James Rainville

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.

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.

Does This Older Adult With Lower Extremity Pain Have the Clinical Syndrome of Lumbar Spinal Stenosis

CONTEXT The clinical syndrome of lumbar spinal stenosis (LSS) is a common diagnosis in older adults presenting with lower extremity pain. OBJECTIVE To systematically review the accuracy of the clinical examination for the diagnosis of the clinical syndrome of LSS. DATA SOURCES MEDLINE, EMBASE, and CINAHL searches of articles published from January 1966 to September 2010. STUDY SELECTION Studies were included if they contained adequate data on the accuracy of the history and physical examination for diagnosing the clinical syndrome of LSS, using a reference standard of expert opinion with radiographic or anatomic confirmation. DATA EXTRACTION Two authors independently reviewed each study to determine eligibility, extract data, and appraise levels of evidence. DATA SYNTHESIS Four studies evaluating 741 patients were identified. Among patients with lower extremity pain, the likelihood of the clinical syndrome of LSS was increased for individuals older than 70 years (likelihood ratio [LR], 2.0; 95% confidence interval [CI], 1.6-2.5), and was decreased for those younger than 60 years (LR, 0.40; 95% CI, 0.29-0.57). The most useful symptoms for increasing the likelihood of the clinical syndrome of LSS were having no pain when seated (LR, 7.4; 95% CI, 1.9-30), improvement of symptoms when bending forward (LR, 6.4; 95% CI, 4.1-9.9), the presence of bilateral buttock or leg pain (LR, 6.3; 95% CI, 3.1-13), and neurogenic claudication (LR, 3.7; 95% CI, 2.9-4.8). Absence of neurogenic claudication (LR, 0.23; 95% CI, 0.17-0.31) decreased the likelihood of the diagnosis. A wide-based gait (LR, 13; 95% CI, 1.9-95) and abnormal Romberg test result (LR, 4.2; 95% CI, 1.4-13) increased the likelihood of the clinical syndrome of LSS. A score of 7 or higher on a diagnostic support tool including history and examination findings increased the likelihood of the clinical syndrome of LSS (LR, 3.3; 95% CI, 2.7-4.0), while a score lower than 7 made the diagnosis much less likely (LR, 0.10; 95% CI, 0.06-0.16). CONCLUSIONS The diagnosis of the clinical syndrome of LSS requires the appropriate clinical picture and radiographic findings. Absence of pain when seated and improvement of symptoms when bending forward are the most useful individual findings. Combinations of findings are most useful for identifying patients who are unlikely to have the diagnosis.

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.

Altering beliefs about pain and impairment in a functionally oriented treatment program for chronic low back pain.

OBJECTIVE This study examined pain and impairment beliefs [measured with the Pain and Impairment Relationship Scale, (PAIRS)] of chronic low back pain patients during rehabilitation and hypothesized that pain beliefs would be stronger in drop-out subjects, decrease during treatment, and after treatment correlate strongly with disability measures. DESIGN Prospective cohort. SETTING Outpatient, functionally oriented rehabilitation program for chronic low back pain. PATIENTS 72 consecutive chronic low back pain referral patients disabled from working because of pain. INVOLVEMENT: Interdisciplinary rehabilitation with a focus on intensive physical reconditioning was employed. OUTCOME MEASURES Program completion versus drop-out groups and pretreatment and posttreatment pain, disability, depression, and PAIRS scores were compared. RESULTS Thirty patients dropped out and 42 subjects completed treatment. The PAIRS scores at evaluation were similar for both groups. The PAIRS scores improved significantly during treatment (p < 0.001). Posttreatment PAIRS scores correlated highly with disability measures (r = 0.79, p < 0.001). CONCLUSION Pain beliefs are of minimal value for predicting treatment compliance, but may be altered during functionally oriented treatment of chronic low back pain. Posttreatment disability closely mirrored attitudes and belief-associated pain and impairment.

Aggressive Exercise as Treatment for Chronic Low Back Pain

Exercise has long been a standard of treatment for back pain. Over the last 2 decades, the use of intense, non-pain-contingent exercises for treatment of chronic back pain has received increased advocacy. The main goals of these treatments are to improve functioning of painful lumbar soft tissue and to decrease the fears and concerns of patients about using their backs for daily activities. The methodology of an aggressive quota-based exercise approach to back pain is outlined in this article. This approach relies on objective quantification of physical capabilities, treatment directed at altering these parameters, and repeat quantification for determination of treatment efficacy and positive feedback. By eliminating impairments in back function, altering fears and beliefs about pain, and reducing disability, patients with chronic low back pain can achieve meaningful improvements in their quality of life.

Does lumbar spinal degeneration begin with the anterior structures? A study of the observed epidemiology in a community-based population

Background-Prior studies that have concluded that disk degeneration uniformly precedes facet degeneration have been based on convenience samples of individuals with low back pain. We conducted a study to examine whether the view that spinal degeneration begins with the anterior spinal structures is supported by epidemiologic observations of degeneration in a community-based population.Methods-361 participants from the Framingham Heart Study were included in this study. The prevalences of anterior vertebral structure degeneration (disk height loss) and posterior vertebral structure degeneration (facet joint osteoarthritis) were characterized by CT imaging. The cohort was divided into the structural subgroups of participants with 1) no degeneration, 2) isolated anterior degeneration (without posterior degeneration), 3) combined anterior and posterior degeneration, and 4) isolated posterior degeneration (without anterior structure degeneration). We determined the prevalence of each degeneration pattern by age group < 45, 45-54, 55-64, ≥65. In multivariate analyses we examined the association between disk height loss and the response variable of facet joint osteoarthritis, while adjusting for age, sex, BMI, and smoking.Results-As the prevalence of the no degeneration and isolated anterior degeneration patterns decreased with increasing age group, the prevalence of the combined anterior/posterior degeneration pattern increased. 22% of individuals demonstrated isolated posterior degeneration, without an increase in prevalence by age group. Isolated posterior degeneration was most common at the L5-S1 and L4-L5 spinal levels. In multivariate analyses, disk height loss was independently associated with facet joint osteoarthritis, as were increased age (years), female sex, and increased BMI (kg/m2), but not smoking.Conclusions-The observed epidemiology of lumbar spinal degeneration in the community-based population is consistent with an ordered progression beginning in the anterior structures, for the majority of individuals. However, some individuals demonstrate atypical patterns of degeneration, beginning in the posterior joints. Increased age and BMI, and female sex may be related to the occurrence of isolated posterior degeneration in these individuals.

Long-term exercise adherence in the elderly with chronic low back pain

Mailloux J, Finno M, Rainville J: Long-term exercise adherence in the elderly with chronic low back pain. Am J Phys Med Rehabil 2006;85:120–126. Objective:Chronic back pain is common in the elderly population and can be treated with exercise. Long-term adherence to exercise recommendations has been documented in adults of <65 yrs of age but not for elderly adults. This study explored exercise behaviors of elderly adults with a history of chronic back pain before and 2 yrs after treatment in an exercise-oriented rehabilitation program. Design:This study utilized a case series design to survey 126 subjects >65 yrs old who underwent physical therapy during the year 2000 for complaints of chronic low back pain. Of these, 89 (70%) responded to the 2-yr questionnaire. Outcome measures included visual analog scale for pain, Oswestry disability questionnaires, back flexibility and strength, and a questionnaire exploring exercise behaviors. All subjects underwent a 6-wk physical therapy program that consisted of exercise coupled with advice to remain active. Results:Improvements in flexibility and strength occurred during treatment. Mean Oswestry disability scores (0–100 scale) improved from 32 to 20, and pain scores (0–10 scale) from 5.0 to 3.0 during treatment (P < 0.001) and were maintained at the 2-yr follow-up, regardless of exercise adherence. The percentage of patients who performed at least some exercise increased from 49% before treatment to 72% at the 2-yr follow-up. The changes in disability or pain observed during treatment did not influence exercise compliance. The most frequently stated reasons for nonadherence was that exercise did not help or aggravated pain (33%). For those who exercised regularly, 80% did so because of the health benefits from exercise. Conclusions:The exercise behaviors of many elderly adults with chronic low back pain can increase after an exercise-oriented spine physical therapy program.

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.

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.