialist equipment, and supplies are not in place. The dearth of rehabilitation medicine specialists in developing regions further complicates the issue, as does the lack of national spinal cord registries. In our 3 makeshift SCI units, however, which are staffed by specialists and residents in rehabilitation medicine, there were no deaths, few complications, and a successful discharge for most patients. Technical concerns include air evacuation, early spinal fixation, aggressive management to optimize bowel and bladder care, and provision of appropriate skin care. Discharge planning requires substantial external support because SCI victims must often return to devastated communities and face changed vocational and social possibilities. Successful rehabilitation of victims of the Pakistan earthquake has important implications. The experience suggests that dedicated SCI centers are essential after a natural disaster. Furthermore, government and aid agency disaster planners are advised to consult with rehabilitation specialists experienced in SCI medicine in planning for the inevitable large number of people who will have disabilities after a natural disaster.