Early Mobilization for Low Back Pain Reduces Sick Time

Доказательства 2012 год.

Early mobilization for low back pain reduces sick time

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Clinical question
Does early intervention with a light mobilization program reduce long-term sick leave for low back pain?

Bottom line
This study finds that early mobilization and education for low back pain for low back pain is an effective way to return patients to function. Other studies have also found this approach also improves pain and quality of life. (LOE = 2b)

Reference
Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000;25(15):1973-6.

Study design: Randomized controlled trial (non-blinded)

Setting: Population-based

Synopsis
Norwegians with more than 8 weeks of low back pain were randomly assigned (blind allocation) to control (n=256) or intervention (n=254). The intervention included a visit at a spine clinic accompanied by a light mobilization program. The spine clinic visit consisted of 1 hour with a physician (this seems impractical) and 60-90 minutes with a physical therapist. The control group was evaluated by their primary care practitioner. The researchers followed the patients for one year and analyzed the groups using intention-to-treat. Patients in the intervention group were slightly more likely to have returned to work (68.4% for the intervention, 56.4% for the control group, NNT=9) and had significantly fewer total sick days (95.5 days, 95% CI 82.2 - 108.8) as compared with controls (133.7 days, 95% CI 118.9-148.5).

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Rehab = spinal fusion for chronic back pain

Daily POEMs

Clinical question
Is intensive rehabilitation as effective as lumbar spine fusion to improve function in patients with chronic low back pain?

Bottom line
Intensive rehabilitation results in a reduction of disability due to chronic low back pain, although it was slightly less effective than spinal fusion surgery. Rehabilitation is more cost-effective and results in fewer complications than surgery. (LOE = 1b-)

Reference
Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R, for the Spine Stabilisation Trial Group. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 2005;330:1220-27.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Uncertain

Setting: Outpatient (specialty)

Synopsis
The researchers conducting this study enrolled patients identified in 15 hospitals in the United Kingdom. They took an interesting approach to patient selection, enrolling 349 patients who were candidates for surgical stabilization of the spine, yet were uncertain (as were their physicians) whether surgery would be better than rehabilitation. The patients were between the ages of 18 years and 55 years and had chronic low back pain for at least 12 months. The patients were randomized, though allocation assignment may not have been concealed from the enrolling surgeon, to be treated with spinal fusion using a technique left to the discretion of the surgeon, or to receive outpatient education and exercise 5 days per week for 3 weeks, with follow-up sessions at 1, 3, 6, or 12 months. The rehabilitation included stretching, spinal flexibility exercises, spinal stabilization exercises, aerobic exercise, and hydrotherapy. It also included cognitive behavioral therapy, which focused on identifying and overcoming fears and unwanted beliefs associated with low back pain. Over the 2 years of the study, there was some crossover, with 28% of patients in the rehabilitation group receiving surgery and 4% in the surgery group received rehabilitation. However, the patients were analyzed in the groups to which they originally were assigned (intention-to-treat analysis). Also, approximately 20% of patients were unavailable for the 2-year follow-up. At 2 years, scores on the Oswestry Disability Index, scored from 0% (no disability) to 100% (completely disabled), improved slightly more in the surgically treated patients, from a baseline of 46.5 to 34.0, as compared with a change in the rehabilitation group from 44.8 to 36.1, for an estimated mean difference between groups of 4.1 (95% CI, 0.1-8.1; P=.045). There was no difference between the groups in the shuttle walking test, a progressive, maximal test of walking speed and endurance. Complications occurred in 11% of patients treated with surgery; there were no complications in the rehabilitation group. A study of the cost-effectiveness of spinal fusion as compared with rehabilitation showed spinal surgery to cost 92,000 USD per quality-adjusted life year, which is more expensive than interventions generally judged to be cost-effective (BMJ 2005; 330:1239-45).

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Minimal differences on average between disc replacement and rehab for back pain

Daily POEMs

Clinical question
In patients with chronic back pain, is surgery with disc prosthesis more effective than rehabilitation to decrease long-term disability?

Bottom line
Two years following intervention, disc replacement surgery decreases pain and disability to a greater extent than intensive rehabilitation, though the difference is not clinically relevant on average. Response to surgery or rehabilitation is quite variable, with some patients receiving substantial benefit, while others are no better or worse. (LOE = 2b)

Reference
Hellum C, Johnsen LG, Storheim K, et al, for the Norwegian Spine Study Group. Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ 2011;342:d2786.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
These Norwegian researchers enrolled 173 patients with a history of long-term (1 year) low back pain with moderate disability and degenerative disk changes to 1 or 2 lower lumbar spine levels. Approximately 30% of patients were not working and were in a rehabilitation program, and all had received continuous physical therapy or chiropractic care without benefit. Using concealed allocation, patients were assigned to undergo lumbar disc replacement (ProDisc II) after complete discectomy or to 60 hours of rehabilitation (over 3 to 5 weeks) using a team approach to improve strength as well as attitudes toward back pain. Despite the randomization process, patients assigned to rehabilitation had back pain scores almost 10 points higher (on a scale of 0-100) and significantly lower mental health scores at the start of the study. Follow-up occurred for 80% of patients. The main outcome was the Oswestry Disability Index, a measure of pain and the effect of low back pain on daily activities. Disability scores dropped from an average initial score of 42 in both groups and were maintained over 2 years. On average, scores were 8.4 points lower at 2 years, which was significantly different, but not clinically meaningful (a 15-point difference is thought to be clinically meaningful). A total of 70% of patients in the surgery group had at least a 15-point improvement in scores at 2 years following surgery as compared with 47% in the rehabilitation group (statistic not reported).

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Bed rest bad for back pain, ineffective for sciatica

Daily POEMs

Clinical question
Is bed rest effective in the short-term treatment of patients with back pain and sciatica?

Bottom line
When they are studied for 3 months, rest in bed for patients with uncomplicated low back pain causes more pain and slows return to function. Similarly, patients with sciatica experience, at best, no benefit with bed rest. (LOE = 1a)

Reference
Hagen KB, Jamtvedt G, Hilde G, Winnem MF.The updated Cochrane Review of bed rest for low back pain and sciatica. Spine 2005; 30:542-46.

Study design: Systematic review

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis
This is an update of the 1999 Cochrane Review of trials on bed rest for short-term (12 weeks) relief of low back pain or sciatica. The authors searched multiple databases for published and unpublished randomized or quasi-randomized studies in any language. Two reviewers independently assessed the methodologic quality of each study and extracted the data. They assessed the quality using 4 criteria: (1) concealment of allocation; (2) cointervention; (3) intention-to-treat analysis or losses to follow-up; and (4) outcome assessment. Since the 1999 review, the authors found only 2 new trials. A total of 6 trials consistently demonstrate that for patients with uncomplicated low back pain, bed rest was slightly worse than staying active for pain relief and return to functional status. For patients with sciatica, the data are less clear, but bed rest has little or no effect on pain or return to function.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

better than no surgery for spinal stenosis

Daily POEMs

Clinical question
In adults with spinal stenosis, is surgical treatment more effective than nonsurgical treatment?

Bottom line
Most patients with lumbar spinal stenosis treated surgically and nonsurgically improve over time. However, patients treated surgically have greater improvement in pain. There are no meaningful differences in disability or in walking capacity. (LOE = 2b)

Reference
Malmivaara A, Slatis P, Heliovaara M, et al, for the Finnish Lumbar Spinal Research Group.Surgical or nonoperative treatment for lumbar spinal stenosis?a randomized controlled trial. Spine 2007;32:1-8.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Inpatient (any location) with outpatient follow-up

Synopsis
In this unblinded study from Finland, 94 adults with at least 6 months of symptoms due to lumbar spinal stenosis were randomly assigned to receive surgery or nonsurgical treatment. The researchers excluded patients with progressive neurologic deficits, with prior surgery, with severe or minimal symptoms, who were poor surgical candidates, and who had other conditions explaining their symptoms. The researchers evaluated the patients 6 months, 12 months, and 24 months after enrollment using intention-to-treat analysis. At the end of the study, approximately 15% of the patients had dropped out. Patients in both groups improved over the course of the study. Although disability scores were more likely to improve in patients treated surgically, the 7.8-point difference on a 100-point scale is not clinically meaningful. However, improvements in pain scores in the patients treated with surgery were clinically better. Finally, there was no significant difference between the groups in self-reported walking ability.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Low back pain

Essentials

Sufficient time for the survey of the history and for the physical examination of the patient
Early recognition of serious causes of back pain and of nerve root compression causing functional disturbance
Adequate treatment of pain: according to the intensity of pain the choice is paracetamol, a NSAID or a combination of a NSAID and a mild opioid analgesic
Avoidance of bed rest
Continuation or resumption of ordinary daily activities as soon as possible
Provision of adequate information; the optimistic view that is based on the usually good prognosis is conveyed to the patient, but the symptom’s tendency to recurrence is, however, also taken up.
Follow-up of the patient up and the aim of restoring activity and ability to work
In prolonged low back pain that has lasted for at least 6 weeks: extensive multidisciplinary assessment of the patient’s situation considering also the psychosocial factors, as well as active rehabilitation
In chronic low back pain that has lasted for more than 3 months: sufficiently intensive multidisciplinary rehabilitation

Epidemiology

Low back pain is a very common condition: nearly 80% of people experience a disabling low back pain at some point in their lives.
Of all patients in general practice 4–6% of working age women and 5–7% of working age men present with low back pain as their main complaint.
It is estimated that 15% to 20% of adults have back pain during a single year and 50% to 80% experience at least one episode of back pain during a lifetime 1. At any one time, about 15% of adults have low back pain 2.

Clinical examination

History

Taking a history is the most important part in the clinical examination of a back pain patient. Data obtained from the history can be classified as follows:
Earlier low back pain (onset of symptoms, visits at a doctor, earlier investigations, treatments and sick leaves)
Current low back pain (onset, nature and intensity of symptoms, pain radiating to the lower extremity, perceived disability in daily living, investigations, treatments and their effectiveness)
Other illnesses (operations, traumas, other musculoskeletal disorders, other diseases such as diabetes and arteriosclerosis in lower extremities, diseases of the urogenital system, allergies, current medication)
Social history (family, education, work and leisure time activities)
Lifestyle (physical exercise, smoking, drinking, diet)

Physical examination

In the physical examination emphasis is placed on the assessment of signs of nerve root compression and functional status. The patient should undress to a sufficient degree.

Inspection of the spine
Flattening of lordosis or scoliosis due to acute pain
Bending of the lumbar spine is restricted; painful restriction may indicate the degree of severity.
Palpation of the vertebrae, sciatic nerve and lower extremities
Unilateral tenderness of the buttocks and thighs is often associated with acute nerve root compression of the sciatic nerve.
A great number of pain spots and associate symptoms may suggest fibromyalgia [1] .
Palpation or Doppler ultrasonography, or both, of the arteries in the lower extremities in patients over 50 years of age with intermittent claudication [2]
Examination of the mobility of the back
Restriction in bending forward, backward and sideways may give a picture of the severity of the back pain.
Mobility of the spine and disturbances in the rhythm of motion provide understanding of the functional capacity of the back, and measuring the mobility is of significance in follow-up of the condition.
The adjusted Schober test has moderate repeatability in measuring the mobility.
The rotational motion of the spine and the mobility of the thorax become early restricted in ankylosing spondylitis [3] .
Assessment of signs of nerve root compression
Straight leg raising (SLR) and Lasègue's test are sensitive but non-specific tests for verifying nerve root compression at S1 and L5 level.
The tests are interpreted as positive when they cause pain radiating from the back to the lower limb. Back pain itself or tightness behind the knee are not positive signs.
In nerve root compression, passive dorsiflexion of the ankle during SLR test increases the pain radiating from the back to the limb.
Crossing pain: Intensified radiating pain when raising the contralateral limb is a specific sign of nerve root compression.
Muscular strength of the lower limbs
Knee extension (L4 root and partially L3 root)
Dorsiflexion of the ankle (L5, partially L4 root), dorsiflexion of the big toe (L5 root) and plantar flexion of the ankle (S1 root)
Walking on heels (L5, partially L4 root) or on toes (S1 root)
Tendon reflexes
Patella (L4 root)
Achilles (S1 root)
Babinski (upper motor neuron)
Patients with lower limb symptoms are examined for sense of touch on the lower medial side of the knee (L4 root), medial (L5 root), dorsal (L5 root) and lateral (S1 root) sides of the foot.
Decreased muscle strength of both legs (paraparesis), enhanced or multiple tendon reflexes, and a positive Babinski's sign suggest a need for neurological or neurosurgical assessment. Paraparesis is an indication for immediate referral.
Rectal touch (tonus of the sphincter) and the sense of touch of the perineum should be examined when caudaequina syndrome is suspected (immediate referral).
Other examinations according to the patient's history
Palpation of the arteries of lower limbs and Doppler stethoscope examination in patients over 50 years of age with intermittent claudication

Psychosocial risk factors

Psychosocial factors may prolong and complicate functional capacity problems and pain behaviour. Factors suggesting an increased risk for chronicity ("yellow flags") are presented in table [1] .

Table1. Factors suggesting an increased risk for chronicity of back pain
Belief that pain and physical activity are harmful
Inappropriate illness behaviour (e.g. prolonged bed rest)
Depressed mood, negativity and social withdrawal
Seeking for many different therapies
Physicallystrenuouswork
Problems at the workplace and dissatisfaction with the work
Overprotective family or lack of support
Complaints, litigations and compensation claims

Clinical classification of urgency

Uncommon but serious causes of back pain should be recognized at an early stage. Also, signs of sciatic syndrome should be recognized.
Back symptoms can be divided into three categories on the basis of the history and the findings in clinical examination:
Possible serious (tumour, infection, fracture, caudaequina syndrome) or specific disease (ankylosing spondylitis, clinically symptomatic spondylolisthesis). See table [2] .
Symptoms in the lower limbs suggesting nerve root dysfunction (sciatic syndrome, intermittent claudication)
Non-specific back pain: symptoms occurring mainly in the back without any suggestion of nerve root involvement or serious disease.

Table2. The most common serious or specific causes for low back pain
Disease / Symptomsandsigns
Caudaequinasyndrome / Urinary retention, anal incontinence, perinealanaesthesia (saddle sensory loss), usually symptoms of lower limb paralysis
Ruptured aortic aneurysm, acute aortic dissecation / Sudden, excruciating pain, age above 50 years, instable haemodynamics
Malignanttumour / Age above 50 years, history of cancer, involuntary weight loss, recurrent febrile episodes, progressive symptoms, nightly pains, duration of pain for over one month, paraparesis
Bacterialspondylitis / Previous back operation, urinary tract or skin infection, immunosuppression, corticosteroid medication, abuse of intravenous drugs
Compression fracture of the spine / Age above 50 years, history of falling, peroral steroid medication
Spondylolisthesis / Adolescent (age 8–15 years)
Spinalstenosis / Age above 50 years, neurogenic claudication
Ankylosingspondylitis / Age below 40 years at the onset of symptoms, pain is not alleviated by bed rest, morning stiffness, duration at least 3 months

Serious or specific diseases