Low Back Pain

10th World Congress on Pain, List of topics

S.A. Chrubasik, E. Eisenberg O. Knzel1, N. Krivoy2, S. Pollak Forensic Medicine, University of Freiburg, Freiburg, Germany , 2 Pain Unit, Rambam Medical Center, Haifa, Israel

Aim of investigation: To evaluate the effectiveness and safety of the proprietary willow bark extract Assalix.

Methods: We included patients suffering from acute exacerbations of chronic low back pain. They were instructed to apply over 4 weeks either the proprietary willow bark extract Assalix with 240 mg (W240, n=296) or 120 mg (W120, n=185) salicin per day or placebo (P, n=70) or conventional treatment (C, n=338) (I: n=679 open controlled, II: n=210 randomized double-blind). Clinical effectiveness was assessed by means of patient diaries and/or the Arhus low back pain index before and at the end of treatment.

Results: Study groups were well matched. After 4 weeks the number of pain-free patients was 40%, 19% and 18% in groups W240, W120 and C, respectively in I and 4, 15 and 27 in groups P, W120 and W240, respectively (p<0.001) in II. These findings were reflected reasonably well in the changes in the Arhus index. Already after one week of treatment, significantly more patients were pain-free in group W240 (p=0.048). Treatment outcome between group W240 and patients receiving rofecoxib 12.5 mg per day did not differ. Treatment in groups W240 and W120 was significantly cheaper than in group C. No specific adverse events were observed except occasional allergic skin reactions. Blood clotting was only minimally affected by Assalix.

Conclusions: Our results indicate that Assalix is superior to placebo and can be used alternatively to NSAIDs.

Ackknowledgements: In part supported by the European Academy of Natural Medicine and Plantina GmbH/Munich.

A. Kumar, O. Tandon, T. Kumar, A. Bhattacharya, M. Kumar Pain clinic, University College of Medical, Delhi, India

Aim of Investigation: To evaluate intrathecal midazolam for chronic mechanical low back pain(LBP) utilizing Brainstem auditory evoked responses (BAER)and VAS,VRS,Pain duration and quality of sleep at intervals.

Methods: Forty patients (M:F::26:14) of chronic Mechanical LBP (1-8 years duration), 20-60 years were randomized into 2 groups- 20 patients each. Ethical Committee approval and written Informed consents obtained. Group-A patients received 80mg. Methylprednisolone in 15ml. 0.375% bupivacaine injected into lumbar epidural space plus 3ml. 5% dextrose into lumbar intrathecal space. Group-B patients received 15ml. 0.375% bupivacaine into lumbar epidural space plus 2mg. preservative free midazolam in 3ml. 5% dextrose into lumbar intrathecal space, using same needle and site in both groups. BAERs evaluated at baseline, 1hr. and 24hrs. following treatments. VAS,VRS assessed at baseline, 1hr,24hrs.,2weeks and 4weeks. Pain duration and quality of sleep assessed at 2weeks and 4weeks. Stat. analysis using unpaired t-test and ANOVA with Tukeys.

Results: Reduction (p<0.05) observed in IPLs (inter-peak latencies) I-III, I-V, and III-V at 1hr and 24hrs following treatments in each group.Improvements (p<0.05) occurred in VAS and VRS at 1hr,24hrs,2weeks and 4weeks. At 4 weeks, intrathecal midazolam patients had less pain duration (amount of time in pain during day). At 4weeks, 16 patients of epidural steroid and 13 patients of intrathecal midazolam, graded quality of sleep as better.

Conclusions: Intrathecal Midazolam is effective treatment in chronic mechanical LBP as based on significant improvements in VAS,VRS,Pain duration,quality of sleep and significant reductions in IPLs.

H.A. Gremillion, Y. Abou-Atme, Dental School, Saint Joseph University, Beirut, Lebanon , 2 School of Dentistry, University of Florida, Gainsville, FL

AIM OF INVESTIGATION The purpose of this study is to assess the effect of dental studies on low back pain LBP in dental students between their first year of studies and their last year.

METHODS In November 1996, all First year dental students (N=32; 25M/7F) at Saint Joseph University (Lebanon) were asked about their low back pain. They were asked to rate their pain on a 0-10 visual analog scale as part of a multi-symptom questionnaire. In January 2001, the same students answered the same questions. The answer 0 was considered a negative answer, and any low back pain rating ranging from 1 to 10 was considered a positive one. McNemars test was used for statistical analysis.

RESULTS 10 students had low back pain LBP during their first year and last year of studies, 5 did have LBP during their first year but not during their last fifth year, 8 had no LBP during their first year but had it during their last year and 9 students did not have any LBP neither during their first nor their last year of dental studies. McNemars test showed no significance in low back pain between first year and last year (chi square = 0.69, P<0.05).

CONCLUSIONS The data suggests that dental studies are not a significant contributing factor to lower back pain.

G.T. Jones, K.D. Watson1, S. Taylor, A.C. Papageorgiou, A.J. Silman, D.P. Symmons, G.J. Macfarlane ARC Epidemiology Unit, University of Manchester, Manchester, United Kingdom , 2 Unit of Chronic Disease Epidemiology, University of Manchester, Manchester, United Kingdom

Aim: Low back pain (LBP) is commonly reported in childhood although aetiological studies have produced inconsistent results. We conducted a large prospective study investigating the role of mechanical load and adverse psychosocial factors on symptom onset.

Methods: A questionnaire-based survey identified 1046 children aged 11-14yrs who were free of LBP. Mechanical load was measured by schoolbag weight. Psychosocial factors were measured using the Strengths and Difficulties Questionnaire. Information was also collected on other childhood somatic symptoms. New onset LBP was identified by questionnaire 1 year later.

Results: 168 children (19%) reported a new episode of LBP (response rate 89%). Onset of LBP was associated with neither daily mechanical load (5th vs 1st quintile RR: 1.2; 95%CI: 0.7 2.1), nor load relative to body weight (0.8; 0.5 1.5). Children reporting the most adverse psychosocial exposures were more likely to report new onset LBP than those with the least (1.6; 1.1 2.3); in particular, conduct problems (2.5; 1.6 3.7). Baseline report of somatic symptoms such as abdominal pain (1.8; 1.1 2.9) were also strongly predictive of onset.

Conclusions: This study has not demonstrated a link between mechanical load and the short-term risk of new onset LBP in adolescents. In contrast, adverse psychosocial factors are predictive, as is the existence of other somatic complaints. These results are consistent with studies of LBP in adults. They also suggest that the origins of the LBP career may partly be from childhood.

Acknowledgements: Colt Foundation; MRC; ARC

B. Spakauskas, A. Sciupokas Neurosurgery, Kaunas University of Medicine, Kaunas, Lithuania , Neurology, Kaunas University of Medicine, Kaunas, Lithuania THE ASSESMENT OF PAIN AFTER LOW BACK SURGERY Br. Spakauskas, A.Sciupokas Department of Neurosurgery, Kaunas University of Medicine, Lithuania Department of Neurology, Kaunas University of Medicine, Lithuania

Aim of investigation: The aim of this study was the assessment of pain after low back surgery and determination of causes for re-operation.

Methods: The patients with persistent pain after low back surgery were investigated using methods of psychological evaluation of pain (VAS, McGill Questionnaire), neurological examination, and according findings in operational materials.

Results: The total number of investigated patients was 175. According to cases of re-operations all patients were subdivided into three groups: one re-operation 132, two 32, three and more 11. Psychological evaluation in 53 patients showed that the pain intensity varied from 4 to 10 by VAS, and the assessment of the quality of pain showed the prevalence of affective pain descriptors in the prolonged chronic pain group (12 months and more). According data of neurological examination sensory disturbance was found in 170 cases, and motor damage signs in 83. Surgery findings were the following: in 68 cases peridural fibrosis, in 52 new level of disc herniation, in 43 recurrence of herniation, and in 9 cases discitis.

Conclusions: (1) Chronic prolonged pain after low back pain surgery was found in 6 % cases; (2) Peridural fibrosis was the most frequent cause of pain; and (3) Psychological factors had a big influence on the persistence of pain.

J. Prochazka neurosurgery, Masaryk hospital, Usti nad Labem, Czech Republic

AIM OF INVESTIGATION: To study an algorithm for non-surgical therapy of failed back surgery syndrome in patients without long-term pain relief after one or more low-back surgeries and without new recurrent herniation.

METHODS: Our algoritm consists of: psychotherapy; exercises and correction of long-term analgesic therapy; and three stages of mini-invasive therapies: (1) trigger-points injection or sacro-illiacal joint injections; (2) administration of spinal steroids; and, (3) intrathecal administration of midazolam. When one of stages is not sufficient, we pass to the next higher one.

RESULTS: Up until the beginning of 2002 we treated 281 patients with failed back surgery syndrome who had undergone surgery between 1974 and 2001. (Follow up for our non-surgical therapy lasts from 4 months to 8 years.) Four patients had undergone four low-back surgeries, 10 patients three surgeries, and 77 patients two surgeries. In the first stage, trigger-point injections were performed in 83 patients and sacro-illiacal joint injections in 222 patients. In the second stage, epidural steroids (with or without hyoluronidase) were administered in 129 patients, and in the third stage intrathecal midazolam was administered in 61 patients. Most often we applied a repeatedly-performed combination of all these methods.

CONCLUSIONS: Combinations of these methods can provide long-term pain relief in many patients usually for several weeks or months. When this therapy has no sufficient long-term effect, clinical findings are relevant. When correspondent lesions are identified with CT or MRI scans, we offer surgical treatment, usually decompresion with stabilisation. This surgical decompression was indicated or performed in 20 patients in our study group.

A. Sciupokas, K. Petrikonis 1 Neurology, Kaunas University of Medicine, Kaunas, Lithuania , 2 Neurology, Kaunas University of Medicine, Kaunas, Lithuania HOSPITALIZATION OF LOW BACK AND PELVIC PAIN IN NEUROLOGICAL DEPARTMENTS OF MULTI-PROFILE HOSPITALS. Arunas Sciupokas, Kestutis Petrikonis Department of Neurology, Kaunas University of Medicine, Mickeviciaus 9, LT-3000 Kaunas, Lithuania

Aim of Investigation: To identify hospitalization rates and evaluate clinical manifestations of LBPP in neurological departments of multi-profile hospitals of Kaunas, Lithuania.

Methods: This was a retrospective study based on statistical documentation of 4 non-specialized neurological departments and 2 specialized neurological departments for spinal diseases. Demographic data, clinical manifestation of LBPP and course of disease were collected for the follow-up evaluation from the one year (2000) medical inpatient records. The IDC-10 codes and the Classification of Chronic Pain (IASP Press, 1994)was used.

Results: The total number of revealed inpatient medical records was 10331 with 2863 (27.7 %) cases of the LBPP syndromes. Neurological syndromes of LBPP like neuropathic pain problems were considered in 2158 cases (75.38 %). Patients of acute both chronic persistent course of LBPP were hospitalized in 4 non-specialized neurological departments, and it consisted of 849 (39.74 %) LBPP patients. Patients of subacute course of LBPP most often were hospitalized in specialized neurological departments for spinal diseases (60.26 %). The rate of neurological syndromes of LBPP was higher in non-specialized neurological departments (86.93 vs. 70.51).

Conclusions:(1)Hospitalization rate of LBPP in neurological departments of Kaunas city multi-profile hospitals was 27.7. (2) Neuropathic pain problems were in majority and consisted of three quarters (75.38 %) of all LBPP cases.

N.N. Yakhno, E.V. Podtchoufarova, V.V. Alexeev Setchenov moscow medical Academy, Moscow, Russian Federation

Aim of investigation: To evaluate the influence of pathopsychological characteristics and structural changes on course of chronic low back pain.

Subjects and methods: 75 chronic low back pain patients undergone objective physical impairment assessment, lumbar spine X-ray and MRI, VAS, McGill pain questionnaire, Zung depression inventory,SCL-90R, MMPI, Toronto alexithymia scale, The Coping Strategy Indicator, Waddell non-organic signs test.

Results: somatoform pain disorder (SPD) diagnosis (DSM-IVR) was established in 33 cases, 42 subjects were diagnosed as having L3-S1 compression radiculopathy, facet dysfunction, iliosacral joints dysfunction and ischiocrural myofascial pain syndrome as well. There was no correlation between objective physical impairment, pain intensity and disease duration both in SPD and neuroorthopedical dysfunction. Levels of depression, anxiety, somatization, interpersonal sensitivity and MMPI 1,2,3,6,7 and 8 scales scores were significantly higher in SPD (p<0,05). Abnormal illness behavioral symptoms and signs were more frequent in SPD (p<0,05) and mildly correlated with MMPI hypochondria and hysteria scales elevation; SCL-90R somatization, depression and affective rigidity scales elevation and also with financial compensation in connection with the disease. The patients who did not return to work during 6 months after treatment had more prolonged absence from work and MMPI hysteria scale score elevation. Those who did not benefit after treatment were characterized by MMPI hysteria and hypochondria scales score elevation.

Conclusion: Psychological factors being more important in chronic low back pain mechanisms than the structural vertebrogenic changes do form inadequate social adaptation thus maintaining pain behavior.

A. Capriati1, M. Mas1, M. Bertolotti1, H. Zippel2, I. Paredes Clinical Research, Menarini Ricerche S.p.A., Florence, Italy , 2 Abteilung Orthopdie, Humboldt, Universitt Charit, Berlin, Germany

Aim of investigation: To evaluate the efficacy and safety of dexketoprofen trometamol (DKP.TRIS) in the management of moderate-severe low back pain vs diclofenac (D).

Methods: A total of 370 M and F ambulatory patients, age between 18 and 75 y, with acute low back pain (<1 week duration), were randomised to 50 mg DKP.TRIS or 75 mg D, both administered I.M. b.i.d. for a total of 4 doses. Pain intensity was rated at pre-specified time-points using a 100 mm VAS. A functional assessment by Roland Disability Questionnaire (RDQ) was scored at baseline and at the end of study period. The control of pain following the first injection of study medication (SAPID0-6h) was the primary efficacy parameter. Safety of treatments was assessed by monitoring AEs.

Results: The two treatment groups characterised by severe pain and compromised functional capacity (mean VAS=74 mm and mean RDQ=13 score). Analgesic efficacy was obtained following the first dose of DKP.TRIS, with comparable effect versus D (SAPID0-6h=117 vs 115 mm.h); the maximum analgesic effect was obtained at the same time-point (tPIDmax=3.6 and 3.7 h); pain control was obtained over the treatment period, with no difference between groups (SAPID0-last=296 vs 283 mm.h). RDQ score improvement was achieved following the four doses of treatments (median difference vs baseline=-6.0 in both groups). The tolerability profile of DKP.TRIS and D was almost overlapping (drug related AEs in 21% and 23% pts). No SAE was reported.

Conclusion: DKP-TRIS given as 50 mg I.M. b.i.d. demonstrated to be an efficacious and safe tool in the medical armamentarium for the acute treatment of moderate to severe musculoskeletal pain.

Acknowledgments: Supported by grants from Menarini Ricerche S.p.A.

L. Moseley P.W. Hodges, M.K. Nicholas, Department of Physiotherapy, Royal Brisbane Hospital & University of Queensland, Brisbane, QLD, Australia , 2 Pain Management and Research Centre, University of Sydney & RNSH, Sydney, NSW, Australia , 3 Prince of Wales Medical Research Institute and UNSW, Sydney, NSW, Australia

AIM OF INVESTIGATION: To determine whether fear of pain disrupts postural control of the back muscles and whether the effect is dependent on the anatomical location of the pain.

METHODS: Eight healthy subjects performed a voluntary arm movement task, which is associated with preparatory postural activation of the back muscles. Electromyographic data were obtained from deep (DM) and superficial (SM) multifidus. Fear of pain was induced by delivering random and unpredictable noxious cutaneous shocks to the elbow or back.

RESULTS: During control and fear of elbow pain, the onset of the response in DM and SM occurred ~50 ms before arm movement. During fear of LBP, the response in DM occurred later (~20ms before movement, P <0.01). The group mean for the response in SM was unchanged, however, consistent changes occurred in individual subjects. Reported distress, galvanic skin response and heart rate showed that there was a similar response during both fear conditions.

CONCLUSIONS: Fear of pain alters postural control of the back muscles during arm movement. Delayed activation of DM is a consistent response and activation of SM is altered in a manner which varies between individual subjects. Fear of elbow pain does not have these effects, which indicates that the anatomical relevance of the pain is important. The findings indicate that when people are afraid of LBP, postural response abnormalities exist even when there is no alteration of the movement.

ACKNOWLEDGMENTS: Financial support from the NHMRC of Australia.

S. Mousavi, L. Mousavi, S. kamal, A. Alavizadeh Physical Therapy, Faculty of Rehabilitation,Isfahan University of Medical Science, Isfahan, Iran

AIM OF INVESTIGATION: The aim of this study was to determine the inter- and intra-examiner reliability of eight static and dynamic palpation tests used to diagnose SIJD.

METHOD:Three motion palpation tests,1) the gillet test, 2) standing flexion test, and 3) sitting flexion test and five static palpation tests, namely palpation and assessment of the levels of 1) posterior superior iliac spine (PSIS) in standing position, 2) PSIS in sitting position, 3) anterior superior iliac spine (ASIS) in standing position, 4) Medial Maleolus (MM) in supine position, and 5) MM in long sitting position were performed on ten patients with chronic low back pain by four examiners. Each test was performed four times by each examiner resulting in 1280 assessments in total.

RESULTS: Intra examiner agreement of static palpation tests revealed a range of reliability from slight to good. Kappa coefficient(k) yielded intra examiner agreement that ranged between slight to good for the PSIS in standing position (k=0.18-0.75), slight to moderate for the ASIS (k=0.15-0.5), and slight to fair (k=0.1-0.35) for other static and all motion palpation tests. Inter examiner reliability of all the static and dynamic tests did not exceed slight reliability (k=0.0-0.2).

CONCLUSION:The results of this study suggest that the reliability of palpation and assessment of the levels of the PSIS, ASIS, and MM in static positions, and the gillet, standing flexion, and siting flexion tests as indicators of sacroiliac joint dysfunction still remain questionable. Therapists should reconsider the usefulness of evaluation techniques that rely on the assessment of the anatomical symmetry of bony landmarks of the innominates in static and dynamic conditions.

R.J. Smeets, L.N. Geken, J.W. Vlaeyen, A. Hidding, G.J. van der Heijden, A.A. Knottnerus Rehabilitation centre Blixembosch, Eindhoven, Netherlands , 2 University Groningen, Groningen, Netherlands , 3 University Maastricht, Maastricht, Netherlands , 4 Institute for Rehabilitation Research, Hoensbroek, Netherlands , 5 Julius Centre, Utrecht, Netherlands

Aim of investigation: Based on the three most common used models for the treatment low back pain disability (physical disuse model, the cognitive-behavioral model and the biopsychosocial model), three new treatment protocols were developed using scientific literature and consensus rounds with experts. The aim of this study is to evaluate the effectiveness of these treatments and a waiting list control group and to identify possible predictors regarding the effectiveness of the three treatments.

Methods: Designing a randomised clinical trial in 4 Dutch rehabilitation centres. Patients with non-specific low back pain disability lasting at least 3 months, aged 18-65 years. Outcome measures that will be gathered (pre-, post, 6 and 12 months after end of treatment):

Disability (Roland Disability Questionnaire, patient specific complaints, overall perceived improvement)

Depression (Becks Depression Inventory)

Pain (McGill Pain Questionnaire)

Physical performance (functional capacity measurements)

Health related quality of life (EuroQol)

Health and non-health costs (cost diary)

Results: During congress the three treatment protocols will be presented and discussed in detail.

Conclusions: schedule for this study:
2001- march 2002 construction treatment protocols
April 2002- 2005 trial and 1 year-follow up assessment
2006 analysis

Acknowledgments: Supported by grant from ZorgOnderzoekNederland (grant number 014-32-007).

A. Ozguler A. Guguen, A. Leclerc, S. Le Gall3, M. Landre, M. Piciotti, M. Morel-Fatio, F. Boureau U 88, INSERM, Saint Maurice, France , 2 CETD, Hpital Saint-Antoine, Paris, France , 3 SMTO, Paris, France , 4 Centre de Rducation, Coubert, France

Aim of Investigation: A longitudinal study was set up in order to identify risk factors of chronicity and sick leave among low back pain (LBP) sufferers and to set up a predictive score for chronic LBP.

Methods: 620 workers with LBP filled in a questionnaire during a visit with their occupational physician. They all had a sick leave of at least 7 days for LBP in 1998; 505 of them answered to a second questionnaire in 1999.

Three groups of LBP sufferers were defined according to answers to a second questionnaire:

Chronic LBP = LBP lasting more than 3 months, with or without sick leave; Sick leave of seven days or more for LBP; Minor or no LBP.

Predictive risk factors and a prediction score have been established with logistic regression models.

Results: Risk factors for chronic LBP were pain severity, pain duration and consequences of LBP in daily life measured with the Dallas Pain Questionnaire;

For sick leave, risk factors were fear avoidance beliefs about work, social isolation or trunk rotation .

A score predicting the risk of chronic LBP the following year was set up. If all risk factors were present the probability of having a chronic LBP the following year was 85%. If there was no risk factor, the probability was 4%.

Conclusions: There is a need for a tool which would facilitate classification and decision making of LBP sufferers . The use of a prediction tool during visits would allow the identification of subjects with a high risk of chronic LBP and could help to refer the patient to an adequate plurimodal program.

Acknowledgments: Supported by grant of Institut UPSA de la Douleur

C. Baude, T. Ben Messaoud, Consultant in Pain, Hopital E. Herriot, Lyon, France

AIM OF INVESTIGATION: Validate a protocol of intravenous analgesic chronotherapy on site implantable by pump "Melodie" (Laboratory Aguettant) for treatment of the mixed chronic pain after lumbar spinal surgery.

METHODS: 10 patients with a mixed chronic pain (ineffective treatments and multiple hospitalizations) after lumbar spinal surgery (L4-L5) were included in the study after implantation of an intravenous site implantable and psychological expertise. An ambulatory pump "Melodie" (4 canals independents : chronotherapy PCA) has put with the following protocol: Amitriphyline 25 to 75mg/J, Ketoprofene 50 to 150 mg/J, Morphine 20 to 240 mg/J and Morphine PCA. Statistical analysis on the general data of the patient, the pain, the side effects of the protocol and its evaluation (VAS, Stai, Dallas) were used in J0, and in J30, J90, J180 after the end of the protocol.

RESULTS: The 10 patients (6 men and 4 women) have mean age of 46 years with a chronic pain for 10 years on average. The intravenous analgesic protocol with pump "Melodie" has last 4,6 months on average (1 only ablation of the catheter for infection). General data did not influence the durable amelioration of the intensity of the pain (VAS: 8,9 J0; 4,8* J30; 5,3* J90; 5,4* J180; p<0,01) and the quality of life brought with this protocol (Dallas: Daily Activity: 78% J0; 48% J30; 52%* J9; 53%* J180; p*<0,01, Dallas: professional activity, depression and sociability also significant p<0,01).

CONCLUSION: The mixed chronic pain after lumbar spinal surgery is difficult to cure. It's a major social problem. A protocol of intravenous analgesic chronotherapy personalize by pump "Melodie" associating all the treatments improve pain and quality of life on a long term after careful selection patients

R.G. Zeynalov, A.V. Musayev Research Inst of Medical Rehabilitation, Baki, Azerbaijan

AIM OF INVESTIGATION: To evaluate the efficacy of naphthalan therapy (NT) - a unique natural and therapeutic factor of Azerbaijan combined with low frequency alternating magnetic field (LFAMF) for treatment of low back pain.

METHODS: The patients received treatment using LFAMF combined with NT (group-I) or LFAMF solely (group-II). All of the patients underwent to clinical and neurologic evaluation, electromyographic (EMG) and electroneuromyographic (ENMG) studies.

RESULTS: 95 patients with low back pain were treated and evaluated. They received treatment using LFAMF combined with NT (group-I - 57) or LFAMF solely (group-II - 38). Treatment was well tolerated. Significant reduction of pain showed 65% of group-I patients and 48% of group-II patients. The patients with reflex syndrome (group-I - 68%, group-II - 60%) showed more marked effect than those with radicular syndrome (group-I - 37%, group-II - 50%). EMG and ENMG also justify the clinical effect of the treatment observed. The improvement of initially disturbed values of muscular bioelectrical activity and normalization of impulse conduction velocities in peripheral nerve were observed.

CONCLUSIONS: NT combined with LFAMF performed provide significant reduction of pain intensity in patients with low back pain. These outcomes had been established by clinical and neurologic as well as electrophysiologic studies.

G.G. Ghinea, D. Gill, L.H. De Souza, A.O. Frank, Information Systems & Computing; Health & Social Care, Brunel University, Uxbridge, United Kingdom , 2 Rehabilitation Medicine, Northwick Park Hospital, Harrow, United Kingdom

Aim of investigation: To investigate visual technological systems that use pain drawings to aid dataset analysis. It aimed to employ user-friendly visual techniques for data-querying and analysis. Web-based technologies were used in view of the importance in healthcare of distributed systems to provide ubiquitous information.

Methods: Three solutions used dermatome-based image maps (IMs) - digitised drawings, broken down into regions, hyperlinked with html to patients assessments (eg disability score). Web-based IMs were constructed using: a) static GIF images, b) Scaleable Vector Graphics (SVG) allowing zoomable & panable images to be designed. We used Geographical Information Systems (GIS), a specialist analyst tool, which inherently works on IMs, allowing visualisation of data hidden in spreadsheets. 25 pain drawings were analysed.

Results: All solutions: a) successfully stored questionnaire data, allowing dynamic updates and presentations; b) developed systems using standard web interface and point and click functions simplifying database use; c) work under a client/server framework placing data on a web server and allow linkage between dermatome images and database information. This enables queries to be done graphically, as region selection is done by point and click instead of a complex query written by the user.

Conclusions: Pain drawings can assist data analysis. The SVG solution is easiest, allowing many people to access data cheaply with minimal training. The GIS solution is best for analysis of the actual data, but adds complexity and cost.

F.A. Pekel, K. Keskinbora, I. Aydinli Cerrahpasa Medical Faculty, Anesthesiology, Agri Bilim Dali, Istanbul University, Istanbul, Turkey

Aim of investigation: Results of a non invazive therapeutic approach with antidepressant and analgesics for low back pain due to herniated disc is presented.

Methods: Low back pain patients (n:87, age:27-83) with moderate to severe pain (VAS>4) originating from MRI approved disc herniation without any neurologic loss were assessed. Assessments were provided on every ten days through 40 days, A0, A10, A20, A30, A40. Analgesics consisted of naproxen sodium/acetominophen, tramadol HCl 400mg/day, amitriptilin 25-100mg/citalopram 20mg. At the first ten days naproxen 550 mg bid was replaced by acetominophen 1500 mg tid at the follow up visits. Treatment outcomes were assessed due to persisting pain intensity and loss of activity tolerance. Analgesics were discontinued in case of VAS<4 while antidepressants were continued until lost activity tolerance was regained. By the sixth week epidural steroid was proposed to the ?unsatisfied? patient with remarkable pain and tolerance loss in activity.

Results: Mean pain scores were; A0, 9.5 A10, 4.8 A20, 2.3 A30, 2.5 A40, 1.6. The rate of patients with satisfactory outcome was as (%) A0 0, A10 28, A20 57, A30 65, A40 88. Only ten patients (%11) did show the need for epidural steroids as the pain intensity was still seriously limiting the quality of life by the sixth week.

Conclusion: In management of low back pain due to herniated disc antidepressants and tramadol seem to provide effective pain control. Remaining is to differentiate those who deserve invazive procedures just at the beginning.

S. Alam, Khulna Pain and Rehabilitation Center, Khulna, Bangladesh

AIM OF INVESTIGATION: Interspinous and supraspinous ligaments are responsible for painful spinal syndrome. Very sensitive to pressure and injection is the treatment of choice. Pain disappears with the injection of local anesthetic. The present study was designed to compare the effects of a combination of corticosteroid with local anesthetic and local anesthetic alone in painful spinal syndrome.

METHODS: Twenty patients with long-lasting low back pain were enrolled in this study. Painful spinal syndrome was clinically diagnosed in one or more segments in the lumbar region. The diagnosis was based on the examination for ligaments' tenderness or pain by applying pressure against the ligaments by a round object or with the tip of the index finger with the patients were placed comfortably with flexion of lumbar spine. Patients were randomized in two groups (n=10). Group I received methylprednisolone acetate 20mg, 2ml of 0.125% bupivacaine and distilled water to a total volume of 6ml for each segment. Group II received the same volume of bupivacaine and distilled water. Visual Analog Scale (0-10) was used to evaluate pain. Patients recorded their tenderness or pain every 24h for 72 and rated their satisfaction with their regimen.

RESULTS: Patients in Group I had significantly lower tenderness or pain. Dramatic improvement of was also mentioned in 60% of patients before 72h. Post-injection response was satisfactory and no other complications were noted in both the groups.

CONCLUSIONS: Judged by the patients' reports of pain and tenderness, combination of corticosteroid and local anesthetic provided early relief than the local anesthetic alone.

E.M. Haldorsen, A. Kvle, L.I. Strand, J.S. Skouen, The Outpatient Spine Clinic, Haukeland Univ Hospital, Bergen, Norway , 2 Section of Physiotherapy Science, Univ of Bergen, Bergen, Norway

Aim of Investigation:A psychological-physical screening instrument containing 19 variables was demonstrated to be useful for allocating patients with long-lasting musculoskeletal pain to different levels of treatment (Pain 2002:95).In this study we try to reduce number of variables and to examine possible difference in predictive ability among the variables according to sex.

Methods: 210 patients with low back pain (54%women,mean age 44,range 21-66) were screened in a randomised,controlled trial.The screening instrument consisted of a 15-item questionnaire related to psychological and motivational factors and 4 standardized physiotherapy(PT)tests: Movement, Tenderpoints, Sock Test,and Lifting (PILE).The data were analyzed by using separate predictive discriminant analyses (PDA).Return to work (yes/no) at 14 months was used as outcome measure.

Results:The questionnaire resulted in 63% correct classification of poor prognosis for return to work, while the 4 PT tests resulted in 66% correct classification.The 15-item questionnaire was reduced by the PDA: in women to 4 items resulting in 71% correct classification, in men to 5 items resulting in 72% correct classification.In women the 4 PT tests resulted in 73% correct classification of poor prognosis, while in men the 4 tests resulted in classification accuracy just about chance (52%). When variables from the two parts of the screening instrument were combined, the classification accuracy increased from 71% to 78% in women, and from 72% to 74% in men.

Conclusions: Number of variables in our screening instrument can be reduced. However, different sets of variables characterize men and women. For both sexes a combination of psychological and PT findings should be included.

V. Rastogi, S.K. Saraf, P. Ranjan, M.M. Shyam, Dept of Anaesthesiology, Banaras Hindu Univ, Varanasi, India

AIM OF INVESTIGATION: To evaluate the efficacy of epidural midazolam for the treatment of chronic low backache and to compare it with depromedrol.

METHODS: Fifty patients of either sex suffering from chronic low backache allocated in two groups, a study group receiving epidural midazolam (5mg/10ml saline) and a control group receiving depomedral (120 mg/10ml saline). The patients subjected for a detailed clinical examination and investigation to establish diagnosis and followed for immediate and long-term pain relief and psychological status based on change in activity, sleep and self-medication.

RESULTS: Excellent relief (75%) observed in 80% of patients in study group as compared to 64% in control group at 2wk interval. Only 20% of patients in control group showed good (<75%) relief of pain as compared to none in study group. Long-term (3 months) relief of pain was better (60%) in control group as compared to 50% in study group. Patients treated with epidural midazolam were more active as compared to patients in control group. The need for medication decreased from 72% at 2wk interval to 53% at 3 months interval in control group but the patients in study group showed increasing demand.

CONCLUSIONS: Immediate relief of pain and improvement is psychological status was better with epidural midazolam but long-term relief of pain in patients receiving epidural depomedrol.

G.B. Georges- Trabert, A. Beyer, R. Pfeiffer, M. Wimbauer, M. Weigl, P. Schops Pain Center, Klinikum Grosshadern, Munich, Germany

Aim of Investigation:This study evaluates the quality of life of patients with chronic low back pain before and one year after the Functional Restoration Program.

Methods: 33 patients (21female,12male) with chronic low back pain entered a full day therapy program for four weeks. QoL was assessed with the following tests: 1.Short Form SF-36; 2.ADS (Allgemeine Depressions Skala) German depression scale; 3.PDI (Pain Disability Index; 4.NRS (Numeric Rating Scale for Pain) und 5.Geissner Pain Questionaire GPQ (German analogue to MacGill Pain Questionaire).

Results:Health related quality of live (SF-36) was still improved after one year in the Physical Components (Physical Functioning p 0,01; Role Physical p 0,01; Bodily Pain p 0,001) and Vitality (p0,01). No change was observed in the Mental Component-SF36 (Role Emotional, Mental Health, Social Functioning) and in General Health Perceptions-SF36. QoL-associated outcomes parameter that we found significantly better were: PDI (p 0,001),ADS (p 0,001)and NRS for Pain(p 0,001). The affective component of GPQ improved long term(p0,01) whereas sensory component remained unchanged.(Wilcoxon test).

Conclusion:This Functional Restoration Program for low back pain succeeded in improving QoL significantly as to the Physical Components-SF36 und Vitality-SF36 as well as subjective self-report of PDI, Depression Scale, NRS und GPQ Affective Component.These changes were sustained up to one year after end of the program.

10th World Congress on Pain, List of topics

10th World Congress on Pain. International Association for the Study of Pain, San Diego, California, USA August 17-22, 2002