Implementation of back to living well, a community-based program for the tertiary prevention of low back pain: a study protocol.

BACKGROUND: The current literature supports the effectiveness of exercise, education, and self-management interventions for the long-term management of persistent low back pain. However, there is significant uncertainty about the implementation of interventions related to barriers, facilitators, and patient's preferences. This study will evaluate the Back to Living Well program implementation from a participant and organizational perspective. More specifically we address the following objectives: 1) identify program barriers and facilitators from participants' perspectives, 2) identify factors related to program, personal and contextual factors that contribute to negative and positive outcomes, and outcome trajectories, 3) identify factors influencing participants' selection of an in-person or e-health program, and 4) evaluate program specific barriers and facilitators from the organization and care delivery perspectives. METHODS: This study will utilize a mixed-method convergent design including a longitudinal cohort strand and a longitudinal qualitative interview strand. The RE-AIM framework will be used to assess program implementation. Participants (n = 90, 1:1: in person or virtual) who choose to register in the program as well as staff (n = 10 to 15) involved in the delivery of the program will be invited to participate. Participants will participate in a 12-week physical activity, education, and self-management program. Implementation outcomes will be measured at 3-, 6-, 12-months, and six months after the end of the follow-ups. Interview scripts and directed content analysis will be constructed based on the Theoretical Domains Framework and the Neuromatrix Model of Pain, Theoretical Domains Framework. Staff interviews will be constructed and analyzed using the Consolidated Framework for Implementation Research. Participants will also complete pain, disability, quality of life and psychological questionnaires, wear an activity tracker at all time points, and complete weekly pain and activity limitation questions using a mobile application. DISCUSSION: The study results will provide evidence to inform potential future implementation of the program. An effective, appropriately targeted, and well implemented exercise program for the long-term management (i.e., tertiary prevention) of LBP could minimize the burden of the condition on patients, the health care system and society. TRIAL REGISTRATION: ClinicalTrials.gov NCT05929846. This (Registration Date: July 3 2023) study has been approved by the Hamilton Integrated Research Ethics Board Project ID#15,354.

Lumbar foraminal stenosis was associated with back pain and leg pain: epidemiological evidence from a population-based cohort.

OBJECTIVES: To determine the characteristics of lumbar foraminal stenosis (LFS) on magnetic resonance (MR) images and their association with back pain and radiating leg pain in a population-based sample of Chinese subjects. METHODS: This study was an extension of the Hangzhou Lumbar Spine Study, a cross-sectional study focusing on back pain and lumbar spine MR imaging findings. Questionnaire data, including demographics, lifestyle, occupational exposures, back pain and radiating leg pain were included. On lumbar spine MR images, disc degeneration was assessed using Pfirrmann grade and Modic changes were evaluated. Using Lee's scale, the L3-S1 intervertebral foramina were evaluated, with grade 2-3 representing substantial LFS and grade 0-1 no LFS. Characteristics of LFS were noted, and associations of LFS with back pain and radiating leg pain were examined. RESULTS: Among the 644 study subjects, 141 (21.9%) had at least one LFS, and its occurrence was associated with greater age (OR = 1.93 for each 10 years, p < 0.001). Substantial LFS was associated with the presence of back pain (OR = 1.92, p = 0.001) and the intensity of the worst back pain (Coef = 8.30, p < 0.001) over the past 12 months, and disabling back pain during their lifetime (OR = 2.25, p < 0.001). Substantial LFS was also associated with leg pain (OR = 14.27, p < 0.001), with a sensitivity of 75.7% for the presence of radiating leg pain and a specificity of 81.4%. CONCLUSION: Substantial LFS on MR images was a common age-related degenerative phenotype in adults, and appears to be an independent risk factor for back pain and leg pain.

Spatiotemporal changes in imaging features associated with diffuse idiopathic skeletal hyperostosis (DISH).

OBJECTIVES: The purpose of our study was to characterise spatiotemporal features of disease progression in people with diffuse idiopathic skeletal hyperostosis (DISH), early-phase DISH, and those not meeting either criterion who had repeated CT scans of the thoracic spine. METHODS: A retrospective study was designed in collaboration with the Rochester Epidemiology Project to evaluate completeness of ectopic bridging across the thoracic spine and corresponding disease status over an average of 2.7 years (range from 0.2 to 15.0 years) in a cohort of 83 female and 74 male individuals. RESULTS: Over 15% of individuals displayed changes in imaging features over time that resulted in a revised diagnosis along the continuum of DISH. Early-phase DISH was marked by new involvement of previously unaffected motion segments, estimated to occur over 2.1 years. Advanced presentations of DISH were marked by increased prevalence of complete bridging (average two of three available motion segments), estimated to occur over 2.6-2.9 years. Localised nodules of ectopic mineralisation external to and within the intervertebral disc were regularly observed in early-phase DISH. CONCLUSIONS: This is the first characterisation of spatiotemporal features across all phases of DISH, indicating that progression of DISH is characterised by distinct features at different phases along the disease continuum. Localised nodules of mineralisation in the spinal ligaments and within the intervertebral discs coincident with early phases of the disease may be a key factor in the pathogenesis of DISH.

Detection and Characterization of Endplate Structural Defects on CT: A Diagnostic Accuracy Study.

STUDY DESIGN: Diagnostic test study. OBJECTIVE: To determine the reliability and validity or diagnostic accuracy of two previously described endplate structural defect (EPSD) assessment methods. SUMMARY OF BACKGROUND DATA: Studies of EPSD may further the understanding of pathoanatomic mechanisms underlying back pain. However, clinical imaging methods used to document EPSD have not been validated, leaving uncertainty about what the observations represent. MATERIALS AND METHODS: Using an evaluation manual, 418 endplates on CT sagittal slices obtained from 19 embalmed cadavers (9 men and 10 women, aged 62-91 yr) were independently assessed by two experienced radiologists and a novice for EPSD using the two methods. The corresponding micro-CT (µCT) from the harvested T7-S1 spines were assessed by another independent rater with excellent intra-rater reliability (k=0.96). RESULTS: Inter-rater reliability was good for the presence (k=0.60-0.69) and fair for specific phenotypes (k=0.43-0.58) of EPSD. Erosion, for which the Brayda-Bruno classification lacked a category, was mainly (82.8%) classified as wavy/irregular, while many notched defects (n=15, 46.9%) and Schmorl's nodes (n=45, 79%) were recorded as focal defects using Feng's classification. When compared to µCT, endplate fractures (n=53) and corner defects (n=28) were routinely missed on CT. Endplates classified as wavy/irregular on CT corresponded to erosion (n=29, 21.2%), jagged defects (n=21, 15.3%), calcification (n=19, 13.9%), and other phenotypes on µCT. Some focal defects on CT represented endplate fractures (n=21, 27.6%) on µCT. Overall, with respect to the presence of an EPSD, there was a sensitivity of 70.9% and a specificity of 79.1% using Feng's method, and 79.5% and 57.5% using Brayda-Bruno's method. Poor to fair inter-rater reliability (k=0.26-0.47) was observed for defect dimensions. CONCLUSION: There was good inter-rater reliability and evidence of criterion validity supporting assessments of EPSD presence using both methods. However, neither method contained all needed EPSD phenotypes for optimal sensitivity, and specific phenotypes were often misclassified.

Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) and early-phase DISH across the lifespan of an American population.

OBJECTIVES: DISH is a common musculoskeletal disorder; however, the imaging features and disease continuum from early to advanced stages is poorly understood. The purpose of this study was to evaluate the prevalence of DISH and early-phase DISH in an American population and to assess the extent and pattern of ectopic mineralization across the thoracic spine. METHODS: Data were retrieved in collaboration with the Rochester Epidemiology Project. We conducted a retrospective image evaluation of a sample of individuals over 19 years of age with CT of the thoracic spine from a Northern US catchment area. Stratified random sampling by age and sex was used to populate the study. We examined the prevalence and extent of ectopic mineralization along the thoracic spine using previously established criteria. RESULTS: A total of 1536 unique images (766 female and 770 male individuals) including 16 710 motion segments were evaluated for imaging features of the continuum of DISH. Collectively, 40.5% of all motion segments evaluated displayed evidence of ectopic mineralization in the thoracic spine. The prevalence of early-phase DISH was 13.2% (10.4% of female and 15.8% of male individuals). The prevalence of established DISH was 14.2% (7.4% of female and 20.9% of male individuals). Remarkable heterogeneity was detected in individuals within each disease classification, based on the extent of the thoracic spine affected and degree of mineralization. CONCLUSIONS: The continuum of imaging features associated with DISH is detected in more than one in four adults and both sexes in an American population.

Depression as a prognostic factor for lumbar spinal stenosis outcomes: a systematic review.

PURPOSE: Lumbar spinal stenosis (LSS) is associated with increased levels of psychological distress, including depression; however, the prognostic value of depression remains unclear. The purpose of this systematic review was to synthesize the evidence on the prognostic value of depression for a range of outcomes in patients with LSS. METHODS: Inclusion criteria were prospective cohort studies that investigated depression in patients diagnosed with LSS. Searches were conducted in 7 databases. Critical appraisal, data extraction, and judgement of cumulative evidence were conducted independently by two reviewers. A meta-analysis was not conducted due to a lack of unique cohorts for each outcome, varying follow-up times, and differences in measurements for both prognostic factors and outcomes. RESULTS: Twenty-three articles were included. There was evidence for an association between preoperative depression and postoperative disability and symptom severity outcomes for patients with LSS. Odds ratios ranged from 1.15 to 2.94 for postoperative disability and 1.16-1.20 for symptom severity at various follow-up times. Using GRADE, evidence supporting depression as a prognostic factor for these LSS outcomes was deemed to be of moderate quality. Similarly strong evidence suggested depressive symptoms are of no prognostic value for postoperative walking capacity. CONCLUSION: Depression appears to have small to moderate prognostic value for LSS outcomes, with the strongest evidence for postoperative disability and symptom severity. The prognostic value of depression for LSS outcomes should be further explored using standardized measures in additional cohorts, including patients managing their condition conservatively, who have been neglected in related research.

Thoracolumbar Vertebral Endplate Defect Morphology: A Descriptive Study of Human Cadaveric Spines Using Micro-Computed Tomography.

STUDY DESIGN: A descriptive, cross-sectional cadaver study. OBJECTIVE: This study aimed to provide a thorough depiction of vertebral endplate defects classified based on their morphologic features and reported with respect to size, location, and prevalence in the human cadaveric spines of older adults. SUMMARY OF BACKGROUND DATA: Back pain has been associated with vertebral endplate defects; however, findings have been inconsistent. This is partially due to miscommunication surrounding the classification of endplate defects observed using clinical imaging, and limited knowledge of the types of defects present on the endplate and their prevalence. A comprehensive study of vertebral endplates is needed to clarify types of structural defects, their character, and prevalence. MATERIALS AND METHODS: Using micro-computed tomography, 3-dimensional reconstructed images were created of 409 endplates from 19 cadaveric spines (9 men and 10 women; aged 62-91; T6-S1). Endplate defects were categorized based on their morphology, size, and location to investigate distribution patterns. RESULTS: Seven types of endplate defects were identified: Schmorl nodes, corner fracture or limbus vertebra, other fractures, erosion, jagged surface, calcification, and depressions. Defects were identified on 63.6% of endplates. Multiple defects were present on 19.1% of endplates. Fracture and erosion were the most common defect types. Defects were more common on the endplate cranial to the intervertebral disc and in male specimens ( P = 0.01). Defects were larger in the lumbar spine and the "total area of endplate defect" was larger on the cranial than the caudal endplate in the thoracic spine ( P < 0.05). CONCLUSION: This is the first study of which we are aware that provides a thorough depiction of the morphology and distribution of endplate defects across the entire lower thoracic and lumbar spine (T6-S1) using micro-computed tomography. Results support the presence of several distinct endplate defect phenotypes with different prevalence rates and provide a reference when considering endplate defects in the elderly.

Bone-GAN: Generation of virtual bone microstructure of high resolution peripheral quantitative computed tomography.

BACKGROUND: Data-driven development of medical biomarkers of bone requires a large amount of image data but physical measurements are generally too restricted in size and quality to perform a robust training. PURPOSE: This study aims to provide a reliable in silico method for the generation of realistic bone microstructure with defined microarchitectural properties. Synthetic bone samples may improve training of neural networks and serve for the development of new diagnostic parameters of bone architecture and mineralization. METHODS: One hundred-fifty cadaveric lumbar vertebrae from 48 different male human spines were scanned with a high resolution peripheral quantitative CT. After prepocessing the scans, we extracted 10,795 purely spongeous bone patches, each with a side length of 32 voxels (5 mm) and isotropic voxel size of 164 µm. We trained a volumetric generative adversarial network (GAN) in a progressive manner to create synthetic microstructural bone samples. We then added a style transfer technique to allow the generation of synthetic samples with defined microstructure and gestalt by simultaneously optimizing two entangled loss functions. Reliability testing was performed by comparing real and synthetic bone samples on 10 well-understood microstructural parameters. RESULTS: The method was able to create synthetic bone samples with visual and quantitative properties that effectively matched with the real samples. The GAN contained a well-formed latent space allowing to smoothly morph bone samples by their microstructural parameters, visual appearance or both. Optimum performance has been obtained for bone samples with voxel size 32 × 32 × 32, but also samples of size 64 × 64 × 64 could be synthesized. CONCLUSIONS: Our two-step-approach combines a parameter-agnostic GAN with a parameter-specific style transfer technique. It allows to generate an unlimited anonymous database of microstructural bone samples with sufficient realism to be used for the development of new data-driven methods of bone-biomarkers. Particularly, the style transfer technique can generate datasets of bone samples with specific conditions to simulate certain bone pathologies.

Lumbar disc herniation in juveniles: A case-control study of MRI characteristics and etiological insights.

Lumbar disc herniation (LDH) is rare in juveniles. LDH occurring at age 20 years or younger is referred to as juvenile disc herniation (JDH). While adult LDH is regarded as an advanced stage of disc degeneration, it remains unclear why intervertebral discs rupture in youth. This study aimed to characterize magnetic resonance imaging (MRI) findings of JDH and investigate possible etiological factors. From 2013 to 2020, JDH patients and controls were identified and interviewed to assess demographics, general lifestyles, and family histories. MRIs were evaluated for disc degeneration, epiphyseal ring separation, Modic changes and endplate lesions. The relationships between JDH and suspected risk factors were examined. A total of 297 JDH patients (199 boys and 98 girls, age 17.3 ± 2.1 years) and 185 controls (age 17.1 ± 2.4 years) were studied. Age, body mass index, exposures to daily physical labor, regular exercise, and daily sitting time were similar between JDH cases and controls. A family medical history of serious back pain was more common in JDH patients than in controls (59.4% vs. 26.5%, p < 0.001), as well as family history of clinically established LDH (45.0% vs. 12.4%, p < 0.001). Epiphyseal ring separation was identified in 102 (29.2%) herniated discs in 91 (36.4%) JDH patients, while occurring in only 5 (1.4%) control participants (p < 0.001). Overall, severe disc degeneration was not a prominent finding in JDH patients. In conclusion, epiphyseal ring separation was a common magnetic resonance feature in JDH. Findings suggest a genetically mediated developmental model of JDH, rather than a model of premature disc degeneration.

Consensus on a standardised treatment pathway algorithm for lumbar spinal stenosis: an international Delphi study.

BACKGROUND: Lumbar spinal stenosis (LSS) is a common degenerative spinal condition in older adults associated with disability, diminished quality of life, and substantial healthcare costs. Individual symptoms and needs vary. With sparse and sometimes inconsistent evidence to guide clinical decision-making, variable clinical care may lead to unsatisfactory patient outcomes and inefficient use of healthcare resources. METHODS: A three-phase modified Delphi study comprising four consensus rounds was conducted on behalf of the International Taskforce for the Diagnosis and Management of LSS to develop a treatment algorithm based on multi-professional international expert consensus. Participants with expertise in the assessment and management of people with LSS were invited using an international distribution process used for two previous Delphi studies led by the Taskforce. Separate treatment pathways for patients with different symptom types and severity were developed and incorporated into a proposed treatment algorithm through consensus rounds 1 to 3. Agreement with the proposed algorithm was evaluated in the final consensus round. RESULTS: The final algorithm combines stratified and stepped approaches. When indicated, immediate investigation and surgery is advocated. Otherwise, a stepped approach is suggested when self-directed care is unsatisfactory. This starts with tailored rehabilitation, then more complex multidisciplinary care, investigations and surgery options if needed. Treatment options in each step depend on clinical phenotype and symptom severity. Treatment response guides pathway entrance and exit points. Of 397 study participants, 86% rated their agreement ≥ 4 for the proposed algorithm on a 0-6 scale, of which 22% completely agreed. Only 7% disagreed. Over 70% of participants felt that the algorithm would be useful for clinicians in public healthcare (both primary care and specialist settings) and in private healthcare settings, and that a simplified version would help patients in shared decision-making. CONCLUSIONS: International and multi-professional agreement was achieved for a proposed LSS treatment algorithm developed through expert consensus. The algorithm advocates different pathway options depending on clinical indications. It is not intended as a treatment protocol and will require evaluation against current care for clinical and cost-effectiveness. It may, however, serve as a clinical guide until evidence is sufficient to inform a fully stratified care model.

The association between whole body vibration exposure and spine degeneration on imaging: A systematic review.

BACKGROUND: Low frequency vibrations from motorized vehicles and heavy equipment have been associated with musculoskeletal disorders. Spine degeneration on diagnostic imaging provides direct and objective measures of the possible effects of such exposures on the spine. OBJECTIVE: The objective of this systematic review was to evaluate the association of exposure to whole-body vibration (WBV) with spine degeneration on imaging. METHODS: We conducted electronic searches in MEDLINE, CINAHL, EMBASE, and Web of Science to July 2021. Two reviewers independently screened search results, assessed quality, and extracted data. Studies evaluating the exposure to WBV and lumbar spine degeneration on imaging were included. RESULTS: Fifteen studies (16 manuscripts) were included. Seven studies including a meta-demonstrated moderate quality evidence of no association between WBV and disc degeneration. There was also moderate quality evidence of no association between WBV and disc height narrowing and osteophytes. Overall, there was low level evidence of no association between WBV and other degenerations findings. CONCLUSIONS: There was moderate to low quality evidence suggesting no association between WBV exposures with spine degeneration on imaging. The results of this study currently do not support assertion that motorized vehicle and WBV exposure accelerates degeneration and causes structural damage to the spine.

Traumatic vertebra and endplate fractures promote adjacent disc degeneration: evidence from a clinical MR follow-up study.

OBJECTIVES: The integrity of endplate is important for maintaining the health of adjacent disc and trabeculae. Yet, pathological impacts of traumatic vertebra and endplate fractures were less studied using clinical approaches. This study aims to investigate their effects on the development of adjacent disc degeneration, segmental kyphosis, Modic changes (MCs), and high-intensity zones (HIZs). MATERIALS AND METHODS: Magnetic resonance (MR) images of patients with acute traumatic vertebral compression fractures (T11-L5) were studied. On MR images, endplate fractures were evaluated as present or absent. Disc signal, height, bulging area, sagittal Cobb angle, MCs, and HIZs were measured on baseline and follow-up MR images to study the changes of the disc in relation to vertebra fractures and endplate fractures. RESULTS: Ninety-seven patients were followed up for 15.4 ± 14.0 months. There were 123 fractured vertebrae, including 79 (64.2%) with endplate fractures and 44 (35.8%) without. Both the adjacent and control discs decreased in signal and height over time (p < 0.001), and the disc adjacent to vertebral fractures had greater signal and height loss than the control disc (p < 0.05). In the presence of endplate fractures, the adjacent discs had greater signal decrease in follow-up (p < 0.05), as compared to those without endplate fractures. Sagittal Cobb angle significantly increased in segments with endplate fractures (p < 0.05). Vertebra fractures were associated with new occurrence of MCs in the fractured vertebra (p < 0.001) but not HIZs in the adjacent disc. CONCLUSIONS: Traumatic vertebral fractures were associated with accelerated adjacent disc degeneration, which appears to be further promoted by concomitant endplate fractures. Endplate fractures were associated with progression of segmental kyphosis.

Reliability and validity of subjective radiologist reporting of temporal changes in lumbar spine MRI findings.

BACKGROUND: The importance of lumbar findings on magnetic resonance imaging (MRI) remains controversial. Changes in lumbar MRI findings over time may provide important insights into the causes of low back pain. However, the reliability and validity of temporal changes are unknown. OBJECTIVE: To (1) investigate the interrater reliability of subjective radiologist reporting of temporal changes in lumbar spine MRI findings and (2) determine how commonly temporal changes are reported when two scans are conducted 30 minutes apart (considered false positives). DESIGN: Cross-sectional study. SETTING: Radiology clinic. PARTICIPANTS: Forty volunteers (mean age 40; 53% female) with current (n = 31) or previous (n = 9) low back pain underwent initial lumbar MRI on a single 3T scanner. Participants then lay on a bed for 30 minutes before undergoing an identical MRI. In addition, we purposely selected five participants from a previous study with repeat lumbar MRI scans where temporal changes were reported in at least one MRI finding (1-12 weeks after initial scan) and another five participants where no temporal change was reported. The 10 participants were included in analyses for aim 1 only. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two blinded radiologists reported on temporal changes between the baseline and repeat scan for 12 different MRI findings (eg, disk herniation, annular fissure) at five levels. RESULTS: The interrater reliability of subjective reporting of temporal changes was poor for all MRI findings based on Kappa values (≤ 0.24), but agreement was relatively high (≥ 90.8%). This is explained by the low prevalence of temporal changes as demonstrated by high values for Prevalence and Bias Adjusted Kappa (≥ 0.82). "False positive" temporal changes were reported by at least one radiologist for most MRI findings, but the rate was generally low. CONCLUSIONS: Caution is required when interpreting temporal changes in lumbar MRI findings owing to low reliability and some false positive reporting.

Paraspinal muscle imaging measurements for common spinal disorders: review and consensus-based recommendations from the ISSLS degenerative spinal phenotypes group.

PURPOSE: Paraspinal muscle imaging is of growing interest related to improved phenotyping, prognosis, and treatment of common spinal disorders. We reviewed issues related to paraspinal muscle imaging measurement that contribute to inconsistent findings between studies and impede understanding. METHODS: Three key contributors to inconsistencies among studies of paraspinal muscle imaging measurements were reviewed: failure to consider possible mechanisms underlying changes in paraspinal muscles, lack of control of confounding factors, and variations in spinal muscle imaging modalities and measurement protocols. Recommendations are provided to address these issues to improve the quality and coherence of future research. RESULTS: Possible pathophysiological responses of paraspinal muscle to various common spinal disorders in acute or chronic phases are often overlooked, yet have important implications for the timing, distribution, and nature of changes in paraspinal muscle. These considerations, as well as adjustment for possible confounding factors, such as sex, age, and physical activity must be considered when planning and interpreting paraspinal muscle measurements in studies of spinal conditions. Adoption of standardised imaging measurement protocols for paraspinal muscle morphology and composition, considering the strengths and limitations of various imaging modalities, is critically important to interpretation and synthesis of research. CONCLUSION: Study designs that consider physiological and pathophysiological responses of muscle, adjust for possible confounding factors, and use common, standardised measures are needed to advance knowledge of the determinants of variations or changes in paraspinal muscle and their influence on spinal health.

Statistical morphological analysis reveals characteristic paraspinal muscle asymmetry in unilateral lumbar disc herniation.

Growing evidence suggests an association of lumbar paraspinal muscle morphology with low back pain (LBP) and lumbar pathologies. Unilateral spinal disorders provide unique models to study this association, with implications for diagnosis, prognosis, and management. Statistical shape analysis is a technique that can identify signature shape variations related to phenotypes but has never been employed in studying paraspinal muscle morphology. We present the first investigation using this technique to reveal disease-related paraspinal muscle asymmetry, using MRIs of patients with a single posterolateral disc herniation at the L5-S1 spinal level and unilateral leg pain. Statistical shape analysis was conducted to reveal disease- and phenotype-related morphological variations in the multifidus and erector spinae muscles at the level of herniation and the one below. With the analysis, shape variations associated with disc herniation were identified in the multifidus on the painful side at the level below the pathology while no pathology-related asymmetry in cross-sectional area (CSA) and fatty infiltration was found in either muscle. The results demonstrate higher sensitivity and spatial specificity for the technique than typical CSA and fatty infiltration measures. Statistical shape analysis holds promise in studying paraspinal muscle morphology to improve our understanding of LBP and various lumbar pathologies.

Back to living well: community-based management of low back pain: a feasibility study.

BACKGROUND: Low back pain (LBP) is a long-term health condition with an unpredictable pattern of symptomatic episodes, remission, and recurrence. Recently published systematic reviews suggest that exercise is the most effective intervention for preventing recurrences of LBP in persons that have recovered. Similar programs may also be effective in preventing flare-ups in persistent LBP. The aim of this study was to test the feasibility of the Back to Living Well program (Physical activity + Education + Self-management) developed to prevent recurrence or flare-ups of LBP. The study evaluated feasibility in terms of recruitment rate, adherence, satisfaction with the exercise and education sessions, and the data collection procedures. We also aimed to evaluate barriers and facilitators to the engagement in the program. METHODS: Seventeen participants with non-specific LBP recently discharged from care from physiotherapy, chiropractors or physician care (< 3 months) were referred to the study by health care providers or community advertisements between December 2018 and February 2019. Participants underwent a 12-week (1 session/week) individualized, group-based exercise in the community and 4 sessions (30 min each) of education. All participants completed an action plan weekly for 12 weeks and wore an activity monitor for 6 months. All participants responded to weekly pain measures and completed study questionnaires at baseline, 3- and 6-months. Feasibility outcomes included recruitment, attrition rates and satisfaction. At the end of the intervention, participants completed an end-of-program survey. RESULTS: Twenty-nine participants were screened for eligibility; 20 were deemed eligible, while 17 were included over a 2-month period meeting our feasibility targets. In total, 16 completed follow-up study questionnaires at 3 months, and 15 completed the 6-month follow-up. Fourteen participants responded to weekly messages, while 3 participants reported not having a mobile device or Internet access. In total, 15 participants responded to our end-of-program survey. Average age was 54.9 (11.7); 9 were female (53%), and the mean duration of LBP was 62.9 (69.7) months. All satisfaction responses in relation to the exercise program, education program and data collection procedures reached our threshold of 70% out of 100%. Reported barriers to engagement in the program included fear of injury, lack of motivation and travel. Facilitators included proximity to home, low cost, flexible schedule and friendly location. CONCLUSION: The results show the program is feasible in terms of recruitment, low attrition, and patient satisfaction. Participants highlighted the excellent, relevant education program and the positive, personalized exercise. Future studies should evaluate the effectiveness of this intervention within a fully powered randomized controlled trial. TRIAL REGISTRATION: NCT03328689.

The association between vertebral endplate structural defects and back pain: a systematic review and meta-analysis.

PURPOSE: To clarify the current state of knowledge on the association of endplate structural defects and back pain. METHODS: Five databases were searched for studies reporting on the association between endplate structural defects and back pain. Covidence and comprehensive meta-analysis software were used for article screening and selection and pooling of extracted data. Overall quality of evidence was assessed using GRADE. RESULTS: Twenty-six studies comprised of 11,027 subjects met inclusion criteria. The presence of moderate heterogeneity (I2 = 73%; p = 0.001) prevented the pooling of estimates across all studies. However, it was possible to pool studies of specific endplate defect phenotypes, such as erosion (OR: 2.69; 95% CI: 1.35-5.50) and sclerosis (OR: 1.97; 95% CI: 1.50-2.58), which yielded significant associations with back pain. Schmorl's nodes were also associated with most individual back pain phenotypes (OR: 1.53-1326, I2 = 0-7.5%) and back pain overall (OR: 1.63, 95% CI: 1.37-1.94, I2 = 26%) in general population samples. The pooling of data from all studies of specific back pain phenotypes, such as frequent back pain (OR: 2.83; 95% CI: 1.77-4.52) and back pain incidence (OR: 1.65; 95% CI: 1.30-2.10), each yielded significant association with endplate structural defects and was supported by low heterogeneity (I2 = < 7.5.%). CONCLUSION: Overall, there is moderate quality evidence of an association between back pain and endplate structural defects, which is most evident for erosion, sclerosis and Schmorl's nodes. Going forward, research on specific endplate defect phenotypes and back pain case definitions using strong study designs will be important in clarifying the extent of associations and underlying mechanisms. The study was prospectively registered in Prospero (CRD42020170835) on 02/24/2020.

The effects of axial loading on the morphometric and T2 characteristics of lumbar discs in relation to disc degeneration.

BACKGROUND: Intervertebral disc degeneration affects the morphology, biomechanics and biochemistry of the disc. The study aimed to compare the effects of compression and traction on lumbar discs measurements in relation to degeneration. METHODS: Thirty-five volunteers (30 (SD 11) yrs.) with and without chronic back pain rested supine 15 min before an unloaded T2-mapping MRI, were then loaded 20 min with 50% body weight with imaging during the last 5 min, and then repeated this process under traction. For lumbar discs, height, angle, width, mean-T2, and T2-weighted centroid locations were calculated. A repeated measure ANCOVA and Cohen's d compared loading conditions. Relations between measurement changes between conditions and degeneration assessed by Pfirrmann ratings were examined graphically. FINDINGS: From compression to traction, we observed significant: decrease in L1-2 mean-T2 (Effect size = -0.35); inferior and posterior shift in L4-5 (0.4, 0.14) and L5-S1 (0.25, 0.33) T2-weighted centroid. From unloaded to compression, we observed a significant: increase in L5-S1 width (Effect Size = 0.22); anterior shift in L1-2 T2-weighted centroid (0.39); and L3-4 (mean 2.1°) and L4-5 (1.8°) extension angle. More degeneration was graphically related with larger changes from Compression to Traction (more superior and, anterior position of the T2-weighted centroid, increased height, reduced extension of segmental angle) and from Unloaded to Compression larger changes in inferior displacement of the T2-weighted centroid, decrease in height) but less anterior displacement of the centroid and less change in segmental angles. INTERPRETATION: The largest loading responses were at lower levels, generally with more degeneration. T2-weighted centroid locations, angle and disc height detected the largest loading response.

Innervation of the Human Intervertebral Disc: A Scoping Review.

OBJECTIVE: Back pain is an elusive symptom complicated by a variety of possible causes, precipitating and maintaining factors, and consequences. Notably, the underlying pathology remains unknown in a significant number of cases. Changes to the intervertebral disc (IVD) have been associated with back pain, leading many to postulate that the IVD may be a direct source of pain, typically referred to as discogenic back pain. Yet despite decades of research into the neuroanatomy of the IVD, there is a lack of consensus in the literature as to the distribution and function of neural elements within the tissue. The current scoping review provides a comprehensive systematic overview of studies that document the topography, morphology, and immunoreactivity of neural elements within the IVD in humans. METHOD: Articles were retrieved from six separate databases in a three-step systematic search and were independently evaluated by two reviewers. RESULTS: Three categories of neural elements were described within the IVD: perivascular nerves, sensory nerves independent of blood vessels, and mechanoreceptors. Nerves were consistently localized within the outer layers of the annulus fibrosus. Neural ingrowth into the inner annulus fibrosus and nucleus pulposus was found to occur only in degenerative and disease states. CONCLUSION: While the pattern of innervation within the IVD is clear, the specific topographic arrangement and function of neural elements in the context of back pain remains unclear.

Functional Recovery after Surgery for Lumbar Spinal Stenosis in Patients with Hypertension.

Hypertension is a prevalent condition that is associated with lower health status in patients with lumbar spinal stenosis. The study determined whether hypertension is a prognostic factor associated with functional recovery after spine surgery for lumbar spinal stenosis. This was a secondary analysis of the Alberta Lumbar Spinal Stenosis Study in which patients were identified as participants at the time of lumbosacral magnetic resonance imaging or computed tomography in Calgary, Alberta, Canada. Multivariable linear regression analyses were performed to examine hypertension as a prognostic factor of functional recovery after surgery (Oswestry Disability Index, the Swiss Spinal Stenosis (SSS)-Symptom Severity and SSS-Physical Function scales). Of the 97 surgical participants, 49 who were hypertensive were older (76.8, SD 11.4 years) than the 48 non-hypertensive participants (66.7, SD 12.4 years) (p < 0.001). No significant associations between hypertension and post-operative function in any of the three multivariable models were seen. The Oswestry Disability Index mean score improved after surgery (effect size: 1.73; 95%CI: 1.39, 2.06), with no differences seen between those with and without hypertension (p = 0.699). Large changes were seen after surgery for the SSS-Symptom Severity (effect size: 1.0, 95%CI 0.7, 1.3) and SSS-Physical Function (effect size: 0.9, 95%CI 0.6, 1.2) scales. Hypertension alone does not negatively impact functional recovery following surgery.