Carol Hartigan

The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain

Study Design. In this prospective, observational, cohort study of 192 individuals with chronic low back pain, the group of individuals was divided based on compensation involvement, and their presentation pain and disability, treatment recommendations, and compliance were compared. For 85 of these individuals who completed a spine rehabilitation program, their pain and disability at 3 and 12 months were compared. Objectives. To test the theory that individuals with compensation involvement presented with greater pain and disability and would report less change of pain and disability after rehabilitation efforts. Background. Previous studies have produced conflicting results concerning this issue. Methods. Individuals were recruited as consecutive patients referred for consultation at a spine rehabilitation center. Pain, depression, and disability were assessed using self‐report questionnaires at evaluation and at 3 and 12 months. Rehabilitation services consisted of aggressive, quota‐based exercises aimed at correcting impairments in flexibility, strength, endurance, and lifting capacity, identified through quantification of back function. Multifactoral analysis of variance models were used to control for baseline differences between compensation and noncompensation patients during analysis of target variables. Results. The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and non‐compensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow‐up visit, pain scores improved for the noncompensation group, but not for the compensation group. Conclusions. In chronic low back pain, compensation involvement may have an adverse effect on self‐reported pain, depression, and disability before and after rehabilitation interventions.

Long-term exercise adherence after intensive rehabilitation for chronic low back pain

PURPOSE The purpose of this study was to examine exercise compliance in patients with chronic low back pain (CLBP) after participation in an intensive spine rehabilitation program. METHODS Exercise behaviors in 122 consecutive subjects with CLBP who completed a program of quota based exercise were examined. Frequency per week of performance of four exercise activities, Oswestry disability scores, and visual analog scale (VAS) scores were assessed at evaluation, 3-month, and 12-month follow-up by patient-completed questionnaires. RESULTS Percentage of patients responding to initial, 3-month, and 12-month questionnaires were 100%, 86%, and 71%, respectively. Frequencies of exercise behaviors were compared by Wilcoxon signed-rank test and were found to increase significantly between evaluation and 3 months (P < 0.000), and evaluation and 12-month follow-up (P < 0.000). The percentages of patients reporting three or more times weekly performance of the following activities at evaluation and at three month follow-up, respectively, were: 1) stretching for the back and legs, 35% and 93%; 2) aerobic exercise, 44% and 87%; 3) back-strengthening exercises, 15% and 82%; and, 4) weight training, 6% and 71%. Evaluation and follow-up Oswestry disability and visual analog scale (VAS) scores for back pain were compared using Students t-test. Significant improvements (P < 0.000) were noted for each of these scales at 3-month follow-up that were maintained at 12-month follow-up. CONCLUSION It is concluded that exercise behaviors can be increased and maintained in CLBP patients without adversely affecting pain or function.

The Accuracy of the Physical Examination for the Diagnosis of Midlumbar and Low Lumbar Nerve Root Impingement

Study Design. Cross-sectional study with prospective recruitment. Objective. To determine the accuracy of the physical examination for the diagnosis of midlumbar nerve root impingement (L2, L3, or L4), low lumbar nerve root impingement (L5 or S1) and level-specific lumbar nerve root impingement on magnetic resonance imaging, using individual tests and combinations of tests. Summary of Background Data. The sensitivity and specificity of the physical examination for the localization of nerve root impingement has not been previously studied. Methods. Sensitivities, specificities, and likelihood ratios (LRs) were calculated for the ability of individual tests and test combinations to predict the presence or absence of nerve root impingement at midlumbar, low lumbar, and specific nerve root levels. Results. LRs ≥5.0 indicate moderate to large changes from pre-test probability of nerve root impingement to post-test probability. For the diagnosis of midlumbar impingement, the femoral stretch test (FST), crossed FST, medial ankle pinprick sensation, and patellar reflex testing demonstrated LRs ≥5.0 (LR ∞). LRs ≥5.0 were observed with the combinations of FST and either patellar reflex testing (LR 7.0; 95% confidence interval [CI] 2.3–21) or the sit-to-stand test (LR ∞). For the diagnosis of low lumbar impingement, the Achilles reflex test demonstrated an LR ≥5.0 (LR 7.1; 95% CI 0.96–53); test combinations did not increase LRs. For the diagnosis of level-specific impingement, LRs ≥5.0 were observed for anterior thigh sensation at L2 (LR 13; 95% CI 1.8–87); FST at L3 (LR 5.7; 95% CI 2.3–4.4); patellar reflex testing (LR 7.7; 95% CI 1.7–35), medial ankle sensation (LR ∞), or crossed FST (LR 13; 95% CI 1.8–87) at L4; and hip abductor strength at L5 (LR 11; 95% CI 1.3–84). Test combinations increased LRs for level-specific root impingement at the L4 level only. Conclusion. Individual physical examination tests may provide clinical information that substantially alters the likelihood that midlumbar impingement, low lumbar impingement, or level-specific impingement is present. Test combinations improve diagnostic accuracy for midlum-bar impingement.

Comparison of total lumbosacral flexion and true lumbar flexion measured by a dual inclinometer technique

Study Design This study investigated the interrelationship between total lumbosacral flexion and true lumbar flexion in a population of chronic low back pain sufferers, measured with a dual inclinometer technique. Correlations with self-reported disability also were assessed. Seld-reported disability was measured with the Million Visual Analog Scale. Objectives To assess whether total lumbosacral flexion could be substituted for true lumbar flexion in the clinical evaluation of trunk mobility. To determine which measure of flexion is a better predictor of self-reported disability after an intensive rehabilitation program for chronic spinal disorders. Summary of Background Data Eighty-nine consecutive patients with chronic low back pain were evaluated. Fourteen subjects were excluded because of previous surgery. Seventy-five meet inclusion criteria and underwent quantification of lumbar mobility. Sixty-four metliteracy criteria and were administered the Million Visual Analog Scale. Thirty-six patients completed rehabilitation and were re-evaluated at program completion for lumbar mobility. Thirty-three were re-evaluated with the Million Visual Analog Scale. Results Pearsons correlation coefficients for lumbar versus total flexion were r = 0.88 for initial evaluation and r = 0.84 after treatment. Correlation coefficients also were calculated for lumbar flexion and total flexion with disability scores. Before treatment, both measurements accounted for similar amounts of the variance in disability scores. However, after treatment, total flexion correlated higher with self-reported disability (r = −0.62 versus r = −0.43). Conclusions Our results suggest that total lumbosacral flexion may be as equally relevant as true lumbar flexion in the measurement of trunk mobility in the clinical examination of patients with chronic low back pain. Regarding their relationship to self-reported disability, total flexion seems to be more relevant to outcome after intensive rehabilitation.

Nonsurgical Treatment of Lumbar Disk Herniation: Are Outcomes Different in Older Adults?

OBJECTIVES: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).

Inciting events associated with lumbar disc herniation.

BACKGROUND CONTEXT No prior study has investigated the frequency of patient-identified inciting events in lumbar disc herniation (LDH) or their clinical significance. PURPOSE To examine the clinical frequency of patient-identified inciting events in LDH, and to identify associations between the presence of inciting events and the severity of the clinical presentation. STUDY DESIGN/SETTING Cross-sectional analysis of data from a cohort study with prospective recruitment, with retrospective data collection on inciting events. The setting was a hospital-based specialty spine clinic. PATIENT SAMPLE One hundred fifty-four adults with lumbosacral radicular pain and LDH confirmed by magnetic resonance imaging. OUTCOME MEASURES Self-report measures of disability measured by the Oswestry Disability Index (ODI), the visual analog scale (VAS) for leg pain, and the VAS for back pain. METHODS Dependent variables included the presence of a patient-identified inciting event, which were categorized as spontaneous onset, nonlifting physical activity, heavy lifting (>35 lbs), light lifting (<35 lbs), nonexertional occurrence, or physical trauma. We examined the association of an inciting event, or a lifting-related event, with each outcome, first using univariate analyses, and second using multivariate modeling, accounting for important adjustment variables. RESULTS Sixty-two percent of LDH did not have a specific patient-identified event associated with onset of symptoms. Nonlifting activities were the most common inciting event, comprising 26% of all LDH. Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. Patient-identified inciting events were not significantly associated with a more severe clinical presentation in crude analyses. Spontaneous LDH was significantly associated with higher baseline ODI scores in multivariate analysis, although the magnitude of this effect was small. There were no significant associations (p< or =.05) between the presence of a lifting-associated event and the outcomes of ODI, VAS leg pain, or VAS back pain. CONCLUSIONS The majority of LDH occurred without specific inciting events. A history of an inciting event was not significantly associated with a more severe clinical presentation. There was no significant association between the occurrence of a lifting-related event and the severity of the clinical presentation. This information may be useful in the counseling of patients recovering from acute LDH.

Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?: A Longitudinal Case-crossover Feasibility Study

Study Design. Prospective, longitudinal case-crossover study. Objective. The aim of this study was to determine whether physical activities trigger flare-ups of pain during the course of acute low back pain (LBP). Summary of Background Data. . There exist no evidence-based estimates for the transient risk of pain flare-ups associated with specific physical activities, during acute LBP. Methods. Participants with LBP of duration <3 months completed frequent, Internet-based serial assessments at both 3- and 7-day intervals for 6 weeks. At each assessment, participants reported whether they had engaged in specific physical activity exposures, or experienced stress or depression, during the past 24 hours. Participants also reported whether they were currently experiencing a LBP flare-up, defined as “a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently.” Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between potential triggers during the past 24 hours, and the risk of LBP flare-ups, using conditional logistic regression. Results. Of 48 participants followed longitudinally, 30 participants had both case (“flare”) and control periods and contributed data to the case-crossover analysis. There were 81 flare periods and 247 control periods, an average of 11 periods per participant. Prolonged sitting (>6 hours) was the only activity that was significantly associated with flare-ups(OR 4.4, 95% CI 2.0–9.7; P < 0.001). Having either stress or depression was also significantly associated with greater risk of flare-ups (OR 2.5, 95% CI 1.0–6.0; P = 0.04). In multivariable analyses, prolonged sitting (OR 4.2, 95% CI 1.9–9.1; P < 0.001), physical therapy (PT) (OR 0.4, 95% CI 0.1–1.0; P = 0.05), and stress/depression (OR 2.8, 95% CI 1.2–6.7; P = 0.02) were independently and significantly associated with LBP flare-up risk. Conclusion. Among participants with acute LBP, prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups. PT was a deterrent of flare-ups. Level of Evidence: 2

Nonsurgical Treatment of Lumbar Disk Herniation: Are Outcomes Different in Older Adults?: LUMBAR DISK HERNIATION IN OLDER ADULTS

OBJECTIVES: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).

Nonsurgical treatment of lumbar disk herniation

OBJECTIVES: To determine whether older adults (aged ≥60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60).

Oefenen als behandeling voor chronische lage-rugpijn

Achtergrond. Oefenen is een veel voorgeschreven behandeling voor chronische lage-rugpijn, met een aangetoonde effectiviteit voor verbetering van functie en werk.