María Teresa Gil del Real

A Consensus Approach Toward the Standardization of Back Pain Definitions for Use in Prevalence Studies

Study Design. A modified Delphi study conducted with 28 experts in back pain research from 12 countries. Objective. To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. Summary of Background Data. Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. Methods. Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. Results. Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. Conclusion. These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Correlation Between Pain, Disability, and Quality of Life in Patients With Common Low Back Pain

Study Design. Correlation among previously validated questionnaires. Objectives. To determine the correlation between pain, disability, and quality of life in patients with low back pain. Summary of Background Data. The Visual Analogue Scale (VAS), and the Roland-Morris (RMQ), Oswestry (OQ), and EuroQol (EQ) Questionnaires are validated instruments to assess pain, low back pain-related disability, and quality of life. Methods. The study was done in the primary care setting, in Mallorca, with 195 patients who visited their physician for LBP. Individuals were given the VAS, RMQ, OQ, and EQ on their first visit and 14 days later. Results. Median duration of pain when entering the study was 10 days (P25,P75: 3, 40). On day 1, simple correlation was r = 0.347 between VAS and RMQ, r = −0.422 between VAS and EQ, and r = −0.442 between RMQ and EQ. On day 15, simple correlation was r = 0.570 between VAS and RMQ, r = −0.672 between VAS and EQ, and r = −0.637 between RMQ and EQ. Multiple linear regression models showed that, on day 1, the VAS score explains 12% of the RMQ score and the VAS and RMQ scores explain 27% of the EQ score. On day 15, the VAS score explains 33% of the RMQ score, and the VAS and RMQ scores explain 58% of the EQ score. On day 1, a 10% increase in VAS worsens disability by 3.3% and quality of life by 2.65%. On day 15, a 10% increase in VAS worsens disability by 4.99% and quality of life by 3.80%. Prestudy duration of pain had no influence on any model. All these correlation coefficients and models are significant at the P < 0.001 level. The OQ had lower correlation values with the other three scales, and only two of them were significant. Conclusion. Clinically relevant improvements in pain may lead to almost unnoticeable changes in disability and quality of life. Therefore, these variables should be assessed separately when evaluating the effect of any form of treatment for low back pain. The influence of pain and disability on quality of life progresses while they last, and doubles in 14 days. In acute and subacute patients, this increase is not dependent on the previous duration of pain.

Risk factors for non-specific low back pain in schoolchildren and their parents: a population based study

&NA; A survey of adolescent schoolchildren and their parents through a self‐administered questionnaire was conducted to determine the prevalence of low back pain (LBP) in schoolchildren and their parents and to assess its association with exposure to known and presumed risk factors. A previously validated, self‐administered questionnaire was used for collecting information on back pain history, anthropometric measures, physical and sports activity, academic problems, hours of leisure sitting, smoking, and alcohol intake. Schoolchildren between the ages of 13 and 15 in schools of the island of Mallorca and their parents (n=16,394) took part in the study. The lifetime prevalence of LBP was 50.9% for boys and 69.3% for girls; point prevalence (7 days) was 17.1% for boys and 33% for girls. There was a significant association with LBP and pain in bed (OR=13.82, 95% CI: 10.47–18.25, P<0.001), reporting scoliosis (OR=2.87, 95% CI: 2.45–3.37, P<0.001), reporting difference in leg length (OR=1.26, 95% CI: 1.02–1.56, P=0.033), practice of any sport more than twice a week (OR=1.23, 95% CI: 1.09–1.39, P=0.001) and being female (OR=1.11, 95% CI: 1.04–1.19, P=0.001). There was no association found between LBP and body mass index, the manner in which books were transported, hours of leisure sitting, alcohol intake or cigarette smoking. Among parents, the lifetime prevalence of LBP was 78.2% for mothers and 62.6% for fathers; point prevalence (7 days) was 41% for mothers and 24.3% for fathers, and there were significant associations with LBP and pain in bed (OR=18.07, 95% CI: 14.72–22.19, P<0.001), report of scoliosis (OR=8.77, 95% CI: 6.44–11.95, P<0.001), report of difference in leg length (OR=2.21, 95% CI: 1.60–3.04, P<0.001), being a university graduate (OR=1.89, 95% CI: 1.21–2.98, P=0.006), being female (OR=1.49, 95% CI: 1.33–1.67, P<0.001), and swimming (OR=1.10, 95% CI: 1.4–1.18, P=0.002). There was no association found between LBP and alcohol intake, cigarette smoking or the practice of other sports. Although there was a positive association in terms of scoliosis between biological parents and their children (P<0.001), there was no association found in familial (biological or not) occurrence of LBP. The prevalence of LBP among adolescents in southern Europe is similar to northern Europe, it is comparable to that in adults, and is associated with several factors. There is a strong association between pain in bed or upon rising in both adolescents and adults. Scoliosis, but not LBP, appears to be related to heredity. Further longitudinal studies are necessary to establish risk factors that are predictive for LBP in adolescents.

Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial

BACKGROUND A firm mattress is commonly believed to be beneficial for low-back pain, although evidence supporting this recommendation is lacking. We assessed the effect of different firmnesses of mattresses on the clinical course of patients with chronic non-specific low-back pain. METHODS In a randomised, double-blind, controlled, multicentre trial, we assessed 313 adults who had chronic non-specific low-back pain, but no referred pain, who complained of backache while lying in bed and on rising. Mattress firmness is rated on a scale developed by the European Committee for Standardisation. The H(s) scale starts at 1.0 (firmest) and stops at 10.0 (softest). We randomly assigned participants firm mattresses (H(s)=2.3) or medium-firm mattresses (H(s)=5.6). We did clinical assessments at baseline and at 90 days. Primary endpoints were improvements in pain while lying in bed, pain on rising, and disability. FINDINGS At 90 days, patients with medium-firm mattresses had better outcomes for pain in bed (odds ratio 2.36 [95% CI 1.13-4.93]), pain on rising (1.93 [0.97-3.86]), and disability (2.10 [1.24-3.56]) than did patients with firm mattresses. Throughout the study period, patients with medium-firm mattresses also had less daytime low-back pain (p=0.059), pain while lying in bed (p=0.064), and pain on rising (p=0.008) than did patients with firm mattresses. INTERPRETATION A mattress of medium firmness improves pain and disability among patients with chronic non-specific low-back pain.

A comparison of two short education programs for improving low back pain-related disability in the elderly: a cluster randomized controlled trial.

Study Design. Cluster randomized clinical trial. Objectives. To assess the effectiveness of 2 minimal education programs for improving low back pain (LBP)-related disability in the elderly. Summary of Background Data. No education program has shown effectiveness on low back pain (LBP)-related disability in the elderly. Methods. A total of 129 nursing homes (6389 residents) in northern Spain were invited to participate in the study. The actual participants were 12 nursing homes randomly assigned to 3 groups and 661 subjects. An independent physician gave a 20-minute talk with slide projections summarizing the content of the Back Book (active management group), the Back Guide (postural hygiene group), and a pamphlet on cardiovascular health (controls). Disability was measured with the Roland-Morris questionnaire (RMQ). Blind assessments were performed before the intervention, and 30 and 180 days later. The effect of the intervention on disability was estimated by generalized mixed linear random effects models. Results. Mean age of participants ranged between 79.9 and 81.2 years. Disability improved in all groups, but at the 30-day assessment the postural education group showed an additional improvement of 1.1 (95% confidence interval, 0.2–1.9), RMQ points and at the 180-day assessment the active education group an additional improvement of 2.0 (95% confidence interval, 0.6–3.4). In the subset of subjects with LBP when entering the study, postural education had no advantages over controls, while an additional improvement of 3.0 (95% confidence interval, 1.5– 4.5) RMQ points at the 180-day assessment was observed in the active education group. Conclusion. In institutionalized elderly, the handing out of the Back Book supported by a 20-minute group talk improves disability 6 months later, and is even more effective in those subjects with LBP.

The Influence of Psychological Factors on Low Back Pain‐Related Disability in Community Dwelling Older Persons

OBJECTIVES To assess the influence of fear avoidance beliefs (FAB) and catastrophizing on low back pain (LBP)-related disability in Spanish community dwelling retirees. DESIGN Correlation between variables measured with previously validated instruments. SETTING Majorca, Spain. PATIENTS 1,044 community dwelling subjects attending conferences for retired persons. OUTCOME MEASURES Visual analog scales for LBP and pain referred to the leg (LP), Roland Morris Questionnaire (RMQ) for disability, FAB-Phys questionnaire (FABQ) for FAB, and the Coping Strategies Questionnaire (CSQ) for catastrophizing. RESULTS In subjects without clinically relevant LBP, FAB correlated moderately with catastrophizing (r = 0.535) and disability (r = 0.390), and weakly with LP (r = 0.119) and LBP (r = 0.197). In subjects with LBP, FAB correlated moderately with catastrophizing (r = 0.418) and disability (r = 0.408), and weakly with LP (0.152), but not with LBP. Correlations among CSQ, FABQ, and RMQ were similar in subjects with and without current LBP. In regression models, the coefficient for effect of FAB on disability was 0.14 for participants with no LBP, and 0.28 for those with pain. Corresponding values for catastrophizing were 0.17 and 0.19. CONCLUSION In Spanish community dwelling retirees, the influence of FAB and catastrophizing on LBP-related disability is clinically small.

Fear avoidance beliefs do not influence disability and quality of life in Spanish elderly subjects with low back pain.

Study Design. Correlation between previously validated questionnaires. Objective. To assess the association of fear avoidance beliefs (FAB) with disability and quality of life in elderly Spanish subjects. Summary of Background Data. As opposed to Anglo-Saxon and Northern European patients, in Spanish low back pain (LBP) patients of working age, the influence of FAB on disability and quality of life is sparse and much less than that of pain. The influence of FAB on LBP-related disability and quality of life in the elderly is unknown. Methods. A visual analogue scale (VAS), the Roland Morris Questionnaire (RMQ), the FAB-Phys questionnaire (FABQ), and the SF-12 questionnaire were used to assess LBP, disability, fear avoidance beliefs, and quality of life in 661 institutionalized elderly in Spain, 439 of whom had LBP. Results. In all subjects, FAB correlated with LBP (r = 0.477), disability (r = 0.458), the Physical Component Summary of SF-12 (PCS SF-12) (r = −0.389), and the Mental Component Summary of SF-12 (MCS SF-12) (r = −0.165). In subjects with LBP, FABs only correlated weakly with disability (r = −0.110). The stronger correlations were found between LBP and disability, both in all subjects (r = 0.803) and LBP patients (r = 0.445). Regression models including all the participants showed that the influence of FABs on physical quality of life was sparse and that FABs were not associated with either disability or mental quality of life. In elderly subjects with LBP, FABs were not associated with either disability or quality of life. Conclusion. In Spanish institutionalized elderly subjects, FABs only have a minor influence on physical quality of life, and none on disability or mental quality of life. In elderly subjects with LBP, differences in FABs are not associated with differences in disability or quality of life. Further studies should explore the potential value of FABs in the elderly in other settings.

Chapter 3European guidelines for the management ofacute nonspecific low back painin 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)