Chronic low back pain

Most episodes of low back pain are mechanical in origin and resolve within a 12-week period. These acute episodes of back pain are associated with muscle strain and intervertebral disc herniation with radiculopathy. A smaller proportion of individuals have back pain with a duration greater than 12 weeks. These patients have back pain secondary to a wide variety of mechanical and nonmechanical disorders. The mechanical disorders associated with chronic low back pain include osteoarthritis and lumbar spinal stenosis; the nonmechanical disorders include infectious, neoplastic, rheumatologic, endocrinologic, vascular, and gynecologic. The clinical symptoms associated with each variety of disorder helps guide the appropriate diagnostic evaluation. Plain roentgenograms are useful in documenting the presence of spinal stenosis, benign or malignant tumors, osteoporosis, sacroiliitis, and spondylitis. CT scan is helpful in defining the bony alterations associated with malignant tumors and the vascular abnormalities associated with aneurysms. MR imaging is the technique of choice to document the extent of malignant processes and the presence of endometriosis in the pelvis. The therapy of these entities are specific for the disease entity causing the chronic low back pain. Although most of the disorders that cause chronic low back pain cannot be cured, therapy can decrease pain and improve function of the symptomatic patient.     

Chronic low back pain. What are the treatment options?

The fragile X mental retardation 1 gene (FMR1) mutation is strongly correlated with specific and marked neurobehavioral and neuroanatomical abnormalities. The protein product, FMRP, is highly expressed in neurons of the normal mammalian brain, and absent or in low levels in leukocytes from individuals with fragile X (FraX)-associated mental impairment. Inferences which arise from these findings are that FMRP has a critical role in the development and functioning of the brain, and that leukocyte-derived molecular assessments provide a good indicator of FMR1 expression in that organ. This latter conclusion appears true in most cases even though the typical FMR1 mutation is an unstable triplet repeat expansion which demonstrates somatic heterogeneity within and across tissues. Blood to brain correspondence in FraX patients has only rarely been confirmed by the direct study of human brain specimens and, to our knowledge, it has never been studied in living individuals with the FMR1 mutation. In this report, we describe the FMR1 patterns in olfactory neuroblasts (ON) from two living brothers with expansion mutations in their leukocytes who are mentally retarded and autistic. ON were chosen for study because they are accessible neurons closely linked to the brain. In both subjects, the ON genotype was highly, but not perfectly, consistent with that observed in leukocytes. Protein phenotypes across tissues were completely consistent showing the absence of FMRP-immunoreactivity (-ir). These results augment the limited amount of direct evidence which indicates that FMR1 mutation patterns in leukocytes are a good, albeit potentially fallible, reflection of such patterns in the brain. This report further demonstrates the feasibility of using ON samples to evaluate the FMR1 mutation in humans in vivo.     

Chronic low back pain: Toward an integrated psychosocial assessment model.

Reports on the integration of 6 dimensions of chronic low back pain to provide a multidimensional profile of the patient. These dimensions were pain intensity, functional disability, attitudes toward pain, pain coping strategies, depression, and illness behavior. Cluster analysis of the data obtained from 100 patients with chronic low back pain revealed the presence of 3 distinct patient groups: patients who were in control, patients who were depressed and disabled, and patients who were active copers with high denial. The validity of these clusters was supported by significance testing on several external variables. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The benefits of back pain

During recent years the gap between the rapid implementation of new technologies in cancer prevention and the slow development of a complementary psychological framework to conceptualize the transmission of genetic informations to patients has been deplored. Such a framework should include all psychological aspects surrounding the genetic consultation, reaching from the information and education of the general public to the impact of prophylactic surgery. While some of the psychological consequences of modern cancer prevention can not be fully foreseen and have first to be documented and analysed, others can easily be anticipated. The authors will try to outline a psychological framework that could help in facing potential negative effects of these beneficial preventive possibilities.     

Patients with low back pain

OBJECTIVES: The aim of this study was to examine the clinical utility of low-dose oral prednisone in preventing severe paclitaxel-associated arthralgias and myalgias. METHODS: Patients treated with paclitaxel in the gynecologic oncology program of the Cleveland Clinic Foundation who developed arthralgias/myalgias which were uncontrolled through the use of nonsteroidal anti-inflammatory medications received low-dose oral prednisone (10 mg B.I.D. starting 24 h after the completion of chemotherapy and continuing for a total of 5 days) with their next paclitaxel course. RESULTS: Of 46 patients meeting the criteria for treatment with the oral prednisone regimen (i.e., subjective feeling of unacceptable discomfort despite the use of nonsteroidal anti-inflammatory agents), 39 (85%) experienced substantial relief of symptoms. All but one of the responding patients requested continuation of the oral prednisone regimen with subsequent paclitaxel treatment cycles. There were no significant toxicities noted in any patient receiving prednisone. CONCLUSION: This low-dose oral prednisone regimen results in substantial improvement in the majority of patients experiencing significant paclitaxel-associated arthralgias/myalgias.     

Chronic pelvic pain

A total of 819 male and female skulls (frontal sections of 250 of these) were examined by traditional craniometry and MBS-2 microscope in order to assess the variability of morphogeometric parameters of biomechanical resistance of human brain skull and designing its structure typology. The following types of construction resistance of human brain skull (craniotypes) were distinguished: 1) structure resistant; 2) configuration resistant; 3) morphologically resistant; and 4) morphologically unstable.     

Evaluating the child with back pain

The most common causes of serious low back pain in children include spondylolysis, Scheuermann disease and musculoligamentous injury. Questions should be asked about the mechanism of onset and exacerbating factors, and the frequency, duration and severity of the pain. The examination should check gait and alignment, flexibility, strength and reflexes, and localize and evaluate the pain. Warning signs of serious problems include constant pain in a child younger than 11 years of age that lasts for several weeks or occurs spontaneously at night, repeatedly interferes with school, play or sports, or is associated with marked stiffness and limitation of motion, fever or neurologic abnormalities. Pain at the lumbosacral junction may suggest spondylolysis or spondylolisthesis. Scheuermann disease is diagnosed by the observance of wedging, irregularity or growth disturbance of three successive vertebrae. Musculoligamentous pain may result from injury to or overuse of muscles or joints of the back. Rare causes include discitis, tuberculosis, bone or spinal cord tumor, pyelonephritis and retroperitoneal infection.     

Physical therapy in low back pain

We report on physical measures in the treatment of patients with lower back pain due to mechanical factors. Acute low back pain improves mostly without specific measures. Intervention for this condition is useful for prevention of relapses. More demanding and difficult is the treatment of chronic lumbar back pain. After an exact diagnosis, information about the disease, the therapeutic procedure and the prognosis follow in order to agree on a common therapeutic goal. To this goal, a close cooperation between physician, physiotherapist, possibly a psychologist and a social worker, is optimal. The employer should be involved in the rehabilitation on the workplace. Patients should become mobilized inspite of pain, and the return to their workplace should be prepared step by step. The most important physiotherapeutic modalities are demonstrated.     

Low back pain problems among steelworkers

The associations between low-back pain and occupational work loads, life-style factors, and sociodemographic factors were examined in 469 steel plant workers (436 males, 33 females), mean age (sd): 40 (12) years. Fifty-one per cent had experienced low-back pain during the preceding year. The strongest associations were found between recent low-back pain and domestic recreational activities (> or = h/wk vs 0-2 h/wk), and between recent low-back pain and work pace (too fast vs. adequate), odds ratios (95% confidence limits) being respectively 3.0 (1.5-5.8), and 2.3 (1.2-4.2). We considered a subject to have a particularly severe history of low-back pain if he or she due to low-back trouble (i) had ever been admitted to a hospital, (ii) had ever had to change work or, (iii) had had more than one week's sick-leave accumulated during the preceding year. There was a strong association between a severe low-back pain history and life-time occupational exposure to heavy and frequent lifting on the job. Forty-seven per cent of severe low-back pain events could be ascribed to heavy and frequent lifting, provided the associations were causal. We conclude that domestic recreational activities may be an important potential confounder in studies on occupational risk factors for low-back pain, and that, based on the results of this and of other studies, a case for prevention still seems to exist regarding lifting of heavy burdens in the work environment.     

Clinical evaluation of low back pain

To properly diagnose and treat low back pain, a thorough history and physical examination are the cornerstones. The most important diagnoses for the physician to be aware of are cauda equina syndrome, back strain, herniated disc, stenosis, and spondylolisthesis.     

Conservative management of low back pain

The importance of using appropriate conservative care in the management of low back pain has been increasingly stressed in recent years, initially as a backlash to the many failures following surgical intervention (particularly repeated surgeries), and, more recently, as a means of controlling health care costs and instituting patient-centered systems of care. It is difficult to define and determine just what "appropriate conservative care" is and should be. Perhaps even more important in this current era of health care reform is the question of who makes this determination.     

Evaluating back pain in older patients

Low back pain in the elderly has a much wider range of possible causes than in younger patients. In addition to nonspecific mechanical causes, malignancy presenting as back pain occurs more often in older patients. Other systemic and visceral causes of back pain such as polymyalgia rheumatica, aortic aneurysm, Paget disease, Parkinson disease, and osteoporosis with compression fracture occur almost exclusively in persons over age 50. Keys to diagnosis and management of low back pain in older patients are presented.