Effects of exercise programmes on pain, disease activity and function in ankylosing spondylitis: A meta-analysis of randomized controlled trials.

BACKGROUND: To evaluate the effects of exercise programmes on pain, function and disease activity in patients with ankylosing spondylitis (AS). MATERIALS AND METHODS: We searched PubMed, Embase, CNKI and Wanfang from inception to February 2020. Randomized controlled trials comparing exercises with nonexercise interventions in AS patients were applied. Studies that assessed the visual analogue scale (VAS) pain score, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were included. Outcomes of home-based exercise intervention were also reported independently. RESULTS: Ten studies met the inclusion criteria in all, including 534 patients (278 exercise, 256 control). Compared with the nonexercise group, exercise group had statistically significant improvements in pain (weighted mean difference [WMD]: -1.02 [95% CI: -1.50 to -0.55]) (I2 : 31%, P <.0001), BASDAI (WMD: -0.85 [95% CI: -1.09 to -0.61]) (I2 : 20%, P <.00001), and BASFI (WMD: -0.66 [95% CI: -0.95 to -0.38]) (I2 : 0%, P <.00001), but not in CRP and ESR. What's more, home-based exercise programmes had positive impacts on BASFI, BASDAI and pain. CONCLUSIONS: For patients with AS, exercise programmes improve pain, function and disease activity. To confirm the results, more well-designed randomized controlled trials with large number of patients are required.

Relative Effectiveness of Electroacupuncture and Biofeedback in the Treatment of Neck and Upper Back Myofascial Pain: A Randomized Clinical Trial.

OBJECTIVE: To determine the differences between clinical effects of electroacupuncture and biofeedback therapy in addition to conventional treatment in patients with cervical myofascial pain syndrome (MPS). DESIGN: Randomized clinical trial. SETTING: Physical medicine and rehabilitation clinic of a university hospital. PARTICIPANTS: Fifty patients (N=50) aged 25-55 years of both sexes with chronic neck pain diagnosed with MPS (characterized by trigger points within taut bands) were randomly assigned to 2 equal groups of 25 individuals. INTERVENTIONS: The patients in electroacupuncture group were treated with standard acupuncture and concomitant electrical stimulation; those in biofeedback group received visual electromyography biofeedback therapy for muscle activity and relaxation. Both groups received the intervention 2 times a week for a total of 6 sessions. Basic exercise training and medicines were administered for all the patients. MAIN OUTCOME MEASURES: Pain severity based on the visual analog scale (VAS), functional status using Neck Disability Index (NDI), cervical range of motion (ROM) using and inclinometer, and pressure pain threshold (PPT) using an algometer were evaluated before and at 3 and 12 weeks after the treatment. Primary outcome was defined as 20% reduction in the 3-month neck pain and dysfunction compared to baseline, assessed through the NDI. RESULTS: Fifty patients (39 women, 11 men) with a mean age (years) ± SD of 39.0±5.5 and neck pain duration (weeks) of 6.0±2.2 were analyzed. All parameters, except for PPT of the lower trapezius and paravertebral muscles were improved significantly in both groups, while baseline values were controlled. The primary outcome was achieved more significantly in the acupuncture group than in the biofeedback group: 20 (80.0%) vs 10 (40.0%); rate ratio=2 with 95% confidence interval (CI), 1.19-3.36; number needed to treat (NNT)=2.5 with 95% CI, 1.54-6.58. Advantages of acupuncture over biofeedback were observed according to values obtained from the NDI, VAS, extension and left lateral-bending ROM, and PPT on the left upper trapezius after the last session of intervention until 3 months (P<.05). CONCLUSIONS: Both electroacupuncture and biofeedback therapies were found to be effective in management of MPS when integrated with conventional treatment. However, intergroup differences showed priority of acupuncture in some parameters vs biofeedback. Thus, electroacupuncture seems to be a better complementary modality for treatment of MPS in the neck and upper back area.

Clinical course of pain and disability following primary lumbar discectomy: systematic review and meta-analysis.

PURPOSE: To conduct a meta-analysis to describe clinical course of pain and disability in adult patients post-lumbar discectomy (PROSPERO: CRD42015020806). METHODS: Sensitive topic-based search strategy designed for individual databases was conducted. Patients (> 16 years) following first-time lumbar discectomy for sciatica/radiculopathy with no complications, investigated in inception (point of surgery) prospective cohort studies, were included. Studies including revision surgery or not published in English were excluded. Two reviewers independently searched information sources, assessed eligibility at title/abstract and full-text stages, extracted data, assessed risk of bias (modified QUIPs) and assessed GRADE. Authors were contacted to request raw data where data/variance data were missing. Meta-analyses evaluated outcomes at all available time points using the variance-weighted mean in random-effect meta-analyses. Means and 95% CIs were plotted over time for measurements reported on outcomes of leg pain, back pain and disability. RESULTS: A total of 87 studies (n = 31,034) at risk of bias (49 moderate, 38 high) were included. Clinically relevant improvements immediately following surgery (> MCID) for leg pain (0-10, mean before surgery 7.04, 50 studies, n = 14,910 participants) and disability were identified (0-100, mean before surgery 53.33, 48 studies, n = 15,037). Back pain also improved (0-10, mean before surgery 4.72, 53 studies, n = 14,877). Improvement in all outcomes was maintained (to 7 years). Meta-regression analyses to assess the relationship between outcome data and a priori potential covariates found preoperative back pain and disability predictive for outcome. CONCLUSION: Moderate-level evidence supports clinically relevant immediate improvement in leg pain and disability following lumbar discectomy with accompanying improvements in back pain. These slides can be retrieved under Electronic Supplementary Material.

Long-term effects on function, health-related quality of life and work ability after structured physiotherapy including a workplace intervention. A secondary analysis of a randomised controlled trial (WorkUp) in primary care for patients with neck and/or back pain.

Objective: To study the long-term effects of a workplace intervention in addition to structured physiotherapy regarding self-reported measures in patients with acute/subacute neck and/or back pain.Design: WorkUp - a cluster-randomised controlled trial in 32 primary care centers in Sweden, from January 2013 through December 2014 (ClinicalTrials.gov ID: NCT02609750).Intervention: Structured physiotherapy with the workplace dialogue 'Convergence Dialogue Meeting' (CDM), conducted by the treating physiotherapist as an add-on. Reference group received structured physiotherapy.Subjects: Adults, 18-67 years (mean 43.7, standard deviation (SD) 12.2), 65.3% women with acute/subacute neck and/or back pain who had worked ≥4 weeks past year, considered at risk of sick leave or were on short-term sick leave (≤60 days) were included (n = 352).Outcome measures: Self-reported function, functional rating index (FRI), health-related quality of life (EQ-5D-3L) and work ability (Work Ability Score, WAS) at 12 months follow-up.Results: The mean differences in outcomes between intervention and reference group were; -0.76 (95% confidence interval (CI): -2.39, 0.88; FRI), 0.02 (95% CI: -0.04, 0.08; EQ-5D-3L) and -0.05 (95% CI: -0.63, 0.53; WAS). From baseline to 12 months, the intervention group improved function from 46.5 (SD 19.7) to 10.5 (SD 7.3) on FRI; health-related quality of life from 0.53 (SD 0.29) to 0.74 (SD 0.20) on EQ-5D and work ability from 5.7 (SD 2.6) to 7.6 (SD 2.1) on WAS.Conclusion: Despite a clinically relevant improvement over time, there were no significant differences in improvement between groups, thus we conclude that CDM had no effect on self-reported measures in this study.Key pointsIn earlier analysis of the primary outcome (work ability measured by absenteeism) in this trial, a positive effect was found when the workplace intervention 'Convergence Dialogue Meeting' (CDM) was added to structured physiotherapy for patients with neck or back pain.By contrast, in this new analysis of secondary outcomes (self-reported function, health and perceived work ability), there was no added effect of CDM above structured physiotherapy alone, although patients in both the intervention and reference group improved over time.The addition of CDM to physiotherapy is therefore justified by its specific effect on behavior (work absence) rather than any effect on clinical outcomes.

[Stay at Work - Feasibility and Acceptance of a Part-Time Medical Rehabilitation]. / Stay at Work ­ Machbarkeit und Akzeptanz einer berufsbegleitenden Form der medizinischen Rehabilitation.

PURPOSE: Back pain is associated with significant impairments of participation, which should be prevented by medical rehabilitation programs. The existing evidence shows that the German rehabilitation model is not effective for all target groups. In addition to intensified measures for patients with a high risk of failed return to work, a less intense rehabilitation form could be useful for patients with moderate disabilities. Therefore, in this study the feasibility of a part-time medical rehabilitation (German abbreviation: BbR) was examined. The BbR was designed as a closed group program with a therapy duration of 48 hours (2 appointments per week over 12 weeks). Furthermore, different access paths to BbR as well as the effects were focused. METHODS: Twelve groups with 6 to 12 participants each were planned in 3 outpatient rehabilitation centers. In addition to the regular application process, insured persons were recruited via the network of rehabilitation centers as well as the company service of the German Pension Insurance. The BbR focused on employed patients who were not on sick-leave and had the need for rehabilitation due to back pain. The evaluation was multi-perspective and multi-methodical. All participants completed questionnaires at admission, while and at discharge of the BbR. In addition, discussions in groups were conducted with representatives of the rehabilitation centers, the pension insurance and employers. RESULTS: In total, 7 groups with 56 participants could be realized in 2 rehabilitation centers. The typical BbR-participant was female, married, without children, 48 years old and working full for medium-sizes enterprise without shift work. The majority had no or minor no time of sick-leave in the year prior to rehabilitation. 59% of them were recruited by the rehabilitation centers; only few persons were assigned by the pension insurance. Two thirds would not have applied for a medical rehabilitation without the offer of BbR. Overall, the participants were very satisfied with the BbR. However, the compatibility of the BbR with the job and everyday life was perceived as a challenge. A pre-post comparison showed moderate to strong differences in self-rated health, pain, functional status and work ability. CONCLUSION: The BbR seems to be a useful additional concept in the German rehabilitation system for patients with moderate disabilities. Before dissemination, the identified challenges should be solved. This applies in particular to the recruitment and compatibility of rehabilitation with work and everyday life.

Association of Back Pain with All-Cause and Cause-Specific Mortality Among Older Women: a Cohort Study.

BACKGROUND: The impact of back pain on disability in older women is well-understood, but the influence of back pain on mortality is unclear. OBJECTIVE: To examine whether back pain was associated with all-cause and cause-specific mortality in older women and mediation of this association by disability. DESIGN: Prospective cohort study. SETTING: The Study of Osteoporotic Fractures. PARTICIPANTS: Women aged 65 or older. MEASUREMENT: Our primary outcome, time to death, was assessed using all-cause and cause-specific adjusted Cox models. We used a four-category back pain exposure (no back pain, non-persistent, infrequent persistent, or frequent persistent back pain) that combined back pain frequency and persistence across baseline (1986-1988) and first follow-up (1989-1990) interviews. Disability measures (limitations of instrumental activities of daily living [IADL], slow chair stand time, and slow walking speed) from 1991 were considered a priori potential mediators. RESULTS: Of 8321 women (mean age 71.5, SD = 5.1), 4975 (56%) died over a median follow-up of 14.1 years. A higher proportion of women with frequent persistent back pain died (65.8%) than those with no back pain (53.5%). In the fully adjusted model, women with frequent persistent back pain had higher hazard of all-cause (hazard ratio [HR] = 1.24 [95% CI, 1.11-1.39]), cardiovascular (HR = 1.34 [CI, 1.12-1.62]), and cancer (HR = 1.33, [CI 1.03-1.71]) mortality. No association with mortality was observed for other back pain categories. In mediation analyses, IADL limitations explained 47% of the effect of persistent frequent back pain on all-cause mortality, slow chair stand time, and walking speed, explained 27% and 24% (all significant, p < 0.001), respectively. LIMITATIONS: Only white women were included. CONCLUSION: Frequent persistent back pain was associated with increased mortality in older women. Much of this association was mediated by disability.

Feasibility and long-term efficacy of a proactive health program in the treatment of chronic back pain: a randomized controlled trial.

BACKGROUND: To facilitate access to evidence-based care for back pain, a German private medical insurance offered a health program proactively to their members. Feasibility and long-term efficacy of this approach were evaluated. METHODS: Using Zelen's design, adult members of the health insurance with chronic back pain according to billing data were randomized to the intervention (IG) or the control group (CG). Participants allocated to the IG were invited to participate in the comprehensive health program comprising medical exercise therapy and life style coaching, and those allocated to the CG to a longitudinal back pain survey. Primary outcomes were back pain severity (Korff's Chronic Pain Grade Questionnaire) as well as health-related quality of life (SF-12) assessed by identical online questionnaires at baseline and 2-year follow-up in both study arms. In addition to analyses of covariance, a subgroup analysis explored the heterogeneity of treatment effects among different risks of back pain chronification (STarT Back Tool). RESULTS: Out of 3462 persons selected, randomized and thereafter contacted, 552 agreed to participate. At the 24-month follow-up, data on 189 of 258 (73.3%) of the IG were available, in the CG on 255 of 294 (86.7%). Significant, small beneficial effects were seen in primary outcomes: Compared to the CG, the IG reported less disability (1.6 vs 2.0; p = 0.025; d = 0.24) and scored better at the SF-12 physical health scale (43.3 vs 41.0; p < 0.007; d = 0.26). No effect was seen in back pain intensity and in the SF-12 mental health scale. Persons with medium or high risk of back pain chronification at baseline responded better to the health program in all primary outcomes than the subgroup with low risk at baseline. CONCLUSIONS: After 2 years, the proactive health program resulted in small positive long-term improvements. Using risk screening prior to inclusion in the health program might increase the percentage of participants deriving benefits from it. TRIAL REGISTRATION: The trial was registered at the German Clinical Trials Register under DRKS00015463 retrospectively (dated 4 Sept 2018).

[Evaluation of a Proactive Health Programme for Insured Persons with Persistent Back Pain: One-year Follow-up of a Randomised Controlled Trial]. / Evaluation eines proaktiv angebotenen Gesundheitsprogramms für Versicherte mit anhaltenden Rückenschmerzen ­ Ein-Jahres-Follow-up einer randomisierten, kontrollierten Studie.

BACKGROUND: To facilitate access to evidence-based care for persisting back pain, a private medical insurance developed a health programme and offered it proactively to their members. The aim of this study was to evaluate the feasibility and efficacy of this procedure. METHODS: The design of the study was a Zelen randomized controlled trial. Adult insured persons with persistent back pain were randomized to the control (CG) or intervention group (IG) prior to giving consent. The IG was invited to participate in the health programme, the CG in a survey. Primary outcomes were back pain intensity and disability (according to von Korff) and health-related quality of life (SF-12). At baseline, 12- and 24-month follow-up, outcomes were documented by identical online questionnaires. RESULTS: 552 of 3462 randomized insured persons agreed to participate in the study; 132 of 258 (51.2%) from the IG and 243 of 294 (82.7%) from the CG completed the questionnaires at the 12-month follow-up. Small beneficial effects were seen for 3 of 4 primary outcomes. Compared to the CG, the IG reported less severe pain intensity (38.6 vs 44.5; p=0.001; d=0.36) and less disability (1.6 vs 2.2; p=0.002; d=0.41). The IG scored better at the SF-12 physical health scale (43.6 vs 39.0; p<0.001; d=0.54); no beneficial effect was seen in the SF-12 mental health scale. CONCLUSIONS: The pro-active health programme seems to be feasible and effective as determined by patient-reported outcomes. Final evaluation awaits cost analysis and the results of the 24-month follow-up.

[Therapy of Chronic Back Pain Considering Psychosocial Aspects]. / Therapie des chronischen Rückenschmerzes unter Berücksichtigung psychosozialer Faktoren.

Chronic pain and especially back pain rank among the most meaningful medical conditions worldwide. This leads to extensive costs in medical care systems. In about 80-85% of cases there is no morphologic evidence for a possible pain etiology, hence such forms are called "non-specific back pain". Therapies with a pure focus on symptomatic aspects are not effective to treat non-specific pain. The origin of chronic back pain can be best explained via a multi causal mechanism with a combination of bio-psycho-social, biographical, neurobiological, genetic, and cognitive factors. Since various aspects of the pain genesis have to be considered, multidisciplinary treatment shows much better results.

[Health Economic Effects of Rehabilitation for Chronic Back Pain - An Observational Study with Combined Secondary Data from Statutory Health Insurance and German Pension Fund]. / Gesundheitsökonomische Effekte der Rehabilitation bei chronischem Rückenschmerz ­ Eine Beobachtungsstudie mittels kombinierten Sekundärdaten einer gesetzlichen Krankenkasse und der Deutschen Rentenversicherung.

BACKGROUND: Chronic back pain is the most common indication in medical rehabilitation. Numerous studies hint on positive effects of rehabilitation on health state. However, there is no evidence about the effectiveness of rehabilitation due to the lack of a valid comparison group. METHODS: Based on combined secondary data from German Pension Fund and statutory health insurance, a comparison group of insured persons was identified by their typical patient career that did not apply for rehabilitation for unclear reasons. Effectiveness was measured by direct and indirect costs of back pain between rehabilitants and non-rehabilitants. RESULTS: Costs of rehabilitation split in 2.742 € direct costs and 2.597 € indirect costs. In the 2 years following rehabilitation, rehabilitants were hospitalized less frequent and caused less indirect costs due to disability. Therefore, the benefit of rehabilitation was 727 € in the first year after rehabilitation and additional 37 € in the subsequent year. CONCLUSION: Rehabilitation for chronic back pain contributes to maintain the ability to work. Moreover, rehabilitation reduces duration of disability and healthcare utilization, hence direct and indirect costs of illness are lowered compared to a treatment without rehabilitation. Effects of rehabilitation by avoidance and delay of retirement are not yet recorded.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence.

BACKGROUND: Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain. METHODS: GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created. RESULTS: Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions. CONCLUSION: From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Rehabilitation access and effectiveness for persons with back pain: the protocol of a cohort study (REHAB-BP, DRKS00011554).

BACKGROUND: Back pain is one of the most common chronic diseases in Germany and has a major impact on work ability and social participation. The German Pension Insurance (GPI) is the main provider of medical rehabilitation to improve work ability and prevent disability pensions in Germany. However, over half of the persons granted a disability pension have never used a medical rehabilitation service. Furthermore, evidence on the effects of medical rehabilitation in Germany is inconclusive. Consequently, this study has two aims: first, to determine barriers to using rehabilitation services, and second, to examine the effectiveness of medical rehabilitation in German residents with chronic back pain. METHODS: In 2017 a postal questionnaire will be sent to 45,000 persons aged 45 to 59 years whose pension insurance contributions are managed by the GPI North or the GPI Central Germany. In 2019 respondents who report back pain in the first survey (n = 5760 expected) will be sent a second questionnaire. Individuals will be eligible for the first survey if they are employed, have neither used nor applied for a rehabilitation programme during the last 4 years and neither received nor applied for a disability pension. The sample will be drawn randomly from the registers of the GPI North (n = 22,500) and the GPI Central Germany (n = 22,500) and stratified by sex and duration of sickness absence benefits. Barriers to rehabilitation services will be related to socio-demographic and social characteristics, pain and attitudes to pain, health and health behaviour, healthcare utilisation, experiences and cognitions about rehabilitation services and job conditions. Propensity score matched analyses will be used to examine the effectiveness of rehabilitation services. Data on use of medical rehabilitation will be extracted from administrative records. The primary outcome is pain disability. Secondary outcomes are pain intensity and days of disability, pain self-efficacy, fear avoidance beliefs, self-rated health, depression, healthcare utilisation, self-rated work ability and subjective prognosis of employability, sickness absence benefits, and disability pensions. DISCUSSION: This study identifies barriers to use of rehabilitation services and determines the effectiveness of medical rehabilitation for patients with chronic back pain. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00011554 , January 26, 2017).

A random-perturbation therapy in chronic non-specific low-back pain patients: a randomised controlled trial.

The purpose of the study was to assess the effectiveness of a specific rehabilitation therapy for chronic non-specific low-back pain patients, based on a random/irregular functional perturbation training induced by force disturbances to the spine. Forty patients (20 controls and 20 in the perturbation-based group) finished the whole experimental design. A random-perturbation exercise, which included variable and unpredictable disturbances, was implemented in the therapy of the perturbation-based group (13 weeks, two times per week and 1.5 h per session). The participants of the control group did not receive any specific training. Low-back pain, muscle strength, and neuromuscular control of spine stability were investigated before and after the therapy using the visual analog scale, maximal isometric and isokinetic contractions, nonlinear time series analysis, and by determining the stiffness and damping of the trunk after sudden perturbations. The perturbation-based therapy reduced patient's low-back pain (35%), increased muscle strength (15-22%), and trunk stiffness (13%), while no significant changes were observed in the control group. It can be concluded that the proposed therapy has the potential to enhance trunk muscle capability as well as sensory information processing within the motor system during sudden loading and, as a consequence, improve the stabilization of the trunk.

Health-care utilization of patients with chronic back pain before and after rehabilitation.

BACKGROUND: Patients with chronic back pain show an increased use of health-care services leading to high direct costs. Multidisciplinary rehabilitation reduces pain intensity, depression, disability and work inability. The study aims to investigate whether health-care utilization in patients with chronic back pain is lower after rehabilitation than before rehabilitation and if, in addition to sociodemographic, medical and psychological characteristics, changes in these characteristics immediately after rehabilitation can predict health-care utilization. METHODS: N = 688 patients with chronic back pain were asked about their overall health-care services use and the use of general practitioners, specialists, physiotherapy, psychotherapy, complementary therapist, massages, and admission to hospital both 6 months before and 6 months after rehabilitation. In addition, various sociodemographic, medical and psychological variables were assessed. To measure changes due to rehabilitation, differences in pain intensity, disability, impairment and coping, quality of life, and days on sick leave before and after rehabilitation were calculated. Dependent t-tests and hierarchical regression analyses were used to analyse the data. RESULTS: Health-care utilization 6 months after rehabilitation was, except for physiotherapy and psychotherapy, significantly lower than before. The effect sizes were rather small (Cohens'd =. 01-.34). After rehabilitation between 15.2% and 39.9% of the variance of health-care utilization could be explained. The baseline values of health-care utilization explained between 3.2% and 15.9% of the incremental variances. The changes in psychological impairment and coping as well as in sick leave after rehabilitation could explain between 0.8% and 2.9% of the variance of health-care utilization after rehabilitation. Its influence was significant for the general use of health-care services, general practitioners and specialists. CONCLUSIONS: The results indicate that use of health-care services after rehabilitation in the present study is slightly lower than before, which has an impact on direct costs due to chronic back pain in Germany. The predictors show the importance in terms of health-care utilization of improving work ability and psychological impairment.

Spinal Cord Stimulation: An Alternative Concept of Rehabilitation?

BACKGROUND: Chronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery. METHODS: We report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric instability and persistent or ingravescent disabling low back and leg pain, with a mean duration of symptoms of at least 18 months. A visual analog scale (VAS) was employed for back and leg pain, and the Oswestry Disability Index (ODI) score was determined, and findings were analyzed after 6 months. FINDINGS: No intra- or postoperative complication was recorded. The mean VAS score for back pain decreased from 7.5 to 2.9, while leg VAS decreased from 8.2 to 3.0. Analysis of ODI values showed evident improvement in daily life activities, ranging from a median value of 75.7% to 32.7 % after the stimulation. CONCLUSION: Spinal cord stimulation has a recognized impact on the pain and on the quality of life of patients with failed back surgery syndrome.

Expectations of pain and functioning in patients with musculoskeletal disorders: a cross-sectional study.

BACKGROUND: Research has suggested that patient expectations are associated with treatment outcome and evolve along with patient communication within the musculoskeletal field. However, few studies have investigated if or how physical medicine and rehabilitation (PMR) consultations affect the attending patients' expectations regarding pain and functional improvement. Hence, the aims of the present study were to compare patient expectations regarding pain and functional improvement before and after a PMR consultation and to assess patient characteristics, including diagnosis, that could perhaps predict changes in expectations. METHODS: The study design was cross-sectional. Eligible participants were first-time patients with neck/back or shoulder complaints who were referred to a PMR outpatient clinic between January and June 2013. Questionnaires (the Patient Shoulder Outcome Expectancies, or PSOE, questionnaire and a numeric rating scale, or NRS) focused on expectations regarding pain and functioning were completed immediately prior to and after a consultation with a PMR specialist. RESULTS: In total, 257 patients were included. In total, 24% of the subjects expected a more positive outcome after the PMR consultation compared with before the consultation, while 10% of the subjects exhibited a negative change in expectations. Few patient characteristics other than sick leave were associated with changes in expectations; however, patients with shoulder complaints seemed to be more optimistic than patients with neck/back complaints. CONCLUSION: Expectations can be influenced by a single specialist consultation. Among clinical prognostic factors, only sick leave influenced the change expectations. However, patients with shoulder complaints seemed to be more optimistic than patients with neck/back complaints. TRIAL REGISTRATION: The study was approved by the Data Protection Office at Oslo University Hospital, 2012/2574. ISRCTN registration: 40963362  (registered retrospectively 12.12.2016).

[Inpatient multimodal pain therapy : Additive value of neuromuscular core stability exercises for chronic back pain]. / Die stationäre multimodale Schmerztherapie : Additiver Wert eines sensomotorischen Stabilisationstrainings bei chronischem Rückenschmerz.

INTRODUCTION: The medical and healthcare economic burden caused by chronic lumbar back pain (CLBP) requires the use of interdisciplinary treatment approaches. The present study aimed to evaluate whether the effectiveness of inpatient multimodal pain therapy (MPT, operations and procedures (OPS) coding 8-918.02), can be increased by implementing additional neuromuscular core stability exercises (NCSE). MATERIAL AND METHODS: As part of a prospective controlled study, subjects with CLBP (n = 48, 17 males, 58.2 ± 11.7 years) were allocated to one of two groups. One group received standard care (SC, n =23) encompassing manual, pharmacological and psychological therapy in addition to passive physiotherapeutic applications. The intervention group (IG, n =25) additionally completed NCSE. On the day of admission and on discharge as well as 1 and 6 weeks after inpatient care, pain intensity (numeric rating scale), pain-related routine daily functions (Oswestry disability index), well-being (SF-12 Health Survey) and motor function parameters (trunk strength, endurance and postural control) were assessed. Data analysis was performed using statistical inference methods. In addition, effect sizes (Cohen's d) of intergroup differences were calculated. RESULTS: Both groups showed significant reductions in pain intensity (p < 0.05, d > 0.6) at all measurement points (MP). Physical well-being and disability (p < 0.05, d > 0.6) were improved 1 week after discharge in the intervention group only. Overall, no systematic differences between groups were detected (p > 0.05). In relation to the motor outcomes, no significant changes over time nor between groups were verified (p > 0.05). DISCUSSION: Despite the use of an additional NCSE, no significant added value in individuals with CLBP could be detected, although a systematic pre-post effect in daily functions and physical well-being (one week after discharge) was observed for the IG only. Therefore, on the basis of the study results, the implementation of additional NCSE into the inpatient MPT cannot be clearly recommended. To further delineate the therapeutic relevance, studies with larger sample sizes are needed.

[Dissemination of Patient Education in the Rehabilitation of Chronic Back Pain - Cost Analysis of a Program Implementation]. / Dissemination eines Schulungsprogramms bei chronischem Rückenschmerz ­ Kostenanalyse der Programmimplementierung.

The aim of the project is a cost analysis of 2 different strategies "train-the-trainer-seminar" (ttt-seminar) and "implementation guideline" (ig) in the implementation of a standardised patient education program in the inpatient rehabilitation of patients with chronic back pain. The implementation strategies were assigned by chance to 10 rehabilitation clinics. Expenditure of time was evaluated by questionnaire. Additionally materials and travel expenses were calculated. The total implementation costs accounted 4 582 € for the ttt-seminar and were about one third (35%) higher than the costs for the ig-strategy. The higher total implementation costs can basically be attributed to higher personnel costs due to the time-consuming seminar. However, in the ig-strategy postprocessing costs were 23.5% higher than in the ttt-strategy.

[Treatment of lumbar sagittal split fracture with combined anterior and posterior short segment fixation and fusion].

OBJECTIVE: To evaluate the efficacy and safety of combined anterior and posterior short segment fixation and fusion for lumbar sagittal split fracture.
 Methods: From March, 2005 to May, 2013, 13 patients of lumbar sagittal split fracture underwent short segment posterior fixation and anterior fusion. Preoperative and postoperative kyphotic Cobb's angle, visual analogue scale (VAS) score of back pain, Oswestry disability index (ODI), as well as the incidence of complication were accessed.
 Results: Mean follow-up duration was 42 months (24-60 months). Average operative time was 248 min (185-300 min) and average bleeding was 950 mL (600-1 500 mL). All patients were significantly improved in function and self-image. In the Cobb angle evaluation, there was significant improvement in 2 days or 12 months after the operation (P<0.05). In terms of average VAS pain score and ODI score, the difference was significant (P<0.05) between before and after surgery; the results of 12 months and the final follow-up after operation were significantly better than those before operation (P<0.05), but there was no significant difference at the 12 months and the final follow-up (P>0.05). According to the American Spinal Injury Association (ASIA) standard, in the last follow-up, 6 patients with grade D recovered to grade E, 3 patients had no further recovery. All patients achieved bony fusion in 4.5 months (3-6) months. There were 3 cases with dural tear and it was repaired during operation. There was no neurologic deterioration and vascular injury.
 Conclusion: The short construct with pedicle screws in the fractured vertebrae and disc space fusion may be a better therapeutic option for the highly lumbar unstable fracture of C1.2.1.

[Rehabilitation of the patients presenting with the operated spine syndrome during the complicated postoperative period after discectomy].

This article presents an analytical review of the literature concerning the problem of rehabilitation of the patients following the surgical treatment of hernias of intervertebral disks. The relevance of this problem and the importance of the related research activities in the context of neurorehabilitation are beyond any doubt. Despite the obvious progress in the modernization of the methods and technologies for medical rehabilitation, the number of re-operations in connection with the recurrences of herniated discs remains too high and the overall success thus far achieved in this field falls short of expectations. The authors discuss in detail the need for and the contemporary approaches to the rehabilitative treatment of the patients undergoing vertebral microdiscectomy including medication therapy, physiotherapy an therapeutic physical exercises. The variants of the application of magnetic stimulation during the early period of the rehabilitative treatment of the patients following the minimally invasive interventions for discogenic radiculopathy are considered.