Neuromuscular exercise and counseling for treating recurrent low back pain in female healthcare workers-Findings from a 24-month follow-up study of a randomized controlled trial.

BACKGROUND: Female healthcare workers have a high prevalence of low back pain (LBP)-related sickness absence. Here, we report findings of a 24-month follow-up of a previously published 6-month randomized controlled trial (RCT). METHODS: By adopting an RCT with 6 months of intervention and follow-up at 6, 12, and 24 months, we assessed the maintenance of changes in the effectiveness (LBP and fear of pain) of the interventions (neuromuscular exercise [NME], back-care counseling, both combined) using a generalized linear mixed model adjusted for baseline covariates. The incremental cost-effectiveness ratio was calculated in terms of quality-adjusted life years (QALY). A bootstrap technique was used to estimate the uncertainty around a cost-effectiveness acceptability curve. RESULTS: Of the 219 females, 71% had data at 24 months. Between 6 and 24 months, LBP intensity (primary outcome) remained low in all intervention arms (-20% to -48%) compared to the control (-10% to -16%). Pain interfering with work remained low in the combined and exercise arms for up to 24 months. At 24 months, the total costs were lowest in the combined arm (€484 vs. €613-948, p < 0.001), as were the number of back-related sickness absence days (0.16 vs. 1.14-3.26, p = 0.003). The analysis indicated a 95% probability of the combined arm to be cost-effective per QALY gained at €1120. CONCLUSIONS: Six months of weekly NME combined with four counseling sessions was cost-effective for treating LBP and the effect was maintained over 24 months. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01465698, 7/11/2011, prospective.

The role of co-occurring insomnia and mental distress in the association between lumbar disc degeneration and low back pain related disability.

BACKGROUND: Lumbar disc degeneration (LDD) is associated with low back pain (LBP). Although both insomnia and mental distress appear to influence the pain experience, their role in the association between LDD and LBP is uncertain. Our objective was to investigate the role of co-occurring insomnia and mental distress in the association between LDD and LBP-related disability. METHODS: A total of 1080 individuals who had experienced LBP during the previous year underwent 1.5-T lumbar magnetic resonance imaging, responded to questionnaires, and participated in a clinical examination at the age of 47. Full data was available for 843 individuals. The presence of LBP and LBP-related disability (numerical rating scale, range 0-10) were assessed using a questionnaire. LDD was assessed by a Pfirrmann-based sum score (range 0-15, higher values indicating higher LDD). The role of insomnia (according to the five-item Athens Insomnia Scale) and mental distress (according to the Hopkins Symptom Check List-25) in the association between the LDD sum score and LBP-related disability was analyzed using linear regression with adjustments for sex, smoking, body mass index, education, leisure-time physical activity, occupational physical exposure, Modic changes, and disc herniations. RESULTS: A positive association between LDD and LBP-related disability was observed among those with absence of both mental distress and insomnia (adjusted B = 0.132, 95% CI = 0.028-0.236, p = 0.013), and among those with either isolated mental distress (B = 0.345 CI = 0.039-0.650, p = 0.028) or isolated insomnia (B = 0.207, CI = 0.040-0.373, p = 0.015). However, among individuals with co-occurring insomnia and mental distress, the association was not significant (B = -0.093, CI = -0.346-0.161, p = 0.470). CONCLUSIONS: LDD does not associate with LBP-related disability when insomnia and mental distress co-occur. This finding may be useful when planning treatment and rehabilitation that aim to reduce disability among individuals with LDD and LBP. Future prospective research is warranted.

Role of the interaction between lumbar kinematics and accelerometer-measured physical activity in bodily pain, physical functioning and work ability among health care workers with low back pain.

The aim of this study was to examine the associations of spinal kinematics and physical activity (PA) with bodily pain, physical functioning, and work ability among health care workers with low back pain (LBP). Spinal kinematics and PA were measured with a wireless Inertial Measurement Unit system (ValedoMotion®) and a waist-worn tri-axial accelerometer (Hookie AM20), respectively. Their association was assessed in relation to Work Ability Index (WAI), bodily pain and physical functioning (RAND-36) in 210 health care workers with recurrent LBP. Greater lumbar movement variability/less deterministic lumbar movement (in angular velocity) during a "Pick Up a Box" functional task was correlated with higher amounts of step counts (r = -0.29, p = 0.01) and moderate PA (r = -0.24, p = 0.03). A higher amount of PA (p = 0.03) as well as less movement control impairment (p = 0.04) and movement variability (p = 0.03) were associated with greater work ability, whilst greater vigorous PA was the only parameter to explain higher physical functioning (p = 0.02). PA and movement variability were relative to each other to explain bodily pain (p = 0.01). These findings show the importance of considering the interaction between lumbar kinematics and physical activity while planning strategies to improve bodily pain, physical functioning and work ability among health care workers with LBP.

Treatment of Sciatica and Lumbar Radiculopathy with an Intervertebral Foramen Opening Protocol: Pilot Study in a Hospital Emergency and In-patient Setting.

AIMS: Perform a pilot study of a static nerve root foramen opening protocol for lumbar radiculopathy from disc hernia in an emergency hospital setting to establish if patients could execute the protocol, consistency would occur across outcomes, superior outcomes would occur in the experimental group, and if the protocol would be safe. METHODS: Patients with sciatica arrived of their own volition at the local emergency hospital department, were admitted for care and were randomized into two groups: 1) control (n = 10): forward bending, walking, and medication; and 2) experimental (n = 10) as control subjects, plus a static lumbar foramen opening protocol using flexion and contralateral lateral flexion (side-lying). Outcomes were back and leg pain (i.e. visual analog scale), disability (i.e. EuroQol5D5L and Oswestry) and straight leg raise. RESULTS: At admission, the baseline outcome variables between groups were not significantly different. All patients had moderate or large disc hernias on MRI and 75% had neurological deficits in electrophysiology. At discharge, patients in the experimental group were significantly better (p ≤ .05) than controls in all outcomes. Statistical analysis of the outcomes produced greater significance, effect sizes and minimal clinically important differences in the experimental group. Patients in the experimental group consumed less medication than control patients (21% versus 79%), including less than half the opioids (tramadol). No adverse responses occurred. CONCLUSIONS: Patients could perform the protocol and superior outcomes occurred, with no adverse effects. The data support more detailed study of therapeutic efficacy, days in hospital, costs, conversion to surgery, and medication consumption, including opioids.

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.

Factors predicting long-term physical activity of breast cancer survivors. 5-year-follow-up of the BREX exercise intervention study.

BACKGROUND: The benefits of exercise training are well documented among breast cancer (BC) survivors. Patients decrease their physical activity during treatment, and many fail to regain their previous exercise levels. There is therefore a need to define factors supporting long-term physical activity behavior in this patient group, to target supporting interventions aimed at preventing the decline in physical activity (PA). AIM: The aim of this study was to determine physical and psychosocial factors explaining long-term physical activity after the adjuvant treatments in BC survivors. METHODS: Four-hundred forty-six BC survivors followed for 5-years within a randomized exercise trial participated. Factors explaining (1) physical activity after the adjuvant treatments and (2) changes in physical activity in long-term were analyzed using linear regression models and general estimating equation models. Pretreatment leisure-time physical activity (LTPA), demographic, and treatment factors, physical fitness, and quality of life (Qol) at baseline were independent factors. RESULTS: Exercise levels increased during the first year, and thereafter remained mostly stable. Higher LTPA, higher fitness level, better Qol and older age at baseline were associated with higher physical activity level after adjuvant treatments (p < .001) in multivariate analysis. Higher levels of fatigue (p < .008) and better emotional functioning (p = .017) at baseline were the main factors associated with increased physical activity during the follow-up. CONCLUSION: Previous exercise habits and Qol after adjuvant chemo-, and radiotherapy were the strongest determinants of long-term physical activity levels in breast cancer survivors. Patients with better emotional functioning increased their exercise activity most as did those patients with higher fatigue levels at baseline. Patients suffering from fatigue after adjuvant treatment managed to increase their exercise levels, in contrast to patients with low emotional functioning, and may benefit from physical exercise interventions. Emotionally deprived patients may benefit from psychosocial support to regain their previous exercise levels.

Depressive Symptoms Are Associated With Decreased Quality of Life and Work Ability in Currently Working Health Care Workers With Recurrent Low Back Pain.

OBJECTIVE: This study investigates the association between depressive symptoms and multisite pain and health-related quality of life and work ability in currently employed health care workers with recurrent low back pain (LBP). METHODS: Multisite pain, depressive symptoms, quality of life, and work ability were assessed by validated questionnaires. A generalized linear model was used for statistical analysis. RESULTS: Notably, 28% of female health care workers with LBP had at least moderate levels of depressive symptoms. Depressive symptoms were significantly associated with decreased health-related quality of life and work ability. Multisite pain was not significantly associated with work ability. CONCLUSIONS: Depressive symptoms are relatively common in female health care workers with LBP, and treatment of these symptoms may be crucial to improve their work ability.

Association of lumbar disc degeneration with low back pain in middle age in the Northern Finland Birth Cohort 1966.

BACKGROUND: Although it has been suggested that lumbar disc degeneration (LDD) is a significant risk factor for low back pain (LBP), its role remains uncertain. Our objective was to clarify the association between LDD and LBP and whether mental distress modifies the association. METHODS: Participants of a birth cohort underwent 1.5-T lumbar magnetic resonance imaging at the age of 47. The association between the sum score of LDD (Pfirrmann classification, range 0-15) and LBP (categorized into "no pain", "mild-to-moderate pain", "bothersome-and-frequent pain") was assessed using logistic regression analysis, with sex, smoking, body mass index, physical activity, occupational exposure, education, and presence of Modic changes and disc herniations as confounders. The modifying role of mental distress (according to the Hopkins Symptom Check List-25 [HSCL-25], the Beck Depression Inventory and the Generalized Anxiety Disorder Scale) in the association was analyzed using linear regression. RESULTS: Of the study population (n = 1505), 15.2% had bothersome and frequent LBP, and 29.0% had no LBP. A higher LDD sum score increased the odds of belonging to the "mild-to-moderate pain" category (adjusted OR corresponding to an increase of one point in the LDD sum score 1.11, 95% CI 1.04-1.18, P = 0.003) and the "bothersome-and-frequent pain" category (adjusted OR 1.20, 95% CI 1.10-1.31, P < 0.001), relative to the "no pain" category. Mental distress significantly modified the association between LDD and LBP, as a linear positive association was consistently observed among individuals without mental distress according to HSCL-25 (adjusted B 0.16, 95% CI 0.07-0.26, P < 0.001), but not among individuals with higher mental distress. CONCLUSIONS: LDD was significantly associated with both mild-to-moderate and bothersome-and-frequent LBP. However, the co-occurrence of mental distress diminished the association between LDD and LBP bothersomeness. Our results strongly suggest that mental symptoms affect the pain experience.

Changes in elbow flexion EMG morphology during adjustment of deep brain stimulator in advanced Parkinson's disease.

OBJECTIVE: Deep brain stimulation (DBS) is an effective treatment for motor symptoms of advanced Parkinson's disease (PD). Currently, DBS programming outcome is based on a clinical assessment. In an optimal situation, an objectively measurable feature would assist the operator to select the appropriate settings for DBS. Surface electromyographic (EMG) measurements have been used to characterise the motor symptoms of PD with good results; with proper methodology, these measurements could be used as an aid to program DBS. METHODS: Muscle activation measurements were performed for 13 patients who had advanced PD and were treated with DBS. The DBS pulse voltage, frequency, and width were changed during the measurements. The measured EMG signals were analysed with parameters that characterise the EMG signal morphology, and the results were compared to the clinical outcome of the adjustment. RESULTS: The EMG signal correlation dimension, recurrence rate, and kurtosis changed significantly when the DBS settings were changed. DBS adjustment affected the signal recurrence rate the most. Relative to the optimal settings, increased recurrence rates (median ± IQR) 1.1 ± 0.5 (-0.3 V), 1.3 ± 1.1 (+0.3 V), 1.7 ± 0.4 (-30 Hz), 1.7 ± 0.8 (+30 Hz), 2.0 ± 1.7 (+30 µs), and 1.5 ± 1.1 (DBS off) were observed. With optimal stimulation settings, the patients' Unified Parkinson's Disease Rating Scale motor part (UPDRS-III) score decreased by 35% on average compared to turning the device off. However, the changes in UPRDS-III arm tremor and rigidity scores did not differ significantly in any settings compared to the optimal stimulation settings. CONCLUSION: Adjustment of DBS treatment alters the muscle activation patterns in PD patients. The changes in the muscle activation patterns can be observed with EMG, and the parameters calculated from the signals differ between optimal and non-optimal settings of DBS. This provides a possibility for using the EMG-based measurement to aid the clinicians to adjust the DBS.

Prognostic factors for pain chronicity in low back pain: a systematic review.

Low back pain is the leading cause for years lived in disability. Most people with acute low back pain improve rapidly, but 4% to 25% of patients become chronic. Since the previous systematic reviews on the subject, a large number of new studies have been conducted. The objective of this article was to review the evidence of the prognostic factors behind nonspecific chronic low back pain. A systematic literature search was performed without date limitation from the MEDLINE, Cochrane library, and Medic databases. Specific inclusion criteria were used, and risk factors before the onset of chronic symptoms were searched. Study quality was assessed by 2 independent reviewers. One hundred eleven full articles were read for potential inclusion, and 25 articles met all the inclusion criteria. One study was rated as good quality, 19 studies were rated as fair quality, and 5 articles were rated as poor quality. Higher pain intensity, higher body weight, carrying heavy loads at work, difficult working positions, and depression were the most frequently observed risk factors for chronic low back pain. Maladaptive behavior strategies, general anxiety, functional limitation during the episode, smoking, and particularly physical work were also explicitly predictive of chronicity. According to this systematic review, several prognostic factors from the biomechanical, psychological and psychosocial point of view are significant for chronicity in low back pain.

Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion.

BACKGROUND: The straight leg raise (SLR) is the most commonly applied physical tests on patients with sciatica, but the sensitivity and specificity ratings for disc hernia and neural compression leave areas for improvement. Hip internal rotation tensions the lumbosacral nerve roots and ankle dorsiflexion tensions the sciatic nerve along its course. We added these movements to the SLR (extended SLR = ESLR) as structural differentiators and tested inter-rater reliability in patients with LBP, with and without sciatica. METHODS: Forty subjects were recruited to the study by the study controller (SC), 20 in the sciatic group and in the control group. Two independent examiners (E1&E2) performed the ESLR and did not communicate to the subjects other than needed to determine the outcome of the ESLR. First, SLR was performed traditionally until first responses were evoked. At this hip flexion angle, a location-specific structural differentiation was performed to confirm whether the emerged responses were of neural origin. Cohen's Kappa score (CK) for interrater reliability was calculated for ESLR result in detection of sciatic patients. Also, the examiners' ESLR results were compared to the traditional SLR results. RESULTS: The interrater agreement between Examiner 1 and Examiner 2 for the ESLR was 0.85 (p < 0.001, 95%CI: 0.71-0.99) translating to almost perfect agreement as measured by Cohen's Kappa When the ESLR was compared to the traditional SLR, the overall agreement rate was 75% (30/40). Kappa values between the traditional SLR and the E1's or E2's ESLR results were 0.50 (p < 0.0001; 95%CI 0.27-0.73) and 0.54 (p < 0.0001; 95%CI 0.30-0.77), respectively. CONCLUSIONS: ESLR with the addition of location-specific structural differentiation is a reliable and repeatable tool in discerning neural symptoms from musculoskeletal in patients with radiating low back pain. We recommend adding these movements to the standard SLR with aim of improving diagnostic ability.

Fear-avoidance beliefs are associated with exercise adherence: secondary analysis of a randomised controlled trial (RCT) among female healthcare workers with recurrent low back pain.

BACKGROUND: Exercise is recommended for the treatment and management of low back pain (LBP) and the prevention of chronicity. Exercise adherence has been only modest in intervention studies among people with musculoskeletal pain. Fear-avoidance beliefs (FABs) are known to affect exercise adherence.The purpose was twofold: to examine which bio-psycho-social factors contributed to exercise adherence during a 6-month neuromuscular exercise intervention among female healthcare workers with recurrent LBP, and to investigate how exercising affects FABs at 6 and 12 months' follow-up. METHODS: Some 219 healthcare workers aged 30-55 years with mild-to-moderate re-current non-specific LBP were originally allocated into: 1) exercise, 2) counselling, 3) combined exercise and counselling, and 4) control groups. In the present secondary analysis, groups 1 and 3 (exercise only and exercise+counselling) were merged to be exercisers and groups 2 and 4 were merged to be non-exercisers. Baseline variables of the exercise compliers (≥24 times over 24 weeks; n = 58) were compared to those of the non-compliers (< 1 time/week, 0-23 times; n = 52). The effects of the exercise programme on FABs were analysed by a generalised linear mixed model according to the intention-to-treat principle (exercisers; n = 110 vs non-exercisers; n = 109) at three measurement points (baseline, 6, and 12 months). A per-protocol analysis compared the more exercised to the less exercised and non-exercisers. RESULTS: A low education level (p = 0.026), shift work (p = 0.023), low aerobic (p = 0.048) and musculoskeletal (p = 0.043) fitness, and high baseline physical activity-related FABs (p = 0.019) were related to low exercise adherence. The exercise programme reduced levels of both physical activity- and work-related FABs, and there was a dose response: FABs reduced more in persons who exercised ≥24 times compared to those who exercised 0-23 times. CONCLUSION: Healthcare workers who had lower education and fitness levels, worked shifts, and had high physical activity-related FABs had a lower adherence to the 6-month neuromuscular exercise programme. Exercising with good adherence reduced levels of FABs, which have been shown to be linked with prolonged LBP. Motivational strategies should be targeted at persons with low education and fitness levels and high FABs in order to achieve better exercise adherence.

Neuromuscular exercise reduces low back pain intensity and improves physical functioning in nursing duties among female healthcare workers; secondary analysis of a randomised controlled trial.

BACKGROUND: Low back pain (LBP) is common among healthcare workers, whose work is physically strenuous and thus demands certain levels of physical fitness and spinal control. Exercise is the most frequently recommended treatment for LBP. However, exercise interventions targeted at sub-acute or recurrent patients are scarce compared to those targeted at chronic LBP patients. Our objective was to examine the effects of 6 months of neuromuscular exercise on pain, lumbar movement control, fitness, and work-related factors at 6- and 12-months' follow-up among female healthcare personnel with sub-acute or recurrent low back pain (LBP) and physically demanding work. METHODS: A total of 219 healthcare workers aged 30-55 years with non-specific LBP were originally allocated to four groups (exercise, counselling, combined exercise and counselling, control). The present study is a secondary analysis comparing exercisers (n = 110) vs non-exercisers (n = 109). Exercise was performed twice a week (60 min) in three progressive stages focusing on controlling the neutral spine posture. The primary outcome was intensity of LBP. Secondary outcomes included pain interfering with work, lumbar movement control, fitness components, and work-related measurements. Between-group differences were analysed with a generalised linear mixed model according to the intention-to-treat principle. Per-protocol analysis compared the more exercised to the less exercised and non-exercisers. RESULTS: The mean exercise attendance was 26.3 (SD 12.2) of targeted 48 sessions over 24 weeks, 53% exercising 1-2 times a week, with 80% (n = 176) and 72% (n = 157) participating in 6- and in 12-month follow-up measurements, respectively. The exercise intervention reduced pain (p = 0.047), and pain interfering with work (p = 0.046); improved lumbar movement control (p = 0.042), abdominal strength (p = 0.033) and physical functioning in heavy nursing duties (p = 0.007); but had no effect on other fitness and work-related measurements when compared to not exercising. High exercise compliance resulted in less pain and better lumbar movement control and walking test results. CONCLUSION: Neuromuscular exercise was effective in reducing pain and improving lumbar movement control, abdominal strength, and physical functioning in nursing duties compared to not exercising.

Normalization of Spinal Cord Displacement With the Straight Leg Raise and Resolution of Sciatica in Patients With Lumbar Intervertebral Disc Herniation: A 1.5-year Follow-up Study.

STUDY DESIGN: A controlled radiologic follow-up study. OBJECTIVE: The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow-up time accompany changes in clinical symptoms. SUMMARY OF BACKGROUND DATA: Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH. METHODS: Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms. RESULTS: Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self-reported clinical symptoms. CONCLUSION: To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects. LEVEL OF EVIDENCE: 2.

The approach of physiatrists to low back pain across Europe.

BACKGROUND: Low back pain (LBP) is the most common type of musculoskeletal pain, thus it is one of the most commonly encountered conditions in Physical and Rehabilitation Medicine. The physicians who are primarily responsible for the nonsurgical management of LBP are physiatrists. OBJECTIVE: The present study aimed to investigate the approaches of physiatrists to low back pain across Europe. Preferences, tendencies, and priorities in the diagnosis, management, and treatment of LBP, as well as the epidemiological data pertaining to LBP in PRM practice were evaluated in this Europe-wide study. METHODS: The study was conducted under the control of the European Society of Physical and Rehabilitation Medicine (ESPRM) Musculoskeletal Disorders Research Committee. A total of 576 physiatrists from most European countries participated in the survey. RESULTS: The results show that physiatrists frequently deal with patients with LBP in their daily practice. Most patients are not referred to other departments and are treated with various conservative methods. Less than one-fifth of patients are primarily referred for surgery. The physiatrists believe that a clear diagnosis to account for cases of low back pain is rarely established. The most common diagnosis is discopathy. History and physical examination remain the most valuable clinical evaluation tools for low back pain according to physiatrists. Less than half the patients require a magnetic resonance imaging. Non-steroidal anti-inflammatory drugs are the most commonly prescribed drugs for low back pain. Exercise, back care information, and physical therapy are the preferred conservative treatments. More than half of the physiatrists offer interventional treatments to patients with low back pain. CONCLUSION: The present study is a preliminary report that presents the attitudes of European physiatrists in the management of low back pain. Further researches are warranted to standardize the conservative management of LBP.

Effectiveness and cost-effectiveness of neuromuscular exercise and back care counseling in female healthcare workers with recurrent non-specific low back pain: a blinded four-arm randomized controlled trial.

BACKGROUND: Registered healthcare workers worldwide have a high prevalence of work-related musculoskeletal disorders, particularly of the back. Multidisciplinary interventions among these workers have improved fear avoidance beliefs, but not low back pain (LBP) and related sickness absences, cost-effectiveness studies are scarce. Our purpose was to investigate the effectiveness and cost-effectiveness of three intervention-arms (combined neuromuscular exercise and back care counselling or either alone) compared with non-treatment. METHODS: We randomly assigned female healthcare workers with recurrent non-specific LBP to one of four study-arms: Combined neuromuscular exercise and back care counseling; Exercise; Counseling; and no intervention Control. We assessed the effectiveness of the interventions on intensity of LBP, pain interfering with work and fear avoidance beliefs against the Control, and calculated the incremental cost-effectiveness ratios for sickness absence and QALY. RESULTS: We conducted three sub-studies in consecutive years of 2011, 2012, and 2013 to reach an adequate sample size. All together 219 women were randomized within each sub-study, of whom 74 and 68% had adequate questionnaire data at 6 and 12 months, respectively. No adverse events occurred. Compliance rates varied between intervention-arms. After 12 months, the Combined-arm showed reduced intensity of LBP (p = 0.006; effect size 0.70, confidence interval 0.23 to 1.17) and pain interfering with work (p = 0.011) compared with the Control-arm. Work-related fear of pain was reduced in both the Combined- (p = 0.003) and Exercise-arm (p = 0.002). Physical activity-related fear was reduced only in the Exercise-arm (p = 0.008). During the study period (0-12 months) mean total costs were lowest in the Combined-arm (€476 vs. €1062-€1992, p < 0.001) as were the mean number of sickness absence days (0.15 vs. 2.29-4.17, p = 0.025). None of the intervention-arms was cost-effective for sickness absence. There was 85% probability of exercise-arm being cost-effective if willing to pay €3550 for QALY gained. CONCLUSIONS: Exercise once a week for 6 months combined with five sessions of back care counseling after working hours in real-life settings effectively reduced the intensity of LBP, work interference due to LBP, and fear of pain, but was not cost-effective. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01465698 November 7, 2011 (prospective).

Levodopa-Induced Changes in Electromyographic Patterns in Patients with Advanced Parkinson's Disease.

Levodopa medication is the most efficient treatment for motor symptoms of Parkinson's disease (PD). Levodopa significantly alleviates rigidity, rest tremor, and bradykinesia in PD. The severity of motor symptoms can be graded with UPDRS-III scale. Levodopa challenge test is routinely used to assess patients' eligibility to deep-brain stimulation (DBS) in PD. Feasible and objective measurements to assess motor symptoms of PD during levodopa challenge test would be helpful in unifying the treatment. Twelve patients with advanced PD who were candidates for DBS treatment were recruited to the study. Measurements were done in four phases before and after levodopa challenge test. Rest tremor and rigidity were evaluated using UPDRS-III score. Electromyographic (EMG) signals from biceps brachii and kinematic signals from forearm were recorded with wireless measurement setup. The patients performed two different tasks: arm isometric tension and arm passive flexion-extension. The electromyographic and the kinematic signals were analyzed with parametric, principal component, and spectrum-based approaches. The principal component approach for isometric tension EMG signals showed significant decline in characteristics related to PD during levodopa challenge test. The spectral approach on passive flexion-extension EMG signals showed a significant decrease on involuntary muscle activity during the levodopa challenge test. Both effects were stronger during the levodopa challenge test compared to that of patients' personal medication. There were no significant changes in the parametric approach for EMG and kinematic signals during the measurement. The results show that a wireless and wearable measurement and analysis can be used to study the effect of levodopa medication in advanced Parkinson's disease.

Bio-psychosocial factors are associated with pain intensity, physical functioning, and ability to work in female healthcare personnel with recurrent low back pain.

OBJECTIVE: To investigate associations of various bio-psychosocial factors with bodily pain, physical func-tioning, and ability to work in low back pain. DESIGN: Cross-sectional study. SUBJECTS: A total of 219 female healthcare workers with recurrent non-specific low back pain. METHODS: Associations between several physical and psychosocial factors and: (i) bodily pain, (ii) physical functioning and (iii) ability to work were studied. Variables with statistically significant associations (p < 0.05) in bivariate analysis were set within a generalized linear model to analyse their relationship with each dependent variable. RESULTS: In generalized linear model analysis, perceived work-induced lumbar exertion (p < 0.001), multi-site pain (p <0.001) and work-related fear-avoidance beliefs (FAB-W) (p = 0.02) best explained bodily pain. Multi-site pain (p < 0.001), lumbar exertion (p = 0.005), FAB-W (p = 0.01) and physical performance in figure-of-eight running (p = 0.01) and modified push-ups (p = 0.05) best explained physical functioning; FAB-W (p <0.001), lumbar exertion (p = 0.003), depression (p = 0.01) and recovery after work (p = 0.03) best explained work ability. In bivariate analysis lumbar exertion was associated with poor physical performance. CONCLUSION: FAB-W and work-induced lumbar exertion were associated with levels of pain, physical functioning and ability to work. Poor physical performance capacity was associated with work-induced lumbar exertion. Interventions that aim to reduce fear-avoidance and increase fitness capacity might be beneficial.

Reduced Spinal Cord Movement With the Straight Leg Raise Test in Patients With Lumbar Intervertebral Disc Herniation.

STUDY DESIGN: Controlled radiological study. OBJECTIVE: To explore whether impairment of neural excursion during the straight leg raise test occurs in patients with sciatic symptoms secondary to lumbar intervertebral disc herniation (LIDH). SUMMARY OF BACKGROUND DATA: Earlier studies have shown that during the straight leg raise (SLR) test in asymptomatic volunteers tensile forces are consistently transmitted throughout the neural system and the thoracolumbar spinal cord slides distally. METHODS: Fifteen patients with sciatic symptoms due to subacute LIDH were studied with a 1.5 T magnetic resonance scanner. First, a spine specialist diagnosed the LIDH using conventional scanning sequences. Following this subjects were scanned using different scanning sequences for planning and measurement purposes. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between manoeuvres. RESULTS: The results showed 66.6% less excursion of conus medullaris with SLR performed on the symptomatic side compared with excursions measured with SLR performed on the asymptomatic side (p ≤ 0.001). CONCLUSION: In patients with LIDH, the neural displacement on the symptomatic side is significantly reduced by the compressing IVD herniation. To our knowledge, these are the first data in intact human subjects to support the limitation of neural movements in the vertebral canal with LIDH. LEVEL OF EVIDENCE: 3.

Evaluation of the Effects of Physical Activity, Cardiorespiratory Condition, and Neuromuscular Fitness on Direct Healthcare Costs and Sickness-Related Absence Among Nursing Personnel With Recurrent Nonspecific Low Back Pain.

STUDY DESIGN: A cross-sectional study, part of a randomized controlled trial. OBJECTIVE: To evaluate the association of physical activity, cardiorespiratory fitness, and neuromuscular fitness with direct healthcare costs and sickness-related absence among nursing personnel with nonspecific low back pain. SUMMARY OF BACKGROUND DATA: Low back pain creates a huge economic burden due to increased sick leave and use of healthcare services. METHODS: Female nursing personnel with nonspecific low back pain were included (n = 219). Physical activity was assessed with accelerometry and a questionnaire. In addition, measurements of cardiorespiratory and muscular fitness were conducted. Direct costs and sickness-related absence for a 6-month period were collected retrospectively by questionnaire. Health care utilization and absence from work were analyzed with a general linear model. RESULTS: The mean total costs were 80.5% lower among women who met physical activity recommendations than inactive women. Those with a higher mean daily intensity level of 10-minute activity sessions showed lower total costs than women in the lowest tertile (middle: 64.0% of the lowest; highest: 54.3% of the lowest). Women with good cardiorespiratory fitness (the highest tertile) as measured with the 6-minute-walk test (based on walking distance) had 77.0% lower total costs when compared with the lowest tertile. Women in the highest third for the modified push-up test had 84.0% lower total costs than those with the poorest results (the bottom tertile). CONCLUSION: High cardiorespiratory and muscular fitness and meeting physical activity recommendations for aerobic and muscular fitness were strongly associated with lower total costs among nursing personnel with pain-related disorders of recurrent nonspecific low back pain. Actions to increase physical activity and muscle conditioning may significantly save on healthcare costs and decrease sick-leave costs due to low back pain.