Michael Norberg

Role of Physical Exercise in Low Back Pain Rehabilitation : A Randomized Controlled Trial of a Three-Month Exercise Program in Patients Who Have Completed Multidisciplinary Rehabilitation

Study Design. Randomized controlled trial with 1-year follow-up. Objective. To analyze the effects of an exercise program or routine follow-up on patients with chronic low back pain who have completed functional multidisciplinary rehabilitation. The short- and long-term outcome in terms of symptoms and physical and social functioning was compared. Summary of Background Data. Systematic reviews have shown that functional multidisciplinary rehabilitation improves physical function and reduces pain in patients with chronic low back pain. However, long-term maintenance of these improvements is inconsistent and the role of exercise in achieving this goal is unclear. Methods. One hundred five chronic patients with low back pain who had completed a 3-week functional multidisciplinary rehabilitation program were randomized to either a 3-month exercise program (n = 56) or routine follow-up (n = 49). The exercise program consisted of 24 training sessions during 12 weeks. Patients underwent evaluations of trunk muscle endurance, cardiovascular endurance, lumbar spine mobility (flexion and extension range-of-motion, fingertip-to-floor distance), pain and perceived functional ability at the beginning and the end of functional multidisciplinary rehabilitation, at the end of the exercise program (3 months) and at 1-year follow-up. Disability was also assessed at the same time points except at the beginning of functional multidisciplinary rehabilitation. Results. At the end of the functional multidisciplinary rehabilitation, both groups improved significantly in all physical parameters except flexion and extension range-of-motion. At the 3 month and 1 year follow-up, both groups maintained improvements in all parameters except for cardiovascular endurance. Only the exercise program group improved in disability score and trunk muscle endurance. No differences between groups were found. Conclusion. A favorable long-term outcome was observed after functional multidisciplinary rehabilitation in both patient groups. Patients who participated in an exercise program obtained some additional benefits. The relevance of these benefits to overall health status need to be further investigated.

Validation transculturelle de l’Oswestry disability index en français

AIM The aim of this study was to interpret and validate a French version of the Oswestry disability index (ODI), using a cross-cultural validation method. The validity and reliability of the questionnaire was assessed in order to ensure the psychometric characteristics. METHOD The cross-cultural validation was carried out according to Beatons methodology. The study was conducted with 41 patients suffering from low back pain. The correlation between the ODI and the Roland-Morris disability questionnaire (RMDQ), the medical outcome survey short form-36 (MOS SF-36) and a pain visual analogical scale (VAS) was assessed. RESULTS The validity of the Oswestry questionnaire was studied using the Cronbach Alpha coefficient calculation: 0.87 (n=36). The significant correlation between the ODI and RMDQ was 0.8 (P<0.001, n=41) and 0.71 (P<0.001, n=36) for the pain VAS. The correlation between the ODI and certain subscales (physical functioning 0.7 (P<0.001, n=41), physical role 0.49 et bodily pain 0.73 (P<0.001, n=41)) of the MOS SF-36 were equally significant. The reproducibility of the ODI was calculated using the Wilcoxon matched pairs test: there was no significant difference for eight out of ten sections or for the final score. CONCLUSION This French translation of the ODI should be considered as valid and reliable. It should be used for any future clinical studies carried out using French language patients. Complimentary studies must be completed in order to assess its sensitivity to change in the event of any modifications in the patients functional capacity.

Clinical classification criteria for radicular pain caused by lumbar disc herniation: the radicular pain caused by disc herniation (RAPIDH) criteria

BACKGROUND CONTEXT Classification criteria are recommended for diseases that lack specific biomarkers to improve homogeneity in clinical research studies. Because imaging evidence of lumbar disc herniations (LDHs) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are required. PURPOSE This study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH. STUDY DESIGN The study design was a two-stage process. Phase 1 included a Delphi process and Phase 2 included a cohort study. PATIENT SAMPLE The patient sample included outpatients recruited from spine clinics in five countries. OUTCOME MEASURES The outcome measures were items from history and physical examination. MATERIALS AND METHODS In Phase 1, 17 spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2, 19 different clinical experts identified patients they confidently classified as presenting with (1) radicular pain caused by LDH, (2) neurogenic claudication (NC) caused by lumbar spinal stenosis, or (3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than US

Development and validation of a questionnaire categorizing behavioral strategies in patients with chronic low back pain

15,000 was received from MSD: It was used to support the conception of the Delphi, data management, and statistical analysis. No fees were allocated to participating spine specialists. RESULTS Phase 1 generated a final list of 74 potential symptoms and signs. In Phase 2, 209 patients with pain caused by LDH (89), NC (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p<.05) were monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test <60° (or femoral stretch test), unilateral motor weakness, and asymmetric ankle reflex. The score had an AUC of 0.91. An easy-to-use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%). CONCLUSIONS Classification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies.

Article originalValidation transculturelle de l’Oswestry disability index en françaisCross-cultural validation of the Oswestry disability index in French

OBJECTIVE The identification of helpful or unhelpful behavioral strategies for coping with pain would assist in optimizing the management of patients with chronic low back pain (CLBP). The objective was to develop and validate a questionnaire for categorizing behavioral strategies in patients with nonspecific CLBP. METHODS (1) Development of a preliminary questionnaire based on a qualitative study in 25 patients with CLBP; (2) Item reduction and questionnaire validation by a multicenter international prospective study in patients with CLBP, with multiple correspondence analysis to identify behavioral profiles, whose characteristics and internal and external validities were assessed; 12-month study of treatments in 58 patients; (3) Evaluation of reproducibility in 30 patients. RESULTS (1) The preliminary questionnaire had 87 items in eight pain-coping domains. (2) Three behavioral profiles were identified: effective coping, emotional distress, and kinesiophobia. The questionnaire was reduced to 21 items in seven domains. Cronbachs α indicated moderate internal consistency (0.47-0.66). External validity versus anxiety, depression, and coping strategies was good. As expected, functional restoration program was used more often by patients with kinesiophobia than by those with effective coping (50% vs. 25%, P<0.05). (3) Reproducibility was good (κ=0.70). CONCLUSION This new, simple questionnaire allows the identification of three behavioral profiles, thus guiding the development of personalized management programs for NCLBP.

Validity of the French version of the Core Outcome Measures Index for low back pain patients: a prospective cohort study

AIM The aim of this study was to interpret and validate a French version of the Oswestry disability index (ODI), using a cross-cultural validation method. The validity and reliability of the questionnaire was assessed in order to ensure the psychometric characteristics. METHOD The cross-cultural validation was carried out according to Beatons methodology. The study was conducted with 41 patients suffering from low back pain. The correlation between the ODI and the Roland-Morris disability questionnaire (RMDQ), the medical outcome survey short form-36 (MOS SF-36) and a pain visual analogical scale (VAS) was assessed. RESULTS The validity of the Oswestry questionnaire was studied using the Cronbach Alpha coefficient calculation: 0.87 (n=36). The significant correlation between the ODI and RMDQ was 0.8 (P<0.001, n=41) and 0.71 (P<0.001, n=36) for the pain VAS. The correlation between the ODI and certain subscales (physical functioning 0.7 (P<0.001, n=41), physical role 0.49 et bodily pain 0.73 (P<0.001, n=41)) of the MOS SF-36 were equally significant. The reproducibility of the ODI was calculated using the Wilcoxon matched pairs test: there was no significant difference for eight out of ten sections or for the final score. CONCLUSION This French translation of the ODI should be considered as valid and reliable. It should be used for any future clinical studies carried out using French language patients. Complimentary studies must be completed in order to assess its sensitivity to change in the event of any modifications in the patients functional capacity.