[Low Back Pain - Value of Prevention and Physiotherapy?] / Rückenschmerzen.

Low Back Pain - Value of Prevention and Physiotherapy? Abstract. Physiotherapy plays a central role in the prevention and treatment of lumbar back pain. There is no clear evidence in science on the effectiveness of individual preventive measures; however, movement and active training as central elements are indispensable here. In the treatment of lumbar back pain, however, the picture is clear: while passive measures such as heat or cold applications as well as ultrasound and electrotherapy should no longer be used alone due to the lack of evidence, the combination of active exercises and patient education shows promising success. If these are supplemented by sporadically applied manual therapy methods, the result is an evidence-based management of both acute and chronic lumbar back pain. One example of a successful implementation of current evidence for the treatment of back pain is GLA:D®, which is also in use in Switzerland since 2021.

Recurrence of low back pain: A difficult outcome to predict. Development and validation of a multivariable prediction model for recurrence in patients recently recovered from an episode of non-specific low back pain.

BACKGROUND: Recurrence of low back pain (LBP) is common. If clinicians could identify an individual's risk of recurrence, this would enhance clinical decision-making and tailored patient care. OBJECTIVE/DESIGN: To develop and validate a simple tool to predict the probability of a recurrence of LBP by 3- or 12-months following recovery. METHODS: Data utilised for the prediction model development came from a prospective inception cohort study of participants (n = 250) recently recovered from LBP, who had sought care from chiropractic or physiotherapy services. The outcome measure was a recurrence of activity-limiting LBP. Candidate predictor variables (e.g., basic demographics, LBP history, levels of physical activity, etc) collected at baseline were considered for inclusion in a multivariable Cox model. The model's performance was tested in a separate validation dataset of participants (n = 261) involved in a randomised controlled trial investigating exercise for the prevention of LBP recurrences. RESULTS: The final model included the number of previous episodes, total sitting time, and level of education. In the development sample, discrimination was acceptable (Harrell's C-statistic = 0.61, 95% CI, 0.59-0.62), but in the validation sample, discrimination was poor (0.56, 95% CI, 0.54-0.58). Calibration of the model in the validation dataset was acceptable at 3 months but was less precise at 12 months. CONCLUSION: The developed prediction model, which included number of previous episodes, total sitting time, and level of education, did not perform adequately in the validation sample to recommend its use in clinical practice. Predicting recurrence of LBP in clinical practice remains challenging.

An Early Biopsychosocial Intervention Design for the Prevention of Low Back Pain Chronicity: A Multidisciplinary Empirical Approach.

OBJECTIVE: Comprehensive intervention models for prevention of chronification of low back pain, in which the early identification of holistic risk factors is considered are needed. The aim of this study is to design a tailored biopsychosocial intervention for patients with low back pain to prevent pain chronicity. DESIGN: A multidisciplinary empirical approach. METHODS: A multidisciplinary team designed a biopsychosocial intervention following an application from the Medical Research Council's complex intervention framework. The methods used included problem identification, identification of the evidence, theory, and needs, examination of the current context and modelling of the theory. Biomechanical, psychological, social and environmental, and lifestyle and personal risk factors were taken into account. RESULTS: The intervention process was introduced in a logic model. The model presents all the required resources, their activities and outputs, as well as the outcomes and impacts of the intervention. The intervention was tailored according to the underlying risk factors for pain chronification in patients with low back pain. CONCLUSION: A comprehensive tailored intervention may decrease the risk of pain chronicity. Further studies are needed to obtain information on the feasibility, effectiveness and cost-effectiveness of such interventions.

The Role of Exercise in Treating Low Back Pain.

ABSTRACT: The purpose of this review is to highlight the role of exercise in preventing and managing acute and chronic axial low back pain (LBP). LBP is one of the leading contributors to years lived with disability as well as health care expenditures in the United States. With an expected increase in prevalence due to an aging population, sports medicine providers have a unique opportunity to provide effective treatment strategies incorporating exercise advice and prescription. Although the majority of individuals with acute LBP will have their symptoms resolve spontaneously, almost 40% will have recurrence or develop chronic LBP within 1 year. No single exercise method has been shown to be more effective than another. The evidence for walking programs, aerobic exercise, yoga, Pilates, and tai chi for LBP is discussed. Our review summarizes the beneficial role of a personalized exercise program and related counseling strategies in the prevention and management of LBP.

Core muscle functional strength training for reducing the risk of low back pain in military recruits: An open-label randomized controlled trial.

BACKGROUND: Core muscle functional strength training (CMFST) has been reported to reduce injuries to the lower extremity. However, no study has confirmed whether CMFST can reduce the risk of low back pain (LBP). OBJECTIVE: This study identified the effects of CMFST on the incidence of LBP in military recruits. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: We performed a prospective, open-label, randomized, controlled study in a population of young healthy male naval recruits from a Chinese basic combat training program. Participants were randomly assigned to either the core group or the control group. In additional to normal basic combat training, recruits in the core group underwent a CMFST program for 12 weeks, while recruits in the control group received no extra training. MAIN OUTCOME MEASURES: At the beginning of the study and at the 12th week, the number of participants with LBP was counted, and lumbar muscle endurance was measured. In addition, when participants complained of LBP, they were assessed using the visual analog scale (VAS) and Roland Morris Disability Questionnaire (RMDQ). RESULTS: A total of 588 participants were included in the final analysis (295 in the core group and 293 in the control group). The incidence of LBP in the control group was about twice that of the core group over the 12-week study (20.8% vs 10.8%, odds ratio: 2.161-2.159, P < 0.001). The core group had better lumbar muscle endurance at 12 weeks than the control group ([200.80 ± 92.98] s vs [147.00 ± 84.51] s, P < 0.01). There was no significant difference in VAS score between groups, but the core group had a significantly lower RMDQ score at week 12 than the control group (3.33 ± 0.58 vs 5.47 ± 4.41, P < 0.05). CONCLUSION: This study demonstrated that the CMFST effectively reduced the incidence of LBP, improved lumbar muscle endurance, and relieved the dysfunction of LBP during basic military training.

Preventing progression from chronic to widespread pain and its impact on health-related quality of life: a historical cohort study of osteopathic medical care.

CONTEXT: It is generally acknowledged that osteopathic physicians take a holistic approach to patient care. This style may help prevent the progression of painful musculoskeletal conditions, particularly if combined with osteopathic manipulative treatment (OMT). OBJECTIVES: The study aimed to determine if osteopathic medical care lowers the risk of progression from localized chronic low back pain to widespread pain and lessens the impact of pain on health-related quality of life. METHODS: A historical cohort study was conducted within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry) using data acquired from April 2016 through March 2021. Registry participants aged 21-79 years with chronic low back pain at the baseline encounter were potentially eligible for inclusion if they had a treating physician, completed all four quarterly follow-up encounters, and did not report physician crossover at the final 12-month encounter. Eligible participants were classified according to the type of physician provider at baseline and thereby into osteopathic or allopathic medical care groups. Participants were also classified according to prior use of OMT at the final encounter. Widespread pain was measured at baseline and each quarterly encounter to determine the period prevalence rate of widespread pain and its severity over 12 months using the Minimum Dataset for Chronic Low Back Pain recommended by the National Institutes of Health. Participants who reported "not being bothered at all" by widespread pain during each encounter were classified as not having widespread pain, whereas those who were bothered "a little" or "a lot" at any quarterly encounter were classified as having widespread pain. The severity of widespread pain was measured by summing participant responses at each encounter. The Patient-Reported Outcomes Measurement Information System was used at each encounter to measure health-related quality-of-life (HRQOL) scores for physical function, anxiety, depression, fatigue, sleep disturbance, participation in social roles and activities, and pain interference with activities. RESULTS: A total of 462 participants were studied, including 101 (21.9%) in the osteopathic medical care group and 73 (15.8%) who used OMT. The mean age of participants at baseline was 52.7 ± 13.2 years (range, 22-79 years) and 336 (72.7%) were female. A lower period prevalence rate of widespread pain was observed in the osteopathic medical care group (OR, 0.47; 95% CI, 0.27-0.81; p=0.006) and in the OMT group (OR, 0.40; 95% CI, 0.21-0.75; p=0.004), although the latter finding did not persist after adjustment for potential confounders. The osteopathic medical care and OMT groups both reported lower widespread pain severity. The osteopathic medical care group also reported better age- and sex-adjusted outcomes for each of the seven HRQOL dimensions throughout the study. The OMT group reported better outcomes in five of the HRQOL dimensions. CONCLUSIONS: This study supports the view that osteopathic physicians practice a holistic approach to medical care that manifests itself through a lower risk of progression from chronic low back pain to widespread pain, lower widespread pain severity, and lesser deficits in HRQOL. Similar findings were generally associated with OMT use.

Computer Kinesiology: New Diagnostic and Therapeutic Tool for Lower Back Pain Treatment (Pilot Study).

The aim of this study was to demonstrate the effectiveness of the diagnostic and therapeutic medical information system Computer Kinesiology in physiotherapy in patients with low back pain who were not responding to conventional therapy. Computer Kinesiology is primarily intended for the diagnostics and therapy of functional disorders of the locomotor system. This pilot study population included 55 patients (Group 1) with acute and chronic back pain and 51 persons (Group 2) without back pain. The third group was a control group of 67 healthy volunteers with no evidence of musculoskeletal pathologies and no back pain. All 173 subjects were examined three times by the diagnostic part of the Computer Kinesiology method. Groups 1 and 2 were treated after every diagnostics. Group 3 was not treated. The effect was evaluated by H score. Improvements after therapy were defined by reducing the H score by at least 1 point. In Group 1, the H score decreased by at least 1 point in 87.3% (95% CI: 75.5-94.7) and in Group 2 in 78.4% (95% CI: 64.7-88.7). There was no change of distribution of H Score grade in Group 3. The improvement neither depended on gender, age, and BMI nor was it influenced by the length of the therapy. This study demonstrated a high therapeutic efficacy of the Computer Kinesiology system in patients with back pain (Group 1) and in persons without back pain (Group 2) who used the Computer Kinesiology system for primary and secondary prevention of back pain.

The Effects of Tai Chi Chuan Versus Core Stability Training on Lower-Limb Neuromuscular Function in Aging Individuals with Non-Specific Chronic Lower Back Pain.

Objectives: For this paper, we aimed to investigate the effects of Tai Chi Chuan (TCC) versus the Core Stability Training (CST) program on neuromuscular function (NF) in the lower extremities among aging individuals who suffered from non-specific chronic lower back pain (NLBP). Regarding the design, during a 12-week intervention, a single-blinded randomized controlled trial was used to compare two intervention groups with a control group on the parameters of NF. Methods: Forty-three Chinese community-dwellers were randomly assigned into two intervention groups (three sessions per week, with each session lasting 60 min in TCC and CST) and a control group. The patient-based Visual Analogue Scale (VAS) was used to measure the level of perceived pain, while parameters of NF as primary outcomes were measured by the Biodex System 3 Isokinetic Dynamometer. Results: For the knee joint, we observed significant differences in the endurance of left extension at a speed of 60°/s: (1) between TCC and control groups (p < 0.01); (2) between CST and control groups (p < 0.01). For the ankle joint, significant differences between CST and control groups were observed on the peak torque of left dorsiflexion (p < 0.05) and the endurance of the left plantar flexion at a speed of 60°/s (p < 0.05). In addition, we observed a significant difference between TCC and control groups in the endurance of the right plantar flexion (p < 0.05). Conclusions: Chen-style TCC and CST were found to have protective effects on NF in aging individuals with NLBP, while alleviating non-specific chronic pain.

Prevention and treatment of low back pain: evidence, challenges, and promising directions.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Intervertebral Disk Degeneration and Repair.

Intervertebral disk (IVD) degeneration is a natural progression of the aging process. Degenerative disk disease (DDD) is a pathologic condition associated with IVD that has been associated with chronic back pain. There are a variety of different mechanisms of DDD (genetic, mechanical, exposure). Each of these pathways leads to a final common result of unbalancing the anabolic and catabolic environment of the extracellular matrix in favor of catabolism. Attempts have been made to gain an understanding of the process of IVD degeneration with in Vitro studies. These models help our understanding of the disease process, but are limited as they do not come close to replicating the complexities that exist with an in Vivo model. Animal models have been developed to help us gain further understanding of the degenerative cascade of IVD degeneration In Vivo and test experimental treatment modalities to either prevent or reverse the process of DDD. Many modalities for treatment of DDD have been developed including therapeutic protein injections, stem cell injections, gene therapy, and tissue engineering. These interventions have had promising outcomes in animal models. Several of these modalities have been attempted in human trials, with early outcomes having promising results. Further, increasing our understanding of the degenerative process is essential to the development of new therapeutic interventions and the optimization of existing treatment protocols. Despite limited data, biological therapies are a promising treatment modality for DDD that could impact our future management of low back pain.

Twelve-Month Follow-up of a Randomized Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain.

Objective: This report conveys 12-month outcomes of subjects treated with intradiscal biacuplasty (IDB) and conservative medical management (CMM) for chronic low back pain of discogenic origin, and results for subjects who elected to receive IDB + CMM 6 months after CMM-alone. Methods: Sixty-three subjects were originally randomized to the IDB + CMM group (N = 29) or CMM-alone (N = 34). Six months following continuous CMM-alone treatment, participants in this study group were permitted to "cross-over" to IDB + CMM (N = 25), and followed for an additional 6 months. The original IDB + CMM study subjects were followed for a total of 12 months (N = 22). Results: Pain reduction at 12 months was statistically significant and clinically meaningful in the original IDB + CMM group compared to baseline. Functional and disability outcomes were also improved statistically and clinically. Fifty-five percent of the IDB + CMM patients responded to treatment with a mean VAS reduction of 2.2 points at 12 months. Furthermore, 50% and 64% of subjects reported clinically significant improvements in SF36-PF and in ODI, respectively. There was a 1.7-point reduction (improvement) on a 7-point PGIC scale, and a 0.13-point increase (improvement) in the EQ-5D Health Index. Fifty-percent of cross-over subjects responded to IDB + CMM intervention. Mean outcome scores for cross-over subjects were similar to those of the originally-treated subjects, and functional and disability endpoints were improved statistically and clinically compared to respective baseline values. Conclusions: The study demonstrated long-term clinical effectiveness of IDB + CMM for treating chronic lumbar discogenic pain. Furthermore, the cross-over study subjects experienced similar improvements in pain, function, disability, and satisfaction.

Effect of education on non-specific neck and low back pain: A meta-analysis of randomized controlled trials.

BACKGROUND: Neck and low back pain are significant health problems due to their high prevalence among the general population. Educational intervention commonly aims to reduce the symptoms and risk for additional problems by increasing the participant's knowledge, which in turn will alter the person's behavior. The primary aim of this study was to review randomize controlled trials (RCTs) to gain insights into the effectiveness of education for the prevention and treatment of non-specific neck and low back pain. METHODS: Publications were systematically searched from 1982 to March 2015 in several databases. Relevant RCTs were retrieved and assessed for methodological quality. Meta-analysis was conducted to examine the effectiveness of education for the prevention and treatment of non-specific neck and low back pain. The overall quality of evidence was assessed using the GRADE system. RESULTS: Thirty-six RCTs (30 high-quality studies) were identified. A total of 15 RCTs, which compared education programs to no education program, were included for further analysis. All studies included investigated the effectiveness of education with intermediate- and long-term follow-ups. The results showed that education programs were not effective in preventing and treating neck pain as well as treating low back pain. Conflicting evidence was found for the effectiveness of education on prevention of low back pain. CONCLUSIONS: Evidence suggests that education programs are not recommended in preventing or treating neck pain as well as treating low back pain, unless supplementary high-quality studies provide evidence to the contrary.

Reflexoterapia podal para alívio da dor lombar aguda relacionada ao trabalho da equipe de enfermagem: ensaio clínico randomizado / Foot Refletotherapy for relief of acute lower back pain related to work of nursing staff: randomized clinical trial

Os Distúrbios Osteomusculares Relacionados ao Trabalho (DORT) são definidos por condições vinculadas a fatores estressores e repetitivos no trabalho que debilitam a estrutura musculoesquelética corpórea. Dentre as profissões da área da saúde, a equipe de enfermagem é a mais afetada pelo distúrbio, uma vez que a própria função exige força, movimentos repetitivos acompanhados de posturas inadequadas para execução de procedimentos nas atividades realizadas. Assim, esse estudo direcionou atenção para a dor aguda, localizada na região lombar, uma vez que é a área mais comprometida por DORT que acomete os profissionais na equipe de enfermagem e propôs uma intervenção para alívio desta dor com a reflexoterapia podal. Para tanto, o objetivo do estudo foi analisar o resultado da aplicação da reflexoterapia podal no alívio da dor lombar aguda, ocasionada por DORT na equipe de enfermagem atuante em ambiente hospitalar. A pesquisa caracterizou-se como um ensaio clínico piloto, randomizado, controlado, duplo cego, desenvolvido pela Universidade Federal de Santa Catarina (UFSC) e aplicado no Hospital Universitário Polydoro Ernani de São Thiago (HU-UFSC), no período de maio a julho de 2016. A pesquisa teve aprovação em abril pelo Comitê de Pesquisa com Seres Humanos (CEPSH-UFSC) sob o registro protocolar CAAE: 54909616.0.0000.0121. Obteve-se publicação no Registro Brasileiro de Ensaios Clínicos (ReBEC) sob registro RBR-5ndq22. Participaram efetivamente da pesquisa 36 profissionais da equipe de enfermagem atuantes, alocados randomicamente em grupos controle e experimental, da qual foram submetidos ao protocolo de reflexoterapia para dor lombar em duas sessões com intervalo de 72 horas. Os instrumentos da pesquisa para coleta de dados foram a escala visual e analógica de intensidade na avaliação da dor (EVA) e o Questionário para lombalgia. Para análise dos dados foram aplicados o teste de Shapiro Wilk, para normalidade da amostra, teste do Qui-quadrado ou Exato de Fisher para calcular associação das variáveis categóricas, o teste de Wilcoxon para distribuição não paramétrica e teste t para dados paramétricos e na avaliação das associações entre variáveis contínuas aplicou-se o Coeficiente de Correlação de Pearson ou Spearman. Adotou-se o nível de significância de p<0,05 para um intervalo de confiança (IC) de 95%. Os resultados apresentaram significância estatística para aplicação da reflexoterapia podal no alívio da intensidade da dor, finalizado com pesquisa p=0,000 para os dados obtidos no instrumento EVA. Nos resultados do questionário para lombalgia, houve significância positiva para redução da dor lombar aguda com aplicação da reflexoterapia (p=0,000). A reflexoterapia é uma técnica milenar de manipulação em pontos específicos dos pés mãos e orelhas (pontos reflexos), cuja resposta ao estímulo é o bem estar, promoção da saúde, tratamento de distúrbios fisiológicos e ou emocionais, alívio da sintomatologia do estresse, e principalmente alívio da dor. Conclui-se que a prática é eficaz na redução da intensidade da dor lombar aguda nos profissionais da Enfermagem participantes deste estudo. (AU)

The Work-Related Musculoskeletal Disorders (WMSDs) are defined by conditions linked to stressor and repetitive factors at work which weaken the body's musculoskeletal structure. Among the health professions, the nursing staff is the most affected by the disorder, since the activity itself requires strength, repetitive movements and generally unsuitable postures for the execution of procedures and activities carried out. Thus, this study directed attention to acute pain, located in the lower back region, since it is the most affected area by WMSDs among professionals in the nursing staff and proposed an intervention for relief from this pain with foot reflexology. Therefore, the objective of the study was to analyze the result of the application of foot reflexology for relieving acute low back pain, caused by WMSDs of the nursing staff working in the hospital environment. The research was characterized as a pilot clinical trial, randomized, controlled and double-blind, developed by the Federal University of Santa Catarina (UFSC) and applied at the University Hospital Polydoro de São Thiago Ernani (HU-UFSC), from May to July of 2016. The research was approved in April by the Research Committee on Human Beings (CEPSH-UFSC) under the registration protocol CAAE: 54909616.0.0000.0121. It was published in the Brazilian Registry of Clinical Trials (ReBEC) under registry RBR5ndq22. Thirty-six (36) active nursing staff professionals participated effectively of the research, randomly allocated into control and experimental groups, and subjected to reflexotherapy protocol for low back pain in two sessions with an interval of 72 hours. The research instruments for data collection were the visual analog scale of intensity in the assessment of pain (VAS) and the Questionnaire for low back pain. For data analysis, were applied the Shapiro-Wilk test for normality of the sample, Chi-square test or Fisher's exact test to calculate the combination of categorical variables, the Wilcoxon test for nonparametric distribution and t test for parametric data; for evaluating the associations between continuous variables, we applied the correlation coefficient of Pearson or Spearman. The p significance level < 0.05 for a confidence interval (CI) of 95% was adopted. The results were statistically significant for the application of foot reflexology in diminishing the intensity of pain, finished with research p = 0.000 for the data obtained in the VAS instrument. In the results of the questionnaire for low back pain, there was a positive significance for the reduction of acute low back pain with the application of reflexotherapy (p = 0.000). Reflexotherapy is an ancient technique of manipulation on specific points of the feet, hands and ears (reflex points). The response to the stimulus is well-being, health promotion, treatment of physiological and or emotional disorders, relieving stress symptoms, and mainly pain relief. It follows that practice was effective in reducing the intensity of acute low back pain of nursing professionals participating in this study. (AU)

[Sciatica. From stretch rack to microdiscectomy]. / Ischias. Von der Streckbank zur Mikrodiskektomie.

In ancient times as well as in the Middle Ages treatment options for discogenic nerve compression syndrome were limited and usually not very specific because of low anatomical and pathophysiological knowledge. The stretch rack (scamnum Hippocratis) was particularly prominent but was widely used as a therapeutic device for very different spinal disorders. Since the beginning of the nineteenth century anatomical knowledge increased and the advances in the fields of asepsis, anesthesia and surgery resulted in an increase in surgical interventions on the spine. In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich O. Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in the New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined. In the late 1960s the surgical microscope was introduced for spinal surgery by the work of the famous neurosurgeon Mahmut Gazi Yasargil and his colleague Wolfhard Caspar and so-called microdiscectomy was introduced. Besides open discectomy other interventional techniques were developed to overcome the side effects of surgical procedures. In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material. In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation.

Interventions for preventing and treating low-back and pelvic pain during pregnancy.

BACKGROUND: More than two-thirds of pregnant women experience low-back pain and almost one-fifth experience pelvic pain. The two conditions may occur separately or together (low-back and pelvic pain) and typically increase with advancing pregnancy, interfering with work, daily activities and sleep. OBJECTIVES: To update the evidence assessing the effects of any intervention used to prevent and treat low-back pain, pelvic pain or both during pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth (to 19 January 2015), and the Cochrane Back Review Groups' (to 19 January 2015) Trials Registers, identified relevant studies and reviews and checked their reference lists. SELECTION CRITERIA: Randomised controlled trials (RCTs) of any treatment, or combination of treatments, to prevent or reduce the incidence or severity of low-back pain, pelvic pain or both, related functional disability, sick leave and adverse effects during pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We included 34 RCTs examining 5121 pregnant women, aged 16 to 45 years and, when reported, from 12 to 38 weeks' gestation. Fifteen RCTs examined women with low-back pain (participants = 1847); six examined pelvic pain (participants = 889); and 13 examined women with both low-back and pelvic pain (participants = 2385). Two studies also investigated low-back pain prevention and four, low-back and pelvic pain prevention. Diagnoses ranged from self-reported symptoms to clinicians' interpretation of specific tests. All interventions were added to usual prenatal care and, unless noted, were compared with usual prenatal care. The quality of the evidence ranged from moderate to low, raising concerns about the confidence we could put in the estimates of effect. For low-back painResults from meta-analyses provided low-quality evidence (study design limitations, inconsistency) that any land-based exercise significantly reduced pain (standardised mean difference (SMD) -0.64; 95% confidence interval (CI) -1.03 to -0.25; participants = 645; studies = seven) and functional disability (SMD -0.56; 95% CI -0.89 to -0.23; participants = 146; studies = two). Low-quality evidence (study design limitations, imprecision) also suggested no significant differences in the number of women reporting low-back pain between group exercise, added to information about managing pain, versus usual prenatal care (risk ratio (RR) 0.97; 95% CI 0.80 to 1.17; participants = 374; studies = two). For pelvic painResults from a meta-analysis provided low-quality evidence (study design limitations, imprecision) of no significant difference in the number of women reporting pelvic pain between group exercise, added to information about managing pain, and usual prenatal care (RR 0.97; 95% CI 0.77 to 1.23; participants = 374; studies = two). For low-back and pelvic painResults from meta-analyses provided moderate-quality evidence (study design limitations) that: an eight- to 12-week exercise program reduced the number of women who reported low-back and pelvic pain (RR 0.66; 95% CI 0.45 to 0.97; participants = 1176; studies = four); land-based exercise, in a variety of formats, significantly reduced low-back and pelvic pain-related sick leave (RR 0.76; 95% CI 0.62 to 0.94; participants = 1062; studies = two).The results from a number of individual studies, incorporating various other interventions, could not be pooled due to clinical heterogeneity. There was moderate-quality evidence (study design limitations or imprecision) from individual studies suggesting that osteomanipulative therapy significantly reduced low-back pain and functional disability, and acupuncture or craniosacral therapy improved pelvic pain more than usual prenatal care. Evidence from individual studies was largely of low quality (study design limitations, imprecision), and suggested that pain and functional disability, but not sick leave, were significantly reduced following a multi-modal intervention (manual therapy, exercise and education) for low-back and pelvic pain.When reported, adverse effects were minor and transient. AUTHORS' CONCLUSIONS: There is low-quality evidence that exercise (any exercise on land or in water), may reduce pregnancy-related low-back pain and moderate- to low-quality evidence suggesting that any exercise improves functional disability and reduces sick leave more than usual prenatal care. Evidence from single studies suggests that acupuncture or craniosacral therapy improves pregnancy-related pelvic pain, and osteomanipulative therapy or a multi-modal intervention (manual therapy, exercise and education) may also be of benefit.Clinical heterogeneity precluded pooling of results in many cases. Statistical heterogeneity was substantial in all but three meta-analyses, which did not improve following sensitivity analyses. Publication bias and selective reporting cannot be ruled out.Further evidence is very likely to have an important impact on our confidence in the estimates of effect and change the estimates. Studies would benefit from the introduction of an agreed classification system that can be used to categorise women according to their presenting symptoms, so that treatment can be tailored accordingly.

Rethinking design parameters in the search for optimal dynamic seating.

Dynamic seating design purports to lessen damage incurred during sedentary occupations by increasing sitter movement while modifying muscle activity. Dynamic sitting is currently defined by O'Sullivan et al. ( 2013a) as relating to 'the increased motion in sitting which is facilitated by the use of specific chairs or equipment' (p. 628). Yet the evidence is conflicting that dynamic seating creates variation in the sitter's lumbar posture or muscle activity with the overall consensus being that current dynamic seating design fails to fulfill its goals. Research is needed to determine if a new generation of chairs requiring active sitter involvement fulfills the goals of dynamic seating and aids cardio/metabolic health. This paper summarises the pursuit of knowledge regarding optimal seated spinal posture and seating design. Four new forms of dynamic seating encouraging active sitting are discussed. These are 1) The Core-flex with a split seatpan to facilitate a walking action while seated 2) the Duo balans requiring body action to create rocking 3) the Back App and 4) Locus pedestal stools both using the sitter's legs to drive movement. Unsubstantiated claims made by the designers of these new forms of dynamic seating are outlined. Avenues of research are suggested to validate designer claims and investigate whether these designs fulfill the goals of dynamic seating and assist cardio/metabolic health. Should these claims be efficacious then a new definition of dynamic sitting is suggested; 'Sitting in which the action is provided by the sitter, while the dynamic mechanism of the chair accommodates that action'.

The efficacy of physiotherapy for the prevention and treatment of prenatal symptoms: a systematic review.

Several studies have described the evidence of prenatal physiotherapy for one symptom, but none has made an overview. We provided a systematic review on the effectiveness of prenatal physiotherapy. A full search was conducted in three electronic databases (Embase, PubMed/MEDLINE and PEDro), selecting randomized controlled trials concerning prenatal physiotherapy. Methodological quality was assessed using the PEDro scale. We identified 1,249 studies and after exclusions 54 studies were included concerning the evidence of prenatal physiotherapy. The majority of studies indicated a preventative effect for low back pain/pelvic girdle pain, weight gain, incontinence, and perineal massage. For leg edema, fear, and prenatal depression, the efficacy was only based on one study per symptom. No preventative effect was found for gestational diabetes, while literature concerning gestational hypertensive disorders was inconclusive. Regarding the treatment of low back pain/pelvic girdle pain and weight gain, most therapies reduced pain and weight respectively. Evidence regarding exercises for diabetes was contradictory and only minimally researched for incontinence. Foot massage and stockings reduced leg edema and leg symptoms respectively. Concerning gestational hypertensive disorders, perineal pain, fear, and prenatal depression no treatment studies were performed. The majority of studies indicated that prenatal physiotherapy played a preventative role for low back pain/pelvic girdle pain, weight gain, incontinence, and pelvic pain. Evidence for the remaining symptoms was inclusive or only minimally investigated. Regarding treatment, most studies indicated a reduction of low back pain/pelvic girdle pain, weight gain, incontinence, and the symptoms of leg edema.

The effect of vitamin D on nonspecific low back pain.

BACKGROUND: Nonspecific low back pain is known as one of the most common reasons for chronic low back pain (CLBP) that burdens healthcare systems with high costs. According to a hypothesis, CLBP has been associated with vitamin D3 deficiency, the goal of this study is to evaluate the effect of vitamin D3 administration on improvements in CLBP. MATERIALS AND METHODS: This double blind randomized clinical trial included 53 patients aged between 18-40 years with nonspecific CLBP. Pain was measured using the pain visual analogue scale score (VAS), and serum 25-OH-vitamin D level was measured using an enzyme-linked immunosorbent assay kit. The patients were randomly divided into two groups based on sex and weight. Pearl of vitamin D(3) (50 000 IU) or placebo was administered orally every week for 8 weeks. Data were analyzed via SPSS 17th edition software using two-tailed paired t-test and chi-square test. RESULTS: There were 26 and 27 patients in drug and placebo groups respectively. Out of 53 subjects, 75.47% were female. There was no statistically significant difference in the mean age, sex, and mean weight between the two groups. The mean serum 25-OH-vitamin D level was 18.86 ± 9.24 nmol/L on the first visit. After 8 weeks of intervention, the mean serum 25-OH-vitamin D level changed from 17.88 ± 9.04 to 27.52 ± 9.04 (P = 0.043) and from 19.81 ± 9.60 to 18.91 ± 7.84 (P = 0.248) in drug and placebo groups, respectively. The mean VAS score for pain decreased from 5.42 ± 1.65 to 3.03 ± 3.14 (P = 0.001) and from 6.42 ± 1.62 to 3.11 ± 3.08 (P = 0.001) among drug and placebo groups, respectively. The mean changes in chronic pain were 2.38 ± 2.62, 95% confidence interval (CI) = 1.32-3.44 in the drug group and 3.33 ± 3.67, 95%CI = 0.61-2.55 in the placebo group. No significant statistical difference between the two groups was observed. CONCLUSION: According to our results, both vitamin D(3) and placebo treatments improved CLBP and there was no significant difference between vitamin D(3) and placebo groups.

Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management.

Low back pain is a common musculoskeletal symptom in pregnancy that can present as lumbar pain or pelvic girdle pain, with significant physical and psychosocial implications. Pelvic girdle pain is more prevalent and results in greater disability than lumbar pain. It is possible to distinguish between these two conditions from a detailed history based on the site of the pain, its intensity, disability and pain provocation tests. Management of low back pain in pregnancy is conservative, with physical exercise for lumbar pain and minimising activities that exacerbate pain, analgesics and bed rest for pelvic girdle pain, as well as avoiding abduction beyond the pain-free zone in labour. There is evidence that stabilising exercises in patients with pelvic girdle pain postpartum have a beneficial effect. Other treatment modalities that have been shown to be safe and effective include pelvic belts, transcutaneous electrical nerve stimulation, spinal manipulative therapy, acupuncture and complementary therapy with yoga. Other orthopaedic complications in pregnancy such as carpal tunnel syndrome, pubic symphysis rupture, transient osteoporosis and osteonecrosis are usually self-limiting with a satisfactory outcome. However, a lack of awareness and failure to recognise these complications can result in long-term morbidity. Knowledge of the preoperative diagnostic investigations, surgical approaches and intraoperative positioning of the mother to avoid gravid uterus compression is vital in orthopaedic emergencies such as lumbar disc herniation, cauda equina syndrome, fractures and acute compartment syndrome of the lower limb to ensure a safe maternal and fetal outcome and to prevent serious disability. Pregnancy is not contraindicated in women with pre-existing orthopaedic complications such as kyphoscoliosis and total hip arthroplasty as there is no evidence to suggest increased maternal or fetal risks.