The efficacy of active treatment for chronic low back pain

Maurits W. van Tulder, PhD, Institute for Research in Extramural Medicine, Free University, Amsterdam, the Netherlands & Ban W Koes, PhD,Department of General Practice, Erasmus University Rotterdam, the Netherlands

Objectives. To assess the efficacy of the most common active types of treatment for patients with chronic low back pain persisting for 12 weeks or more.
Summary of background data. In the last decade, there has been a change in the management of chronic low back pain patients towards a more active approach.

Methods. Studies were selected in electronic databases such as Medline, Embase and Psyclit. Two reviewers independently assessed the methodological quality of the trials and extracted relevant data on study populations, interventions and outcomes. A qualitative analysis was conducted using a rating system consisting of four levels of scientific evidence : strong, moderate, limited or no evidence.
Results. In general, the methodological quality of the trials was poor and various methodological flaws were identified. Especially in the field of active treatments for chronic pain, blinding of patients, outcome assessors and care providers is difficult. Exercise therapy and multidisciplinary treatment programmes are beneficial for chronic low back pain. However, the current evidence only shows short-term effects and sufficient evidence on long-term effects is lacking. Back schools and behavioural treatment are likely to be beneficial for chronic low back pain, but evidence for these interventions is less strong.
Conclusions. Scientific evidence shows that an active approach to chronic low back pain patients is effective. There is no reason to believe that this would not apply to other types of chronic musculoskeletal pain patients. A challenge for the future will be to identify which types of active treatments (or which components of multimodal treatment packages) are most (cost-effective for what specific subgroups of patients.
References
(1) Tulder MW van, Assendelft WJJ, Koes BW, Bouter LM and the Editorial Board of the Cochrane Collaboration Back Review Group. Method guidelines for systematic reviews in the Cochrane Collaboration back review group for spinal disorders. Spine 1997 ;
22 : 2323-2330.
(2) Tulder MW van, Koes BW, Bouter LM. Conservative treatment of acute and chronic non-specific low back pain : a systematic review of randomized controlled trials of the most common interventions. Spine 1997 ; 22 : 2128-2156.
(3) Tulder MW van. Low back pain and sciatica. BMJ Clinical Evidence 1999 ; 2 : 406-22.

The efficacy of passive treatments for chronic low back pain

Bart W Koes, PhD, Department of General Practice, Erasmus University Rotterdam, the Netherlands & Maurits W van Tulder, PhD, Institute for Research in Extramural Medicine, Free University, Amsterdam, the Netherlands

Objectives. To assess the efficacy of the most common passive types of treatment for patients with chronic low back pain persisting for 12 weeks or more.
Summary of background data. Various types of passive treatments have been and are current applied in the management of chronic low back pain patients. The efficacy of many interventions, however, is still unclear.
Methods. Studies were selected in electronic databases such as Medline, Embase and Psyclit. Two reviewers independently assessed the methodological quality of the trials and extracted relevant data on study populations, interventions and outcomes. A qualitative analysis was conducted using a rating system consisting of four levels of scientific evidence : strong, moderate, limited or no evidence.
Results. In general, the methodological quality of the trials was poor and various methodological flaws were identified. Strong or moderate evidence in favour of the efficacy of the passive interventions included in the review could not be found. Strong evidence was found against the efficacy of traction therapy. For other interventions including, physical modalities (TENS, short wave diathermy, ultrasound, ice, heat, massage), spinal manipulation, back belts, the evidence is unclear (only limited or no evidence available). Limited evidence against the efficacy of acupuncture and EMG-biofeedback was identified.
Conclusions. Scientific evidence shows that for most passive approaches for approaches for chronic low back pain patients the evidence is unclear. Strong evidence was found against the efficacy of traction therapy. Since many passive interventions are widely applied, as mono therapy or as additional therapy in the management of patients with chronic (low back) pain, further high quality RCTs are clearly needed. A challenge for the future will be to identify which types of the passive treatments (are most (cost-effective for what specific subgroups of patients.
References
(1) Tulder MW van, Assendelft WJJ, Koes BW, Bouter LM and the Editorial Board of the Cochrane Collaboration Back Review Group. Method guidelines for systematic reviews in the Cochrane Collaboration back review group for spinal disorders. Spine 1997 ; 22 : 2323-2330.
(2) Tulder MW van, Koes BW, Bouter LM. Conservative treatment of acute and chronic non-specific low back pain : a systematic review of randomized controlled trials of the most common interventions. Spine 1997 ; 22 : 2128-2156.
(3) Tulder MW van. Low back pain and sciatica. BMJ Clinical Evidence 1999 ; 2 : 406-22.

Assessment of physical fitness in chronic pain patients

H. Nielens, MD. Physical medicine and rehabilitation. Cliniques universitaires Saint-Luc, Universite catholique de Louvain, avenue Hippocrate, 10 - 1200 Bruxelles

Physical fitness may be described as "A set of attributes that people have or achieve that relates to the ability to perform physical activity" (1). Although it often refers to performance in sports, some authors have recently underlined that fitness is an important determinant of functional capacity in general (2). As chronic pain patients often present with a "disuse" (3) or "deconditioning" (4) syndrome, any information regarding fitness that could be collected in such patients should thus be particularly relevant. Moreover, as fitness relates to the ability to perform physical activity, it may also be considered as an important determinant of quality of life in such patients. Practically, physical fitness is generally described as a multifactorial construct that includes several components : cardiorespiratory endurance, muscular strength and endurance, flexibility and body composition (5).
Theoretically, a thorough evaluation of physical fitness should include assessment of all components. Although some have included such thorough fitness assessment in their clinical reseach protocols in chronic low back pain patients (4), it is obviously time-consuming and requires expensive and sophisticated equipment. Moreover, it is sometimes not well tolerated by chronic pain patients. Finally, the validity and reliability of many fitness testing procedures in patients with pain remain widely debated (6,7).
Validity and reliability of fitness assessments in pain patients
Most studies including fitness assessment in pain patients simply implemented testing protocols validated for healthy subjects. Common protocols often require a maximal physical effort from the subjects to be tested. For instance, muscular strength and endurance, and flexibility (or range of motion) can only be evaluated by asking the subjects for a maximal participation in a specific task, e. g lifting as hard as possible (lifting strength), sitting and reaching as far as possible (flexibility)... On the other hand, cardiorespiratory endurance is generally evaluated using maximal testing protocols (V02max assessment, ie. oxygen uptake measurement at the end of an exertion test where intensity is gradually increased until exhaustion of the subject), but it may also be reliably evaluated by means of submaximal tests (8). In pain patients, as in untrained and older subjects, it seems preferable to use submaximal protocols for safety, acceptability as well as accuracy (validity and reliability) reasons (9,10). For instance, maximal oxygen uptake (V02max) measured at the end of a maximal cycle ergometer or treadmill test is likely to systematically underestimate true maximal aerobic capacity in such subjects who are often clearly limited by pain or fear of pain enhancement during such intense exercise which they generally avoid in every day life.
Fitness assessment in chronic pain patients
In clinical researches, a thorough evaluation of all components of physical fitness may be needed. In that context, muscular strength and endurance may be estimated using standardized protocols (4). Strength evaluation usually requires expensive equipment as the Cybex'isokinetic torque meters which allow assessment of most relevant muscle groups in chronic low back pain patients (trunk muscles and leg extensors). Maximal lifting capacity may also be evaluated by means of standardized protocols which only require simple and inexpensive equipment. Several methods to assess range-of-motion (flexibility) as the "fingertip-floor distance" and the "Schober test" or " modified Schober test " according to Macrae and Wright have been used in several studies on pain patients (11,12). The "sit and reach" test (13) may also be a useful tool in flexibility assessment.
However, it must once more be recalled that most standardized protocols for strength and flexibility assessment have never been idated in pain patients. Hence, the validity of such methods which mandatorily require maximal participation from the ijects must be questioned, particularly in the context of pain.
Routine clinical equation of fitness in chronic pain patients may focus only on cardiorespiratory endurance and body rnposition assessment which can be conducted in less than thirty minutes. As cardiorespiratory endurance is often advocated the optimal single measure of fitness (10) and as it can be reliably evaluated by submaximal testing protocols not requiring ygen uptake measurements, its assessment seems definitely more suitable for pain patients. The well known Astrand 6-minute cle ergometer test which allows reliable estimation of V02max using a nomogram (8) has been used by several authors. :veral submaximal work capacity indexes as the PWC170, PWC160 or PWC150 which reliably reflect cardiorespiratory idurance (8) have also been used in pain patients as they can be obtained with submaximal cycle ergometer tests. However, as e chronic pain patients population covers a wide age range, a submaximal working capacity index as the PWC75% (11) which calculated for the same relative work intensity (75% of maximal heart rate according to the age of the subject) should be prefered in such patients. Others have proposed and discussed the validity of a similar index (W65%/kg) (14,15) obtainable with step-test and a cycle ergometer in pain patients.
Preferences
1) Casperson C, Powell KE, Christenson GM. Physical activity, exercise and physical fitness : Definitions and distinctions for health-related research. Public Health Reports. 1985 ; 100 : 126.
2) HuangY, Macera CA, Blair SN, Brill PA, Kohl HW III, Kronenfeld JJ. Physical fitness, physical activity, and functional limitation in adults aged 40 and older. Med Sci Sports Exerc, 1998 ; 30 : 1430-1435.
3) Bortz W. The disuse syndrome. West J Med, 1985 ; 141 : 691-694.
4) Mayer TG, Gatchel RJ, Kishino N, Keeley J, Mayer H, Сарга Р, Mooney V. A prospective short-term study of chronic low back pain patients utilizing novel objective functional measurement. Pain 1986 ; 25 : 53-68.
5) American College of Sports Medicine. ACSM's Guidelines/or Exercise Testing and Prescription, Sixth edition. Philadelphia, Williams & Wilkins, 2000.
6) Harding VR, de С Williams AC, Richardson PH, Nicholas MK, Jackson JL, Pither CE. The development of a battery of measures for assessing physical functioning of chronic pain patients. Pain 1994 ; 58 : 367-375.
7) Wittink H. Physical fitness, function and physical therapy in patients with pain : Clinical measures of aerobic fitness and performance in patients with chronic low back pain. In Mitchell Max Ed. Pain 1999- An Updated Review. Refresher Course Syllabus. IASP Press ; 1999 : 137-144.
8) Astrand PO, Rodahl К. Textbook of work physiology, physiological bases of exercise. New York : Me Graw-Hill, 1977.
9) Lamb KL, Brodie DA. Leisure-time physical activity as an estimate of physical fitness : a validation study. J Clin Epidermal 1991 ; 44,1:41-52.
10) Gore С. J., Booth M. L., Bauman A., Neville P. Utility of PWC75% as an estimate of aerobic power in epidemiological and population-based studies. Med Sci Sports Exen 1999 ; (31): 348-351.
11) Mayer TO, Tencer AF, Kristoferson S, Mooney V. Use of noninvasive techniques for quantification of spinal range-of-motion in normal and chronic low-back pain patients. Spine 1984 : 9, 6 : 588-595.
12) Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 1984 ; 9, 2 : 106-119.
13) Wells KF, Dillon EK. The sit and reach : a test for back and leg flexibility. Res Q 1952 ; 23 : 115-118.
14) Nielens H, Plaghki L. Evaluation of physical adaptation to exercise of chronic pain patients by a step-test procedure. The Pain Clinic 1991 ; 4: 21-28.
15) Nielens H, Plaghki L. Perception of pain and exertion during exercise on a cycle ergometer in chronic pain patients. Clin J Pain 1994 ; 10: 204-209.

Reconditioning program for chronic pain patients

Peter HTG Heuts, rehabilitation physician, Hoensbroeck Rehabilitation Centre, The Netherlands.

Although reconditioning in chronic pain patients is a very important issue, there exists not such a thing as one reconditioning program for chronic pain patients (Tulder 1999).
Instead there is a wide array of approaches to chronic pain problems, which is usefully described by Main & Benjamin in four groups (Main and Benjamin 1995) : general medical approach, back schools, functional restoration programs and pain management programs. When we focus on physical fitness, which is relevant regarding the detrimental effects of the deconditioning syndrome (Waddell 1998), it is crucial to realise that chronic pain syndromes and disability do not depend on either physical nor psychological mechanisms. Rather, it is now generally accepted that there exist close links between physiologic and psychologic events, and that pain and pain disability are also profoundly influenced by environmental and socioeconomic factors. During the lasts decades several important improvements are made in the management of chronic pain and pain disability (Moriey, Eccleston et al. 1999). Pain management programs nowadays are based on a comprehensive biopsychosocial model, which integrates the biological, physical basis of symptoms and the full range of social and psychological factors that influence pain, distress and disability (Turk 1996).
Therefore, reconditioning programs in chronic pain patients must incorporate physical, psychological and environmental factors to be succesful. As Waddell stated in his book on back pain problems (Waddell 1998) : The successes and failures of treatment for spinal disorders reflect the value and limitations of the disease model, and the need for a biopsychosocial approach ((Waddell 1998), page 236). Because many chronic pain patients are entrapped in a complex of several vicious circles, it is not easy to achieve improvement of physical fitness.
Pain management programs and functional restoration programs (Mayer and Polatin P 1995) are very promising and can improve physical fitness (Waddell 1998), but it is difficult to assess the differential effect of the several components of these treatment programs. We badly need theoretical models which incorporate important physical, psychological and environmental factors, e. g. (Vlaeyen, Kole Snijders et al. 1995), as well as empirical, prospective studies to validate them.
This presentation focuses on :
1. Clinical experiences with rehabilitation programs in regaining physical fitness in chronic pain patients.
2. Reviews in the literature on reconditioning in the chronic pain population.
3. Research on the disuse syndrome in our group.
References
Main, C. and S. Benjamin (1995). Psychological treatment and the health care system ; the chaotic case of back pain. Is there need for a paradigm shift ? Treatment of functional somatic symptoms. R. Mayou, C. Bass and Sharpe. Oxford, Oxford University Press : 214-230.
Mayer, T. G. and S. B. Polatin P, Smith C, Gatchel R, Herring S, Hall H, Donaldson R, Dickey J & English W. (1995). "Spine rehabilitation :
Secondary and tertiary nonoperative care". Spine 20 : 2060-2066.
Morley, S. , C. Eccleston, et al. (1999). "Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour and behaviour therapy for chronic pain in adults, excluding headache". Pain 80 : 1-13.
Tulder, v. M. , Koes BW, Assendelft WJJ & Bouter LM (1999). The effectiveness of conservative treatment of acute and chronic low back pain. Amsterdam, EMGO Institute.
Turk, R. J. G. D. C. (1996). Psychological Approaches to Pain Management; A Practitioner's Handbook. New York, London, The Guilford Press.
Vlaeyen, J. W. , A. M. Kole Snijders, et al. (1995). "Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance". Pain 62(3): 363-72.
Waddell, G. (1998). The back pain revolution. Edinburgh London New York Philadelphia Sydney Toronto, Churchill Livingstone

Information and advice to patients with low back pain: does it have an effect?

Kim Burton, Spinal research Unit, University of Huddersfield, UK

Introduction: Numerous international guidelines recommend that patients be given appropriate written information/advice about back pain and its management. However, there is little evidence that traditional educational booklets influence clinical outcomes. The Back Book0 was designed to accompany the UK acute back pain guidelines. It differs from previous booklets in that it is evidence based, focuses on what patients themselves should do rather than "medical" or ergonomic information, specifically addresses fear avoidance beliefs, and gives strong advice about staying active. This RCT tested its effects on beliefs and clinical outcomes in primary care patients.
Methods: Sequential patients (n=161) attending six primary care practices agreed to join a trial of an informational booklet. Each patient received "usual care" ; no attempt was made to influence clinical management. Patients were randomised individually from a previously generated random list to receive either The Back Book' or a traditional commercially available booklet that provided what are generally considered to be negative messages as a neutral control. The two booklets were visually similar to equalise the interventions. The study was double-blinded. At base-line each patient completed a visual analogue pain scale, the Roland Disability Questionnaire (RDQ), the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Back Beliefs Questionnaire (BBQ). We hypothesised that the experimental booklet would produce a positive shift in beliefs which would then lead to reduced disability, but would have no effect on pain. Patients were followed up by mail at 2-weeks, 3-months and 12-months, with a 12-month response rate of 78%. The main outcome measures were the physical activity subscale of the FABQ (FABphys), BBQ, RDQ, return physician visits and work loss.
Results: Most patients showed a marked reduction in RDQ by three months. There was a significantly greater improvement in BBQ with the experimental booklet compared with the control. Patients receiving the experimental booklet were more likely to exhibit a reduction in FABphys than patients receiving the control booklet at all three assessment points. For the detailed analysis, a >2-point shift in RDQ and a >4-point shift in FABphys were considered clinically relevant (termed "reduction" hereafter). A greater proportion of patients with an initially high FABphys score who received the experimental booklet had clinically important improvement in FABphys at 2-weeks, followed by a clinically important improvement in RDQ at 3-months. There was no difference in pain reduction between the booklets.
Discussion: Simply handing each patient a small booklet is a weak intervention, yet it demonstrated a significant positive shift in beliefs, which led to a significant reduction in self-reported disability. An approach in which the educational material is reinforced by physician behaviours is likely to be even more powerful; this remains to be tested. The present trial took place in several routine primary care settings, so the results are likely to be generalisable but, because most of the patients did well, returned to work and did not seek further health care, it did not have sufficient power to detect any effect on work loss. The main message of mis study is the empirical evidence showing the importance of appropriate information and advice given to back pain patients.

To analgesic effect of combined use of different physical factors in the treatment of patients with low back pain

A.V. Musayev, R.G. Zeynalov. Sh.T. Talybov
Research Institute of Medical Rehabilitation, 3 Khatai ave, 370008 Baki, Azerbaijan

Objective: To study the development of new more effective methods of treatment of low back pain combined with different physical factors.
Methods: Interference current (1С), electromagnetic decimetre wave (DMW), iodine-bromine baths (IBB) were used. Clinical observations (CO), EMG and electroneuro-myographic (ENMG) studies were performed.
Results: 149 patients were observed. 72 patients (I group) received 1С, 40 patients (II group) - 1С with the following exposure of DMW, 37 patients (Ш group) - subsequent application of 1С, DMW, IBB. Significant reduction of pain showed 45% of I group patients, 66% - of П group, 81% - of Ш group. The patients with subacute painful syndrome developed similar effect in 66%, with moderate syndrome -in 71%, mild - in 77% of cases.
Conclusions: 1. Analgesic effect of interference therapy (45%) was increased by 21% if immediately after the sessions of 1С the patients were indicated DMW exposure. 2. This effect was much higher if above said factor was used in combination with M and IBB.

Epidural prednisolone effect, comparison on pain scale variation in intervertebral disc herniation in relation with laminectomy

Dr.V. Hassani.Dr. A Khamsei.Dr. F. Soleimani, Rassol Akram Hospital, Niayesh St.,Sattarkhan Ave., Dept. of anesthesiology, Iran Medical Sciences University, Tehran, Iran.

Aim of investigation: To investigate the effect of epidural prednisolone on pain scale/scores variation in intervertebral disc hemiation and in relation with laminectomy.
Methods: 44 middle age patients with low back pain were selected non-randomized clinical trial diagnosed with intervertebral disc hemiation in 2 groups.Group A (28 patients) had no laminectomy. Group В (16 patients) with laminectomy history. Pain score was determined by visual analogue scale before injection of 1 ml solution of 5% marcaine and 80 mg perdnisolone with 7 ml normal saline at lumbar level and at 1st and 8th week later.
Results: No meaningful age, gender.injection level,and pain score differences were observed.At 1st week group A with 82% good (0-2) and 7% with no pain score relief and group В with 56% and 6% respectively. At 8111 week group A with 68% good ,7% with no relief and group В with 31% and 19% respectivly.
Conclusions: In comparision, pain relief in patients with no laminectomy was more effective. Therefore the corticostroids can be used in patients with chronic low back pain to relief pain at longer time and to prevent the side effects of other procedures.
Acknowledgements:The authors have no proprietary interest in any of the products mentioned in this article.

The role of epidural ropivacaine in the treatment of radicular pain

Alexander Gnezdilov. Alexei Ovechkin, Anatoly Syrovegin, Mikhail Kukushkin, Idrak Gasanov. Dept. of Anaesthesia, Intensive Care and Pain Relief, Central Research Prosthetic Institute, Moscow, Russia.

Aim of investigation: This study was done to compare the efficacy of epidural administration of three different local anesthetics (LA) in the treatment of patients suffering from lower extremity radicular pain (RP).
Methods: A total of 73 patients with RP were treated with 80 mg 2% lidocaine (group 1, n=35), 20 mg 0.5% bupivacaine (group 2, n=21) and 30 mg 1% ropivacaine (group 3, n=17) given epidurally with 80 mg triamcinolone (group 3) acetonide. Analgesic effect was assessed during 24 and 48 h. Subsequent epidural blocks (up to three) were repeated in 48-72 hr intervals
Results: Of the patients who received ropivacaine with 80 mg triamcinolone (group 3), 100% reported complete pain relief for 24 h after the injection, compared with 82,8% of the lidocaine group (1) and 90.5% of the bupivacaine group (2). It was revealed, that RP resumed in 1.8*0.35 h after lidocaine injection and persisted for 14-16 h until triamcinolone began to act as antiinflammatory agent. Patients received bupivacaine had resumed RP at the interval 7-15 h after epidural block. Ropivacaine and bupivacaine caused similar degree of motor blockade but ropivacaine provided a greater analgesic efficacy and more rapid recovery to full patient mobilisation.
Conclusions: We believe that epidural administration of ropivacaine with triamcinolone is the most effective in the treatment of patients suffering from lower extremity radicular pain.

The role of pain and fear of pain as predictors of an attentional bias in healthy subjects

Jeffrey Roelofs, Dept of Medical, Clinical and Experimental Psychology, Maastricht University, 6200 MD Maastricht. The Netherlands.

Aim of investigation: To investigate to what extent pain and fear of pain predict an attentional bias (selective attention to pain-related information) in healthy subjects. The hypothesis is that fear of pain and the combination of pain and fear of pain would lead to a larger attentional bias compared to pain alone.
Methods: In a 2 x 2 factorial experimental design, ischemic pain was induced by using the Tourniquet test. Subsequently, fear of pain was induced by letting subjects anticipate an electric shock. All subjects performed an emotional Stroop task. It was predicted that naming the colour of pain relevant words is much more slowed-down, compared to neutral words. Furthermore, it was expected that this effect was larger for subjects experiencing fear of pain or the combination of pain and fear of pain than subjects experiencing pain only.
Results and conclusion: Results and conclusions will be presented at the congress.
Acknowledgements: Supported by a fund of Maastricht University.

An acute back pain service - three year outcome review

P J Toomey. A M Bermingham, P A Hall, P J Moss. - York District Hospital, York, Y031 SHE, England.

Aim: To determine pain and functional status of 240 patients 3 years after referral to an Acute Back Pain Service.
Methods: Questionnaires were sent to a cohort of patients who had been reviewed in a previous one year follow-up study'. Patients had been treated by early intervention with physiotherapy and direct referral, as indicated, to the orthopaedic or pain clinic.
Results: Response rate 43%. Follow Up interval: 42 months (S.D. 5.3) Original Pain: 37% back & leg pain. 58% back only. 5% leg only. Pain after treatment: 91% pain improved after treatment. 22% had a recurrence of pain. 9% no better or worse. Pain at 3 year review: 47% have no pain. 37% have the same pain. 16% have a different pain. Functional status now: 41% normal function. 41% normal function with some limitations. 16% were limited in their activities and 2% were severely disabled. 64% had had further episodes of their pain
Conclusion: The goal of managing low back pain is maintenance of function. The long term outcome of 82% patients maintaining normal activity at 3 years is encouraging. Early intervention from the Acute Back Pain Service has been effective in this group.
PA Hall, PJ Toomey, PJ Moss. Acute Back Service - One Years Experience, II EFIC Congress 1997; 250.

Low back pain in primary care: the role of pain patient-physiotherapist interactions. A study proposal

Ruud M.A. Houben. Johan W.S. Vlaeyen, Suzanne van den Berg, Dept of Medical, Clinical and Experimental Psychology, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands

Aim of investigation: To examine the effects of trait negative affectivity, patient-physiotherapist interaction patterns, and the interaction between both on catastrophizing and pain related fear during the course of physical therapy.
Methods: 200 patients, from 20 physical therapy practices in primary care, who visit a physical therapist (PT) with the first episode of non-specific low back pain since 2 years will be included. The PTs will provide their usual care. At baseline (before start of treatment), the following data will be collected from patients: sociodemographics, pain characteristics, pain catastrophizing, pain-related fear, negative affectivity, functional disability and pain intensity. Follow-up measurements (all measures, except sociodemographics and negative affectivity) take place after the second PT session, at 6 weeks and at 3 months after the initial session. To assess the pain patient-PT interactions, all PT sessions will be audio-taped. Audio-tapes will be coded according to Roter's Interaction Analysis System and behavior counts such as explanation of pain and diagnosis, and pain management strategies. A more global assessment of the PT-patient interaction will be done by means of Visual Analogue Scales measuring the utilization of positive reinforcement of pain behavior, ambiguous information and pain-contingent treatment approach. Multiple regression models will be used to assess the influence of the pain patient-PT interaction on catastrophizing and pain related-fear.
Acknowledgement: This study is supported by Grant nr. 904-59-108 of the Council for Medical and Health Research of the Netherlands (MW-NOW).

Sulphurous mineral waters from calimanesti-romania and their use in the treatment of back pain

Sorin Danciu. student, U.M.F. "Caroi Davila" Bucharest;
Dorin Danciu. M.D., U.M.F "Caroi Davila" Bucharest, Calimanesti Clinic

Aim of investigation: Showing the favorable effects of thermal mineral sulphurous hydrotherapy.
Methods: These effects are based on the combined action of three factors: thermal, mechanical and chemical The mobifization of water and mineral salts from the integumentary reserve and the penetration in the extracellular space have a very low speed, so that the acute contraregulatory mechanisms can not appear, as after intestinal absorption.
Results: The consequences of contact between skin and sulphurous mineral water are: activation of the integumentary circulation, appearance of keratolysis, reduction of the skin sensibility, reequilibration of vagal and sympathetic tonuses.
Conclusions: The sulphurous mineral water baths may be recommended for: locomotory diseases; degenerative, chronic inflammatory or abarticular rheumatism; post-traumatic sequaelae; diseases of peripheral nerves: neuritis, polineuritis, psoriatic rheumatism; allergies; gout. The general contraindications are: acute infectious diseases; epilepsy; hemorrhages; Parkinson's disease; neoplasm; cardio-vascular insufficiency; respiratory insufficiency; hepatic insufficiency; renal insufficiency The specific contraindications are: acute locomotory diseases with complications or associated with some other diseases that are inadvisable for a balnear treatment.

Osteoartrosis chronic pain. Compliance index (ci) as a method of comparative measumng for therapy effectiveness

Maurizio Evangelista. Domenico Camaioni. Universita Cattolica del Sacro Cuore, Istituto di Anestesiologia e Rianimazione, 00168, Roma. Italia.

Aim of Investigation: In a patient group with chronic osteoartrosis pain, to determine the compliance index (CI) difference between tramadol and NSAIDs drugs.
Methods: In the setting area of the Center for the Study of the pathophysiology and for the therapy of pain in Catholic University of Rome, we have studied a group of one hundred patient with osteoartrosis pain. The group was composed by 46 males and 54 females, mean age 67.4 yrs; all the patients have experienced treatment with NSAIDs and with tramadol. In this study, to establish the effectiveness of any treatment we propose a simple method of scoring that is Compliance Index obtained by the ratio between the number of provisions daily true assumed and the total number of givings, daily prescribed; CI range will be: max=l, min.=0. The period of observation has been of four mounths.
Results: The prolonged use of NSAIDs is associated with significant adverse effects that represent the most common cause of drop out of the therapy. The CI score that we have noticed for mis drug is 0.77 (185/240) Tramadol is a synthetic opioid analgesic, which also modulates monoaminergic mechanism in the inibitory pain pathways, resulting in a synergistic analgesic effect. The CI score that we have noticed for mis drug is 0.94(226/240).
Conclusions: This is an ongoing study and the results about validation data and procedures of CI will be presented at the meeting.

Pain-related fear in acute low back pain patients

Judith M Sieben. Johan WS Vlaeyen, Piet JM Portegijs, Sandrine Tueriinckx. Departments of General Practice and of Medical, Clinical and Experimental Psychology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands

Aim of investigation: 1. To investigate the early course of fear of movement/(re)injury, pain and disability in patients consulting the general practitioner with a new episode of low back pain (LBP). 2. To assess predictors of disability and pain-related fear two weeks later.
Methods: Data were collected from 33 patients with a new episode of LBP. Instruments: Tampa Scale for Kinesiophobia (TSK), Roland Disability Questionnaire (RDQ), Pain Catastrophizing Scale (PCS), back pain history (day of consultation and two weeks later) and diaries with Visual Analogue Scales (VAS) on fear, catastrophizing and pain intensity during mis two-week period. Analysis: Time Series Analysis (TSA) for each patient (diaries), multiple regression (dependent variable TSK and RDQ at two weeks, resp.).
Results: Mean TSK-scores did not change. TSA of individual diary-data yielded a (significant) decrease of pain-related fear in 10 patients, no change in 18, and an increase in 5. Pain decreased over time in all subgroups. Initial TSK-score was the best predictor of both pain-related fear and disability two weeks later.
Conclusions: Our results are in line with earlier studies in subacute and chronic LBP in emphasizing the role of pain-related fear as a predictor of disability. Individual-level analyses of change in pain-related fear reveal differences, not visible on the group level, that are relevant but as yet unexplained.
Acknowledgements: This study is supported by the Dutch Council for Medical and Health Research (MW-NWO) grant nr. 904-65-090.

Psychological evaluation of low back pain patients at the university hospital

A.Sciupokas. Department of Neurology, Kaunas University of Medicine, Mickeviciaus 9, LT-3000 Kaunas, LITHUANIA

Aim of investigation: To investigate methods of psychological evaluation of Low Back Pain (LBP) patients.
Methods: Participants were LBP patients in Departments of Admissions, Neurology, Neurosurgery at the University Hospital. The investigation was made in fixed three month period, all LBP patients divided into three groups: 1) after neurosurgical treatment; 2) before planned neurosurgical treatment; 3) before planned conservative treatment. Pain intensity and affective levels were examined using the Visual Analogue Scale (VAS -Lithuanian version) and McGill Pain Questionnaire (MPQ-Lithuanian version). Cognitive-verbal responses were measured by originally standardized behavioral interview and by the Minnesota Multiphasic Personality Inventory (MMPI)
Results: 91 LBP patients was examined ( 47 male, 44 female, 20 to 65 years old, mean - 45.44), and chronic pain (duration more 6 month) patients were 76.92 % among them. Intensity of LBP scored from 1 to 10 by VAS (mean -8.16), Quality of LBP investigated by MPQ-LV, and in 35.3 % cased scores were sensory based, in 50.0 % - affective based. MMPI assessment reveals that LBP patients have high scores for scales reflecting Hypochondriasis, Depression, Hysteria, Psychastenia. Data of behavioral interview suggest that pain persistence has high impact to quality of life: in 86.8 % in relation to affective disturbances, in 61.8 % - to lowed levels of communications, in 51.5 % -to changes in interpersonal relations with family and friends.
Conclusion: Based on results the program of psychological evaluation of LBP patients to be included into diagnostic-treatment protocols will be determined.

Chronic low back pain and muscle involvement

Aage Indahl MD, PhD, Sten Holm PhD Dept. of Physical Med. and Rehab. Kysthospitalet ved Stavem, Stavem, Norway. Dept. of Orthopaedics, Sahlgrenska University Hospital, Goteborg, Sweden.

Aim: Investigate the role of muscles in the generatation of low back pain.
Methods: Phase I: 77 patients age 19 -78 years of whom 28 had undergone surgery, were injected with lidocain into back muscles. The sites were chosen based on tendemess/pain on palpation in mm. psoas, quadratus lumborum, multifidus and piriformis. Phase П: 36 patients were injected with botolinium toxin A (Botox®) in painful muscles. 5 patients were injected 2 times, 1 patient 3 times, 1 patient 4 times and 1 patient 11 times. Needle position was verified by CT scans. For paraspinal muscles, EMG guided injections were performed.
Results: Phase I: 20% reported close to complete pain reduction, 40% had 70 - 80% reduction 30% had no effect and 10% reported increased pain. Phase П: Pain reduction: 20% excellent, 40% good, 25% fair, 10% none and 5% worse. One patient injected 11 times had a 4 level fusion and pain reduction of 70 -80% every time. Blocking of EMG activity inside the fused region seemed to be a major contributor to the result. For the others, reinjection into the same muscles did not produce the same effect; by choosing new muscles better effect was achieved.
Conclusion: Muscles seem to be an important pain generator. The findings suggest that the disturbance is more of a neuromuscular dysfunction than a muscular problem. Muscle activation inside a fused segment may be a cause of pain in failed back surgery and treatment using Botox® is promising.
Acknowledgments: ALLERGAN has partly supplied the drug and the project has been funded by grant 1997/179 from the foundation: Health and Rehabilitation, Oslo, Norway.

Analysis of the efficiency of the epidural analgesia in low back pain syndrome using dallas pain questionnaire

SACLIER J.L., BONAMOUR J.D., LARHANTEC C., BAUD P.
Pain Unit. Hopital de NEMOURS 15 Rue des Chaudins 77140 NEMOURS France.

Aim of Investigation: A prospective study to investigate the long term analgesic effect of epidural injections and their place in therapeutical management of low back pain (LBP).
Methods: 40 LPB patients (range 30-70 yrs) refered from an orthopaedic consultation were included : criteria were the following:
- Low back pain since at last 6 months
- Unoperated lumbar disc hernia
- Or operated hernia with painful sequellae
- Failure of medical treatment conducted during one month (NSAIDs, rest, muscle relaxant).
Patients were clinically evaluated by physician (day 0 and 45) : Strength, mobility, sensibility, amplitude. They completed Dallas Pain Questionnaire upon entry into the study and after 45 days. Then epidural analgesia was performed as a single treatment method : decubitus position, involved side down, loss of resistance technique, inject local anaesthetic and steroid. The epidural injected substances were : bupivacai'ne 0,5%, 5 ml plus cortivazol 3,75 mg.
Results: the study is still in progress at this time. Complete data will be collected for next summer. Data will be analysed with ANOVA.
Conclusion: Dallas Pain Questionnaire allows a simple and practical measure of consequence of LPB. It could be a tool to evaluate long term efficacy of pain therapeutics.

Effectiveness of botulinumtoxin in chronic low back pain

Bahman Jabbari. MD
Department of Neurology - USUHS, 4301 Jones Bridge Road, Bethesda, Maryland 20814, USA

Aims of investigation: To study the effectiveness of botulinum toxin A in chronic , mechanical low back and disability
Methods: Thirty -eight patients with chronic low back pain were studied using either an open (10) or a randomized, double blind design (28). In the double blind group, half received 200 units of botulinum toxin type A (Botox), 40units/site, at five lumbar paravertebral levels, on the side of maximum discomfort. The other half received normal saline (NS). Each patient's baseline level of pain and degree of disability was documented using the visual analogue scale (VAS) and the Oswestry's Low Back Pain Questionnaire (OLBPQ). We re-evaluated the patients at three and eight weeks (VAS) and at eight weeks (OLBPQ).
Results: Seven of ten patients in the open study showed significant improvement (>50%) at three weeks and two months. In the double blind group, at three weeks, 11 of 14 who received Botox (78%) showed significant (> 50%) pain relief versus 4 of 14 (28%) in the NS group (p=0.021). At eight weeks, 9 of 14 in the Botox group (61%) and 2 of 14 (14%) of NS group reported relief (P=0.018). Repeat OLBPQ at eight weeks showed significant improvement in 10 of 14 (70%) in the botulinum toxin group versus 3 of 14 (21%) in the NS group (P= 0.022).
Conclusion: This study shows that paravertebral administration of botulinum toxin A can ameliorate chronic low back pain and improve the disability.

The efficacy of dynamic lomber stabilization exercise program in chronic mechanical low back pain

Aysegiil Ketenci, Liitfiye Musliimanqglu, Emel Ozcan, Aliye Aydogan, Buket Aksac, Nalan Sen, AyBegul Ellialtyoglu, Ender Berker
Ystanbul University, Ystanbul Medical Faculty, Department of Physical Medicine and Rehabilitation, Ystanbul Turkey

In industrialized countries, chronic mechanical low back pain has become a major health issue due to its high prevalance in the general population and adverse effects on the work-day losses. Various assessments and therapeutic interventions with relatively long periods of rest lead to in immobilization of the patient and chronicity of pain with decreased return-to-work rates. Dynamic lomber stabilization exercises (DLS), performed for 8 weeks, three sessions weekly, aim to increase aerobic capacity, elasticity of the soft tissues and over-all fitness of the patient.
Methods and material: 31 patients with chronic mechanical low back pain admitted to our Department of Physical Medicine and Rehabilitation were recruited for this study. The group were randomized into DLS exercise (n=31) and Back School (BS)(n=6) groups and the therapeutic effects were assessed after two years with two-year follow-up. There was no significant difference between the groups in relation to age, educational level, gender and follow up period.
Results: The assessment parameters of Schober and Modified Schober, muscular strength (abdominal and extensor muscles, PILE test) functional status (Oswestry Disability Index), pain (VAS) and depression (Back Depression Inventory) showed significant improvement in the DLS group compared to baseline data. Lomber muscles extensor strength was the sole parameter that showed significant (P<0.01) improvement in the BS group. The initial baseline data showed no significant difference between the group whereas control scores showed significant difference (p<0.05-p<0.001). The above findings led us to conclude that patients with chronic mechanical low back pain given intensive exercises have a better outcome on long term follow-ups.

Regional variations in chronic low back pain

Liitfiye Muslumanoglu (1), AyBegul Ketenci (1), Jale Sarac(2), Vesile Sepici(3), Ben-in Durmaz(4), Aker AkyokuB(5), Vural Kavuncu(6), Omer Kuru(7), AyBe Karan(l), Emel Ozcan(l), EnderBerker(l)
1- Ystanbul University, Ystanbul Medical Faculty, Department of Physical Medicine and Rehabilitation, Ystanbul, Turkey
2- Dicle University, Department of Physical Medicine and Rehabilitation, Diyarbakyr, Turkey
3- Gazi University, Department of Physical Medicine and Rehabilitation, Ankara, Turkey
4- Ege University, Department of Physical Medicine and Rehabilitation, Yzmir, Turkey
5- Akdeniz University, Department of Physical Medicine and Rehabilitation, Antalya, Turkey
6- Fyrat University, Department of Physical Medicine and Rehabilitation, Elazyg, Turkey
7-19 Mayys University, Department of Physical Medicine and Rehabilitation, Samsun, Turkey

Mechanical low back pain is a major health issue threathening industrialized country because of substantial work-day losses. Various studies have demonstrated that 60-80% of the general population has at least one low back pain episode during their life-time. Pain lasting longer than 6 months is considered chronic and pain perception and behavior in chronic pain is affected not by the underlying pathology but with personality, beliefs, upbringing, psychological status and sociocultural factors of each patient which should not be over looked when assessing patients with chronic pain.
Turkey has severe different geographic areas where people with different cultures.beliefs and habits live.
We aimed to determine the patterns of pain behavior, functional impairement due to pain and quality of life in people with chronic low back pain living for at least 10 years in these areas. 350 patients with chronic LBP filled in a questionnarie in pilot center at each geographic area. The form included personal data, Oswestry disability and Roland-Morris questionnaires for functional impairement, SIP for QL under subgroups of recreation, social interaction, sleep, awakeness and working capacity.
The results of the study have demonstrated that pain perception during movement was significantly higher in patients living in the Black Sea region whereas scores of SIP subgroups and Oswestry and Roland Morris questionnaire scores were significantly higher in patients living in the South-eastern anatolia region (p<0.001).
This evaluation showed that pain perception was higher in patients on the Black Sea region whereas functional impairement due to pain was higher in those in the South-eastern anatolia region.

Back pain in cancer patients: specifics in diagnosis and treatment

DALIA SKORUPSKIENE MD. PhD. ONCOLOGY CLINIC, KAUNAS UNIVERSITY OF MEDICINE, KAUNAS 3007, LITHUANIA

Aim of investigation. To determine better diagnostic and treatment algorhitm for cancer patients with back pain.
Methods.The data was collected about 86 cancer patients (seen in Kaunas Medical University Hospital, 1998-1999), who suffered from back pain.All patients were formerly diagnosed having cancer. Back pain intensity varied (VAS:5-10). Diagnostic X-rays were performed for all patients, osteoscintigraphy (Tc 99m) for 57, CT for 36, MRI- 6 patients. After determining the cause of the back pain treatment was revised.
Results. The causes of back pain were: metastases in vertebral bodies (71 patient-82,5 %), metastases in suprarenal glands (3 cases-3,5%), sarcoma in pelvis bones (lease- 1,2%), metastases in the lower ribs - 4 cases (4,6%), non malignant pain- 7 cases -8,1%. X-rays for vertebral metastases were highly informative only in 25 cases, 30 showed some low possibility of metastases, 16 were absolutely uninformative. In these cases osteoscintigraphy strongly advised metastases in vertebral bodies and CT confirmed the diagnosis (in 2 cases only MRI). The pharmacotherapy was performed according to the WHO analgesic "ladder". 65 patients with bone lesions received palliative radiotherapy. It allowed lowering drugs doses for 60 patients (92%). Heat and some other physiotherapy procedures were urgently discontinued (14 cases).
Conclusions. The presence of back pain calls for a very thorough examination of the cancer patient. While suspecting metastatic lesion in bones, the negative X-ray cannot reject this possibility. The palliative radiotherapy for vertebral or bone metastases is beneficial. Some physiotherapy modalities must not be used for cancer patients.

Neuromodulation in the failed back surgery syndrome

Scafuro M.A.. Natale M., R. Molinari, Puglisi A., Rizzo B., M. Chiefari.
Institut of Anesthesiology Intensive Care. Institut of Neurosurgery. II University of Naples

Aims of investigation: The aim of this study is to evaluate the role of the neuromodulation: spinal cora stimulation (SCS) and intrathecal opioid therapy in the treatment of the failed back surgery syndrome (FBSS) unresponsive to the conventional treatments.
Methods: Among 6 patients affected by FBSS unresponsive to previously administered SCS 3 patients are been treated with the SCS associated with a intrathecal opiopid treatment. After the trial tests for both procedures the neurostimulators and the programmable pumps for the delivery of the morphin were implanted. In the others 3 patients the alone SCS was continued.
Results: In all 3 patients the neuromodulation give a pain relief in absence of collateral effects.
Conclusion: FBSS is not ever responsive to the SCS; the results obtained with the neuromodulation encourage a more large application of this treatment in the patients affected by chronic back and leg pain. The keys to success are: accurate candidates selection preoperative evaluation with trial treatments for SCS and for opiods.

A long-term follow-up of a pain rehabilitation model focused on emotions, in patients with chronic back pain

Ragnhild Raak. Ingrid Hurtig, Anders Raak, LisKarin Wahren

Aim of investigation: The aim was to test a pain rehabilitation model focused on emotions. This model would allow nurses to help patients modify their own explanatory model. A further purpose was to evaluate the participants in the program with regard to pain coping strategy and quality of life after 3 and 6 years, respectively.
Methods: Twenty-two patients, 12 in the program and 10 in a control group, (aged 33 to 57 years) all with severe pain despite treatment were included in the study and a quasi-experimental design was used to test the model. Coping strategies and HRQL were evaluated using the Coping Strategy Questionnaire (CSQ) and the SF-36, respectively.
Results: Several of the participants returned to work after the program, which was an objective sign of successful rehabilitation. No significant differences were found in the standard treatment group when comparing pre- and post-test reports. Evaluating coping strategies after 3 years resulted in decreased cathastrophising which remained 6 years later. Measuring HRQL showed a significantly increased physical function and general health both at 3 and 6 years follow-up, while mental health was improved only after 6 years.
Conclusions: The rehabilitation program did result in improved general and mental health but not in less pain. The catastrophising behaviour was de-creased and therefore we suggest that perceived health might be due to pain coping strategy use.

Graded exposure in vivo in the treatment of pain-related fear

Johan W.S. Vlaeyen, Jeroen de Jong, Mario Geilen, Peter H.T.G. Heuts, Gerard van Breukelen4. 'Dept. of Medical, Clinical & Experimental Psychology, and "Methodology & Statistics, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands; Pain Management and research Center, University Hospital Maastricht; Poensbroeck Rehabilitation Center, The Netherlands

Aim of investigation: To examine the effectiveness of a novel graded exposure in vivo treatment with behavioural experiments in reducing pain-related fears, pain catastrophizing and pain disability.
Subjects: Six consecutive CLBP patients who were referred for outpatient behavioural rehabilitation, and who reported substantial fear of movement/(re)injury.
Methods: Using a single-case cross-over design, a no-treatment baseline measurement period was followed by one of two interventions. In intervention A, three patients received the exposure in vivo first, followed by graded activity. In intervention B, the sequence of treatment modules was reversed for the other three patients. Eighty-four daily measures of pain and pain-related cognitions and fears were recorded with visual analogue scales. Accelerometer data with taken for one week in each treatment phase. For both treatments, credibility checks were performed.
Results: Treatments were rated equally credible. Improvements in pain-related fears and disability only occurred during the graded exposure in vivo, and not during the graded activity, irrespective of the treatment order. For accelerometer data, a similar pattern was observed.
Acknowledgement: Ibis study was supported by Grant nr. 904-65-090 of the Council for Medical and Health Research of the Netherlands (MW-NWO).

Behavioral graded activity and problem solving therapy in the treatment of non specific low back pain (LPB)

J.H.C. van den Hout, J.W.S. Vlaeyeni, A.M.J. Kole-Snijders, P.H.T.G. Heuts, J.E.H.L. Willen, W.J.T. Sillen, Department of Medical, Clinical and Experimental Psychology, Maastricht University, PO Box 616, 6200 MD Maastricht, NL; institute for Rehabilitation Research, Hoensbroek, NL; Department of Pain Rehabilitation, Limburg Foundation for Rehabilitation, Hoensbroek, NL.

Aim of investigation: This randomised controlled trial investigates the surplus value of Problem Solving Therapy (PST) when added to Graded Activity (GA).
Methods: Subjects are included when they are having LBP for more than 6 weeks and are on the sick list at the time of the intervention, but no longer than 20 weeks continuously. Subjects are exclu-ded when they have specific back complaints, have been sick listed for more than 120 days during the last year, or have severe psychopatho-logy. After selection, subjects are randomly assigned to one of two conditions: A) GA + PST; B) GA + Group Education. Primary outcome measures are functional disability (QBPDS; RDQ); days ofsickleave (cost diary; registration);
and health care utilization (cost diary). Secondary outcome measures are fear avoidance beliefs (FABQ); pain cata-strophizing (PCS); pain-related fear (TSK); pain behaviour (PGS); problem solving skills (SPSI-r); and depressive symptoms (BDI). Data are collected pretreatment; immediately after treatment; and at a 6- and 12-months follow-up. Multiple regression analyses will be used to analyse the data.
Results: Both condition A and В appear to be promi-sing in reducing disability levels, fear-avoidance beliefs, pain catastrophizing; pain-related fear; and pain behaviour. Comparisons between condition A and В are currently being analysed, and will be presented at the congress.
Acknowledgments: Supported by the Dutch Organization for Scientific Research, Grant no 940-31-004.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 128, 129, 130, 140, 237, 238, 240 - 243, 257, 258, 260, 264, 270, 273, 274, 309, 332, 337, 342, 343.