3rd State of the Art
in Chronic Low Back Pain
Using
sensorimotor integration to improve pain perception in chronic low back pain
patients
Dimitrios
Mitroudis
Introduction The conventional view among many
therapists is that the pain in chronic back pain patients can be reduced by
analgesics, physiotherapy or back exercise. This assumption has not been
examined in detail. This study aimed to determine whether sensory integration
exercises improve pain perception in CLBP patients.
Method Sixty-one patients with chronic back pain
(>or = 50 y, onset > 5 y) from a rehabilitation center participated. Pre
and post intervention assessment included 30 minutes of videotaped dialogues
between patients in pairs, who talked about one important and one minor issue
about their perception of pain. Proceeding this verbal and non-verbal messages
were exchanged between them. The intervention program promoted two skills:
bilateral hand lifting activity and bed mobility. Messages were categorised and
a frequency table was made with five message categories and four columns with
important and non-important issues pre and post intervention. Factorial
Correspondence Analysis for qualitative data was used.
Results First factor’s interpretation showed that there was a
significant improvement of pain perception as an intervention consequence.
Second factor’s analysis revealed a consistency in the subject’s views
regardless of the intervention.
Discussion Findings suggest that a sensory integration program
which focused on bilateral hand lifting activities and bed mobility can improve
the perception of pain in CLBP patients. This outcome has lain the foundations
for a larger clinical trial, whose main objective would be to show that broader
application of the method is also valid.
Key words chronic low back pain, sensory integration,
and pain perception
.
Change of TNFalpha, MMP-3,
PGE2 in patients herniated disc undergoing MPT.
Simona Bellometti, Plinio Richelmi, Francantonio Bertè
Internal Medicine Department,
l.go marconi 8, 35031, Abano T. (PD),
simonab@studitermali.org
tel 0039-049-8669877
Introduction low back pain (LBP) is a ubiquitous condition,
affecting 80% to 90% of the population at some point of their life ( Cassidy J
D et al, 1998) and herniated discs are responsible for symptoms in up to 40% of
all the patients with LBP (Haroa H et al, 2000). The protrusion of herniated
disc ( HD) into the spinal column results in contact between inflammatory
macrophages and the cartilage tissue. The macrophages produce abundant amount
of TNFalpha, inducing MMP-3 production (Okada Y et al, 1992; Grange L et
al 2002). MMPs are assumed to play a pivotal role in tissue degradation and in
loss of normal disc function while prostaglandin E2 is a key factor in the
generation of the spinal pain sensation evoked. A rational therapeutic strategy
should combine pharmacologic and non-pharmacologic interventions, such us
massages, physical treatments, physiotherapy, ecc.
Aim of the present study to investigate if Mud Pack Therapy (MPT),
which consists of a natural anti-inflammatory treatment (Corda et al. 2005),
frequently applied in rheumatic diseases, is able to influence the serum levels
of: TNFalpha, PGE2, MMP-3
Materials and methods: we
have enrolled 80 patients suffering from LBP, with a diagnosis of HD, provided
by the orthopaedic and documented by RMN examination. The patients underwent a
cycle of MPT and the blood samples were collected before and after the end of
the treatment to assay TNFalpha, PGE2, MMP-3 serum values. The assay were
performed by Quantitative sandwich ELISA
technique (R and D Systems Inc,
Results
before after p
TNFalpha (pg/ml)
23.7 (+/-)23.5 11.9 (+/-)
17.8 <0.05
PGE2 (pg/mL)
3465 (+/-)1828 1815 (+/-)
480 <0.05
MMP-3 (ng/ml)
14.21 (+/-)6.5 7.2 (+/-) 3.6
<0.05
The data of this study show changes statistically
significant in the serum levels of all the studied parameters (p<0.05).
Conclusions TNFalpha is directly involved in the process
of disc degeneration and in the genesis of pain in herniation, inducing the
production of PGE2. MPT seems able to induce a reduction of the substances
involved in tissue degeneration, inflammation and pain. These results suggest
that MPT could be introduced in a multidisciplinary strategy of treatment in
order to inhibit and to slow the disc degeneration.
Different health scientists’ views about
motor characteristics of low back pain patients
Abstract
submitted by Maria Askita,
Aim
This abstract aims to investigate the views that different health
scientists have about the motor characteristics of low back pain patients . In
order to ascertain this an inquiry for common motor categories of
characteristics was contacted, along with whether the response’s
differentiation is due to different specialty, or subject’s age .A sample of
137 adult therapists: 47 occupational therapists, 43 physiotherapists and 47
orthopaedics were examined by a multiple choice questionnaire asking to list
the motor characteristics of LBPP .The internal consistency of the
questionnaire was good as Cronbach’s alpha was found to be 0,88 (95% CI
:0.81-0.39) suggesting that all items were appropriate to measure. Exploratory
Factor analysis was applied to the answers given to 39 questions and yielded
five factors accounting for 33% variance: diminished mobility, slow walking
speed, poor flexibility, bad body posture and lumbar instability
.MANOVA(3specialties x 10 ages x 5 average response to the questions which
formed the5factors)showed that age influenced every factor (Pilais=0.687
,F(9,296)=11.754 ,p=0.000 ,F(9.296)=3.589,p=0.000,F(9,296)=12.644,p=0.000,F(0,296)=2.528,p=0.008,F=9,296=6.855,p=0.000).
The effect of the specialty was significant only for the second factor
(Pilais=0.208, F(9.296)=2.451 ,P=0.011) .This study indicates that there are
some commonly recognized categories of motor characteristics in LBPP among
therapists. Their age and specialty effected their views. There is a question
mark regarding these findings and they are currently under discussion.
Key words
motor characteristics ,low back pain patients, health scientists.
McKenzie Exercises for Low Back Pain, Our Experience
EM
Skikic1, S Trebinjac1, D Avdic2,
1.
2.
3.
Objective To investigate influence of McKenzie
exercises on decreasing the pain in patients with low back pain, to show
occurrence of Centralization sign, as a predictor of good treatment outcomes
and to evaluate use of McKenzie exercises, as a routine method for lower back
pain in Physical Medicine and Rehabilitation Centres.
Material & Methods Thirty-four patients with symptoms of low back pain. McKenzie exercise
program was performed individually to the need and possibility of each patient.
All patients were assessed before and after the treatment. Visual Analog Scale
(VAS) measured intensity of pain, localization of pain was noted on special
forms and Shober test was used to show differences in spinal movement before
and after the treatment.
Results Measurements of spinal movements
and flexibility of spine showed significant improvement in all patients. Average difference in values of Shober test
before and after treatment was 1,1 cm with SD 0,98. Difference test was t=6,263
with significant difference p<0,01. Mean pain intensity was reduced
significantly as a result of treatment. Pain was reduced on VAS for X=2,8 with
S.D. 1,56. Difference Test was t=10,332, with significant difference p<0.01.
61,5% of total
number of participants had signs of centralisation (6% were in acute stage of
pain, 32% in sub acute and 23,5% in chronic pain). Centralisation sign was
noted in 40% of acute patients, 57.5% sub acute and 80% of chronic patients
with a low back pain who exercised McKenzie program.
Conclusions McKenzie exercises for low back pain are beneficial treatment for
increasing flexibility of spine and improving the pain with better results in
pain relief.
Although done
by minimally trained physiotherapists in McKenzie approach, McKenzie exercises
are successful method for decreasing and centralising the pain and increasing
spinal movements in patients with low back pain.
Disturbance of balance in patients with
surgical cure of a herniated lumbar disc
Daniela
Poenaru, Paul Patrascu, Delia Cinteza, Simona Popescu
UMF
Carol Davila ,
Objective
identification of balance disorders in patients with operated lumbar
herniated disc, in the first 3 – 6 days after the minimal intervention (fenestrectomy)
;
Material and method 15 patients, 25 – 45 years, with a
recent minimal surgical intervention (fenestrectomy) for herniated lumbar disc.
We excluded pre-existent balance and auditive complaints, central neurological
disorders, age above 45, diabetes mellitus. We evaluated the patients with
functional parameters - lumbar dynamic, gait characteristics on a modified
Tinetti Scale and balance parameters (tested on the balance platform) in the
following conditions: open eyes – solid support, closed eyes – solid support,
open eyes – elastic support, closed eyes – elastic support.
Results
We found a positive correlation, statistically semnificative, between
the functional and balance parameters (on anteroposterior and lateral
directions) and the limits of stability (anterior, posterior, right, left). We
can say that the most impaired in-put system in lumbar operated patients is the
proprioceptive one.
Operated herniated nucleus pulposus - a
balance training program
Daniela
Poenaru, Paul Patrascu, Delia Cinteza, Simona Popescu
UMF
Carol Davila ,
Objective
to study the evolution of patients with operated lumbar herniated disc
after 10 days of visual biofeedback on the balance platform.
Material and methods
15 patients with a fenestrectomy for herniated lumbar disc (L4 or L5).
Auditive troubles, central neurological disorders, diabetes mellitus and age
above 45 were excluded. The patients were evaluated at the beginning and the
completion of 10 days training program. The evaluation consisted in functional
parameters (lumbar dynamic, gait characteristics on a modified Tinetti Scale)
and balance parameters (balance coefficient on antero-posterior and lateral
directions, limits of stability on anterior, posterior and lateral directions).
The training program used the ankle strategy to control the center of gravity
on the platform. The main steps of training were: stabilization, loading, load
transfer and postural control.
Results
We demonstrate a semnificative improvement of the functional and
platform-tested parameters after 10 days of training program. The most
important gain was the improvement of proprioceptive system. The visual and
vestibular systems improved, but the correlation was nor semnificative.
Tolperisone: a non-benzodiazepine muscle relaxant
Author: V. Kemény MD. PhD., M.
Misnyovszki MD., Gy. Németh MD. PhD., A. Rácz MD.
Gedeon Richter Ltd.,
Introduction Centrally acting muscle relaxants are
effective in the management of non-specific low back pain, but the adverse
effects require that they be used with caution. One of the most important and
frequent side effects is the sedative effect. As early mobilisation is
important in the case of such patients, non-sedative muscle relaxants are required.
Tolperisone
is a non-benzodiazepine centrally acting muscle relaxant without sedative
effect.
Mechanism of action Tolperisone has a lidocaine-like activity and
stabilizes nerve membranes. It blocks in a dose-dependent manner mono- and
polysynaptic reflexes at the spinal level.
Indications, clinical profile Tolperisone is an effective and well-tolerated agent in the treatment
of painful reflex muscle spasm associated with various musculoskeletal diseases
such as low- and high back pain, spastic syndrome caused by different
aetiologies.
Tolperisone
is supposed to mediate muscle relaxation without concomitant sedation or
withdrawal phenomena. Clinical data proves that it does not impair reaction
time either. It does not limit everyday activities, not even driving.
Conclusions Due to its pharmacological properties as a
centrally acting muscle relaxant without sedative side effects, tolperisone
suffices the principal requirements of a beneficial drug in these indications.
In view of therapeutic alternatives, the risk-benefit-profile of tolperisone
definitely represents a clear-cut advantage in the spectrum of centrally acting
muscle relaxant drugs.
Tolperisone
is used in a lot of European countries (
A Modified Thoracolumbar Orthosis for a Pregnant Woman with POTT’S
Disease
CASE REPORT
Primary
Investigator: Tan, Samuel Arnado, M.D.
Supervising
Investigator: Alviar, Maria Jenelyn, M.D.
Institution:
Department of Rehabilitation Medicine,
Abstract
A 33-year-old female diagnosed with Pott’s disease with compression
fracture at T9 level. She was put on
quadruple anti-Koch’s therapy. A thoracolumbar orthosis – total contact body
jacket was fabricated to support her unstable spine. She was diagnosed pregnant
two months after she was diagnosed with Pott’s disease. A team from Orthopaedic Surgery,
Obstetrics-Gynaecology, and Rehabilitation Medicine managed the patient. A modified thoracolumbar orthosis that
accommodated the rapidly enlarging gravid uterus and maintained the support on
an unstable spine was fabricated.
Key Words Pott’s disease, Thoracolumbar Orthosis,
Pregnancy
Predictors of Outcome after AO-Type A Fractures of the Dorsolumbar Spine
Peter Vorlat,
Heinz Hulsmans.
Department of Orthopaedics,
Background
This is the first regression analysis of the numerous factors that might
influence outcome.
Methods 47 conservatively treated and 33
posteriorly instrumented patients were prospectively studied. The pretrauma
versus 12 months of follow-up differences of impairment (forward-bending pain,
FBP), back pain (VAS), Oswestry disability index (ODI) and a global outcome
score (OS) were recorded. Satisfaction and weeks lost from work were noted. The
influence of the other scores on satisfaction was studied.
Results Pain is only influenced by pain before
trauma: Back patients, recovered 20% better. The ODI is influenced by fracture type, smoking and the
VAS on the first day after trauma: For each
increase in fracture type, the ODI recovered 7% less. Smokers won back
12% less of ODI. For each point post trauma pain, the loss of ODI was 3%. The
outcome score is influenced by fracture type, smoking and body mass index
(BMI): For each increase in fracture type, OS recovery was 9% less. Smokers won
back 13% less. Patients with BMI more than 25 won back 18% more. For each
increase of education level (from 1 to 7) return to work was 3 weeks sooner.
With FBP return to work was 22 weeks later. Satisfaction was only influenced by
FBP: patients with such pain were 16% less satisfied. (All p’s < 0.04)
Fracture localisation, workers’
compensation, nor sagittal index influenced outcome.
Conclusion
Smoking, fracture type, post trauma pain and low education level are
strong negative predicting factors. Surprising only FBP influences
satisfaction.
Topic
Intervention
The Effect of Thermo-undulation Therapy
on the Patients with Chronic Low Back Pain
JH KIM1, SH JUNG, IS CHOI, SG
LEE
Department of
Physical Medicine & Rehabilitation, Research Institute of Medical Sciences,
Chonnam National University Medical School & Hospital, 1Chonnam
National University Hwasun Hospital, Gwangju, South Korea
Introduction The thermo-undulation therapeutic device
(InarexTM) has a dual therapeutic effects of the thermal and the
undulating massage effect for the treatment of chronic low back
pain (LBP). The aim of this study was to verify the effect of InarexTM
on the patients with chronic LBP.
Materials and methods One hundred and fifteen patients with back pain (mean age: 51.2 year-old; male, female: 46, 69)
were recruited. Experimental group (n, 85) was subjected to InarexTM treatment
for 30 minutes, once a day, five days a week during eight weeks and control
group (n, 30) was performed with sham procedure. Before and after treatment,
spine range of motion (ROM) and muscle flexibility of lower extremities were
evaluated by goniometry. The functional status was measured by Roland Morris
disability questionnaire and quality of life was measured by the SF-36 and
SF-12 scales. The STAI-6 (Spielberger State-Trait Anxiety Inventory) was used
for anxiety. We checked the degree of pain by visual analog scale (VAS) and
evaluated the effect of far-infrared ray with Digital Infrared Thermographic
Imaging (DITI) technique.
Results After InarexTM treatment,
the scores of muscle flexibility, spine ROM, VAS, Roland Morris disability
questionnaire, SF-36, SF-12 and STAI-6 were improved in experimental group
(p<0.05). The temperature differences of experimental group by means of DITI
were significantly lower than those of control (p<0.05).
Conclusion and relevance We think that
InarexTM treatment may be an adjuvant therapeutic thermo-undulation
device for chronic LBP.
“This work was supported by Regional Research
Centers Program of the Korean Ministry of Education & Human Resources
Development, 2005"
Topic :
Epidemiology,
The Clinical Patterns of Low Back Pain
in Cancer Patients
JH KIM1, IS CHOI, HL IM, SG LEE
Department of
Physical Medicine & Rehabilitation, Research Institute of Medical Sciences,
Chonnam National University Medical School & Hospital, 1Chonnam
National University Hwasun Hospital, Gwangju, South Korea
Introduction Low back pain
(LBP) is a significant problem for many patients with cancer. The aim of this
study was to know the clinical patterns of LBP in cancer patients and the
results of pain rehabilitation.
Materials and methods The medical records of 123
cancer patients (48 males, 75 females, mean age 55.2±0.5 years, the mean period
of admission 29.0±9.6 days) who were presented to our rehabilitation center
between May 2004 and July 2005 were reviewed. We analyzed the etiology of LBP,
primary cancer, the site of metastasis and the rehabilitative procedure by
means of physical examination, electro diagnostic study and imaging study such
as simple radiography, MRI, CT, bone scan and PET study. And we measured the
pain disability index (PDI) and visual analogue scale (VAS) before and after
treatment.
Results 1) The most common etiology of
LBP was myofascial pain syndrome (38.7%), followed by vertebral compression
fracture (14.5%), lumbar radiculopathy (12.9%), spondylolisthesis (11.3%) and
spinal stenosis (4.8%). 2) The most common type of primary cancer was lung
cancer (22.9%), followed by hepatobiliary cancer (14.5%), breast cancer
(12.9%), ovary cancer (12.9%) and gastric cancer (4.8%). The distant metastasis were 59.7% and the spine
metastasis were 29.0% (lumbar 17.7%, thoracic 14.5%, other spine 3.2%). 3) The
commonly prescribed rehabilitative procedure were physical modality (88.8%), trigger points
injection and intramuscular stimulation (37.1%), epidural block (27.4%), lumbar
facet block (9.8%), gluteal bursa injection (6.6%). 4) After rehabilitative
procedure, the mean score of PDI was improved from 62.5 to 53.2 and the mean
score of VAS was decreased from 9.3 to 5.0 (p<0.05).
Conclusion and relevance Our results
would be helpful in understanding the various clinical patterns of LBP in
cancer patients and the need of pain rehabilitation.
“This
work was supported by Regional Research Centers Program of the Korean Ministry
of Education & Human Resources Development, 2005"