No diagnostic utility of antibody patterns against Klebsiella pneumoniae capsular serotypes in patients with axial spondyloarthritis vs. patients with non-specific low back pain: a cross-sectional study.

OBJECTIVES: To investigate whether antibody response patterns against Klebsiella pneumoniae capsular serotypes can discriminate patients with axial spondyloarthritis (axSpA) from patients with non-specific low back pain (LBP). METHOD: Immunoglobulin (Ig)G and IgA antibodies against K. pneumoniae capsular serotypes K2, K26, K36, and K50 were measured, and antibody seropositivity compared between groups and analysed for patient correlation in five different groups: (a) 96 patients fulfilling the Assessment of SpondyloArthritis International Society (ASAS) classification criteria for axSpA; (b) 38 patients with either a positive magnetic resonance imaging (MRI) scan as defined by ASAS or a positive human leucocyte antigen (HLA)-B27 status plus one clinical SpA feature, characterized as 'non-axSpA'; (c) 82 non-specific LBP patients; (d) 40 healthy blood donors and (e) 43 patients with diagnosed ankylosing spondylitis (AS) served as the negative and positive control groups. RESULTS: There was no difference in IgG and IgA seropositivity against all serotypes between the axSpA, non-axSpA, and LBP groups. No significant correlations were found between anti-Klebsiella antibodies and age, gender, HLA-B27, or high-sensitivity C-reactive protein (hsCRP). IgG seropositivity against K50 was more frequent in AS (25.6%) than in axSpA (13.5%, p < 0.05). axSpA patients with radiographic sacroiliitis and AS controls concordantly had the highest frequency of seropositivity for ≥ 2 serotypes (21%). CONCLUSIONS: The antibody patterns against K. pneumoniae serotypes K2, K26, K36, and K50 did not discriminate between early axSpA and non-specific LBP.

The discriminative value of inflammatory back pain in patients with persistent low back pain.

OBJECTIVES: To estimate the prevalence of inflammatory back pain (IBP) characteristics and analyse the discriminative value of IBP relative to axial spondyloarthritis (SpA) according to the Assessment of SpondyloArthritis international Society (ASAS) criteria. METHOD: Patients who had low back pain for > 3 months were selected from a cohort of secondary care patients aged 18-40 years. Data included information on SpA features, human leucocyte antigen (HLA)-B27 typing, C-reactive protein (CRP) level, magnetic resonance imaging (MRI) of the sacroiliac joints, and self-reported IBP questions covering the pain characteristics included in the Calin, Berlin, and ASAS IBP definitions. RESULTS: Of the 759 included patients, 99% [95% confidence interval (CI) 98-100] had at least one IBP characteristic. The prevalence of the single IBP characteristics ranged from 10% (95% CI 7-12) for 'pain worst in the morning' to 79% (95% CI 76-82) for 'morning stiffness'. Two-thirds of the patients (67%, 95% CI 63-70), met at least one of the three IBP definitions. In all, 86 (11%) were classified as 'SpA according to ASAS'. All three IBP definitions were significantly associated with 'SpA according to ASAS'; however, the discriminative value was low, with sensitivity, specificity, and balanced accuracy values of 64, 50, and 57% for Calin, 59, 60, and 60% for Berlin, and 35, 79, and 57% for ASAS IBP definitions, respectively. CONCLUSIONS: In this study population, IBP characteristics were in general common and the discriminative value was low, as IBP could not differentiate patients with SpA according to ASAS criteria from patients with other causes of back pain.

No evidence for presence of bacteria in modic type I changes.

BACKGROUND: Recent studies suggest an association between sciatica and Propionibacterium acnes. "Modic type I changes" in the vertebrae are closely associated with sciatica and lower back pain, and recent studies have questioned the ability of conventional magnetic resonance imaging (MRI) to differentiate between degenerative Modic type I changes and vertebral abnormalities caused by infection. PURPOSE: To test whether bacteria could be cultured from biopsies of Modic type I changes. MATERIAL AND METHODS: Twenty-four consecutive patients with Modic type I changes in lumbar vertebrae had a biopsy taken from the affected vertebra by a strict aseptic procedure. The biopsy was split into two specimens, which were inoculated into thioglycolate agar tubes in the surgical theatre and transported to the microbiology laboratory. In the laboratory, one specimen was streaked onto plates and analyzed for anaerobic and aerobic culture. The other tube was left unopened and incubated directly. Plates and tubes were incubated for 2 weeks and observed for visible growth. RESULTS: None of the biopsies yielded growth of anaerobic bacteria. In one patient, both biopsies yielded growth of Staphylococcus epidermidis, and in another patient coagulase-negative staphylococci were isolated from one biopsy. Both patients received oral antibiotics without convincing effect on symptoms. CONCLUSION: Our results showed no evidence of bacteria in vertebrae with Modic type I changes. The isolation of staphylococci from two patients probably represented contamination.

The reproducibility of quantitative measurements in lumbar magnetic resonance imaging of children from the general population.

STUDY DESIGN: Quantitative lumbar magnetic resonance imaging (MRI) measurements in children were taken twice and analyzed for intra- and intertester reproducibility. OBJECTIVE: To evaluate the reproducibility of a variety of lumbar quantitative measurements taken from MRIs of children from the general population. SUMMARY OF BACKGROUND DATA: The reproducibility of lumbar quantitative measurements has never been tested on MRIs of children from the general population. This is a prerequisite for a reliable anatomic characterization of the immature spine in normal and pathologic conditions. METHODS: Lumbar quantitative measurements from 40 T2-weighted lumbar (L1-S1) MRIs of children from the general population were taken twice by 1 tester for intratester reproducibility and compared with the same measurements (L4-S1) of the same MRIs taken by a second tester for intertester reproducibility. The following parameters were measured using the iQ-VIEW system (IMAGE Information Systems Ltd., version 1.2.2, Plauen, Germany): Linear measurements--zygoappophyseal facets and interfacet widths, and vertebral body (VB), pedicle and intervertebral discs heights, widths, and lengths. Angular measurements--zygoappophyseal tranverse superior facet angles, sagittal VB, and disc wedging, lumbar lordosis, and sacral inclination. Statistical analysis included the concordance correlation coefficient (CCC), and Bland and Altman's limits of agreement (LOA). RESULTS: A total of 6160 measurements were analyzed. Good to excellent intratester reproducibility (0.75 < or =CCC < or =0.99) was indicated for all linear measurements (except for pedicle heights) (LOA: -4.76; 5.74 mm) and for angular measurements related to the facets orientation, lumbar lordosis, and sacral inclination (LOA: 11.22 degrees ; 12.34 degrees). VB and disc sagittal wedging manifested poor intratester reproducibility (CCC < 0.75). Good to excellent intertester reproducibility was indicated for 70% of all linear measurements (LOA: -5.83; 4.59 mm) and for all angular measurements in the lumbar spine (L4-S1) (LOA: -9.96 degrees ; 14.62 degrees) except for VB and disc sagittal wedging at L5 (CCC < 0.75). CONCLUSION: Quantitative lumbar MRI measurements in children from the general population were found to be reproducible indicating a good visualization of immature vertebral anatomic margins on MRIs and an accurate definition of the measurement protocol.

Poor outcome in patients with spine-related leg or arm pain who are involved in compensation claims: a prospective study of patients in the secondary care sector.

OBJECTIVE: To investigate whether poor outcome after spinal pain episodes is linked with the claim process and, if so, whether this link is independent of other potential risk factors of chronic pain and disability in patients with spine-related leg or arm pain. METHODS: A 1-year prospective outcome study with internal control groups in two Danish secondary care, public, multidisciplinary, non-surgical spine clinics. Patients with low back pain (LBP) radiating to the leg (n = 1243) or with neck and arm pain thought to emanate from the neck (n = 202) were referred to the clinics by their general practitioners. Rheumatologists, physiotherapists, and nurses examined, treated, and informed the patients based on cognitive principles. Follow-up data were collected with a postal questionnaire. Claim, defined as seeking some sort of financial compensation or filing any sort of financial claim, such as workers' compensation, was the main independent variable. Potential confounders examined were: age, sex, social class, smoking, duration and severity of pain and disability. The main outcome measures were: global assessment (main outcome variable), pain, disability, and intake of analgesics. RESULTS: Financial claims were registered by 31% of patients. After adjustment for covariates, the odds ratio for claim and no improvement was calculated to be 4.2 (95% CI 2.8-6.2) for the LBP/leg patients and 17.4 (95% CI 5.1-60.1) for the neck/arm patients. CONCLUSION: A claim for financial compensation is strongly and independently linked with a poor prognosis for Danish patients with pain radiating from the low-back or neck.

Antibiotic treatment in patients with low-back pain associated with Modic changes Type 1 (bone oedema): a pilot study.

OBJECTIVE: The aim of this study was to assess the clinical effect of antibiotic treatment in a cohort of patients with low-back pain (LBP) and Modic changes Type 1 (bone oedema) following a lumbar herniated disc. DESIGN: This was a prospective uncontrolled trial of 32 LBP patients who had Modic changes and were treated with Amoxicillin-clavulanate (500 mg/125 mg) 3 x day for 90 days. All patients had previously participated in a randomised controlled trial (RCT) that investigated active conservative treatment for a lumbar herniated disc (n = 166). All patients in that RCT who had Modic changes and LBP at 14 months follow-up (n = 37) were invited to participate in this subsequent antibiotic trial but five did not meet the inclusion criteria. RESULTS: 29 patients completed the treatment, as three patients dropped out due to severe diarrhoea. At the end of treatment and at long-term follow-up (mean 10.8 months) there was both clinically important and statistically significant (p

The Copenhagen Neck Functional Disability Scale: a study of reliability and validity.

OBJECTIVE: To determine whether a newly developed disability scale for patients with neck pain demonstrated acceptable reliability and validity. METHODS: Testing was conducted using three different samples of patients with neck pain (n = 162). Test-retest reliability of the scale was carried out on the same day with one sample (n = 39), and between-day reliability was carried out with another (n = 21). Differential item functioning with regard to the influence of gender and age was carried out with these two patient groups, as was construct validity. Responsiveness was measured using patients participating in a clinical trial involving patients with chronic neck pain (n = 102). Additionally, scale scores were compared with a wide range of physical measurements using the patients in the clinical trial. RESULTS: Short-term, between-day and postal questionnaire reliability coefficients were all extremely high. The Cronbach's alpha coefficient for internal consistency was 0.9 for the entire scale, and the coefficients for individual items were all greater than 0.88. Disability scale scores correlated strongly to pain scores as well as to doctor and patient global assessments, indicating good construct validity. Relative changes in disability scores demonstrated a moderately strong correlation to changes in pain scores after treatment. Scale scores correlated weakly to all physical measurements. CONCLUSIONS: The disability scale demonstrated excellent practicality and reliability. The scale accurately reflects patient perceptions regarding functional status and pain as well as doctor's global assessment and is responsive to change over long periods of time. We feel that this scale can be a valuable tool for the assessment of patients in future clinical trials and quality of care studies.

[Back pain--from the viewpoint of medical technology. Danish National Board of Health]. / Ondt i ryggen--set i et MTV-perspektiv.

The appearance of various consensus reports, guidelines, Cochrane Centers, and other evidence-based medicine initiatives during the past decade has resulted in marked improvement in the rational utilisation of available knowledge of attitudes toward the issue of low back pain (LBP). Moreover, owing to the ready access to updated data bases, this knowledge has been disseminated with incredible speed. In the spring of 1995, the Danish National Board of Health in Denmark convinced a multidisciplinary team of back specialists to tailor data available in the international reports for Danish needs. The article outlines the findings of this team, the major recommendations being that providing information is preferable to treatment, that patients should be encouraged to remain active, that physical exercise should be kept up except during the acute phases, that most episodes of LBP are to be considered life events rather than automatic reasons to seek treatment, and that passive treatment should be minimised, though manipulation may be helpful in the short term.

Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial.

OBJECTIVES: To compare the clinical effectiveness of an intensive three-month training programme with a less intensive programme on females suffering from chronic neck/shoulder pain. STUDY DESIGN: A prospective observer-blinded clinical trial including 12-month pretreatment follow-up. SETTING: Patients were referred to the Departments of Rheumatology and Physical Medicine at Hvidovre Hospital by their general practitioners. Training was undertaken at a satellite clinic for physiotherapy of Hvidovre Hospital. SUBJECTS: Female patients aged 18-65 years suffering from chronic neck/shoulder pain for a minimum of six months. INTERVENTION: Patients were examined by a physician in order to exclude serious diseases. They were then randomized to either an intensive neck/shoulder training programme or a programme of lesser intensity but of similar duration. MAIN OUTCOME MEASURES: Scales measuring pain and activities of daily living (ADL) were used, and strength and endurance measurements of the cervical and shoulder muscles were carried out at baseline and completion of the study. Follow-up measurements were carried out by postal questionnaire at 6 and 12 months after inclusion, and included pain, ADL and treatment satisfaction measurements. RESULTS: Seventy-seven patients were included in the trial, of whom 27 (69%) completed the intensive programme and 25 (61%) the lighter programme. Forty-one (>80%) completed the follow-up questionnaires. The patients in the two groups did not differ with regard to age, pain, ADL scores and physical measurements prior to training. Patients in both groups that completed the trial demonstrated statistically significant improvements in nearly all of the outcome measurements at completion. ADL scores maintained statistical significance at 12 months in both groups, but pain scores were only significantly improved in the intensive group at 12 months follow-up. There was no statistically significant difference between groups regarding pain or ADL, but overall 50% of all patients showed improvement. CONCLUSIONS: The type of low-tech dynamic training used in either of our two programmes resulted in both subjective and objective improvements in patients suffering from chronic neck/shoulder pain, but there were no statistically significant differences in outcome between the two approaches. The subjective improvements were maintained throughout the follow-up period.

[Lumbar disk prolapse surgery with or without free fat transplantation. A prospective triple-blind randomized study]. / Lumbal diskusprolaps-operation med eller uden fri fedt-transplantation. Prospektivt tripelblindt randomiseret studie.

The aim of this prospective triple-blind randomized study was to determine if a free fat transplant used in operation in lumbar disc herniation could reduce the degree of intraspinal scar tissue and to evaluate whether the scar tissue could lead to symptoms. Ninety-nine patients were subsequently examined after median 376 days. The clinical outcome was scored using the Low Back Pain Rating Scale. Enhanced CT-scanning was assessed regarding the degree of scar tissue and survival of the fat transplant. There was no difference in the clinical outcome between the two groups. Significantly fewer had dural scarring in the group who had a free fat transplantation, but there was no difference regarding the degree of radicular scarring. The transplant was shown on CT-scan at the follow-up examination in 66% of the patients who had a fat transplantation. Free fat transplantation can reduce the degree of dural scar tissue after operation for lumbal disc herniation, but does not result in a clinically better outcome.

First-time operation for lumbar disc herniation with or without free fat transplantation. Prospective triple-blind randomized study with reference to clinical factors and enhanced computed tomographic scan 1 year after operation.

STUDY DESIGN: This prospective triple-blind randomized study of 99 patients concerned the use of free fat transplantation for operation for lumbar disc herniation. OBJECTIVE: To subsequently examine the patients after median 376 days who were subjected to enhanced computed tomographic scan. SUMMARY OF BACKGROUND DATA: In studies on experiments with animals, the degree of intraspinal scar tissue has shown to be reduced in connection with free fat transplantation. Scar tissue is seen frequently after operation for lumbar disc herniation, but it is uncertain whether the scar tissue can lead to symptoms. METHODS: The clinical outcome was scored using the Low Back Pain Rating Scale. Enhanced computed tomographic scan was assessed regarding the degree of scar tissue and survival of fat transplant. RESULTS: There was no different in the clinical outcome between the two groups. Significantly fewer patients had dural scarring in the group who had a fat transplantation, but there was no difference regarding the degree of radicular scarring. The transplant was shown on computed tomographic scan at the follow-up examination in 66% of the patients who had a fat transplantation. CONCLUSIONS: Free fat transplantation can reduced the degree of dural scar tissue after operation for lumbar disc herniation but does not result in a clinically better outcome.

Clinical benefit of intensive dynamic exercises for low back pain.

Over the years there has been an apparent contradiction between the widely utilized treatment of low back pain through exercise, and the often apparently disappointing results reported in the scientific literature. Recently published studies have shown that the most important factor regarding the training effects of chronic low back patients is the administration of a high training stimulus (number of repetitions of the exercise, exercise resistance, and the total number of sessions). This would explain why several of the previously published studies regarding training show insignificant results. Simply stated, in many low-dosage or short-time studies, the positive effects of training have not had adequate opportunity to take hold in the chronic low back pain patient. The patient group which has been operated on for disc prolapse often exhibits considerable functional deteriorations post-operatively. Rehabilitation studies have shown that many of these patients also benefit from post-operative rehabilitation including high dosage exercise programs. Exercise programs are generally free of side-effects.

Assessment and exercise in low back pain. With special reference to the management of pain and disability following first time lumbar disc surgery.

Eight articles including 555 low back pain patients have been published. They included the following topics: 1) A ratio interval rating scale (Low Back Pain Rating Scale (RS)) was introduced. The possibility of registering the actual status in low back pain patients including; Back Pain, Sciatica, Functional Disability and Physical Impairment was studied. Methods of evaluating index-scales developed in the field of psychometry were applied in the validation process of RS. RS was found to be both valid and user friendly. 2) Using Low Back Pain Rating Scale the general outcome following first-time lumbar disc surgery was analysed through a survey. The results showed that more than half of the patients still suffered from considerable Back Pain, Sciatica, and Functional Disabilities. Approximately 25% of the patients risked reduced work capabilities, and many receive pensions. 3) By means of a comprehensive statistical analysis of 18 studied preoperative demographic and physical findings, sex, hypoalgesia, smoking and Finneson-index were found to have prognostic value. 4) Attempts at influencing the results obtained from lumbar disc surgery have been tested in 3 randomized trials, including back training and peroperative glucocorticoid administration. 5) Three randomized trials including patients suffering from chronic low back pain (with or without previous lumbar disc surgery) attempted to convey which elements of a training programme provide patients with the greatest effect and the least risk of side-effects. It was concluded that Low Back Pain Rating Scale is a useable assessment instrument in both clinical trials and as a daily quality control instrument of back patients. There is a need of increased patient scrutiny in patient selection prior to lumbar disc surgery. Postoperative rehabilitation should include intensive back training, which has been shown to be of value in behavioural support and restoration of functional deficits. This has resulted in increased work capacities for disc operated patients. The exercise programmes are generally free of side-effects. As regards chronic back pain patients with or without previous lumbar surgery, high dosage exercises with training periods lasting at least 12 to 16 sessions are of crucial importance for success. Exercises should be dynamic and full-range, and carried out following the adage "Don't let the pain be your guide.