Journal of Back and Musculoskeletal Rehabilitation - Volume 22, issue 2
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Journal of Back and Musculoskeletal Rehabilitation is a journal whose main focus is to present relevant information about the interdisciplinary approach to musculoskeletal rehabilitation for clinicians who treat patients with back and musculoskeletal pain complaints. It will provide readers with both 1) a general fund of knowledge on the assessment and management of specific problems and 2) new information considered to be state-of-the-art in the field. The intended audience is multidisciplinary as well as multi-specialty.
In each issue clinicians can find information which they can use in their patient setting the very next day. Manuscripts are provided from a range of health care providers including those in physical medicine, orthopedic surgery, rheumatology, neurosurgery, physical therapy, radiology, osteopathy, chiropractic and nursing on topics ranging from chronic pain to sports medicine. Diagnostic decision trees and treatment algorithms are encouraged in each manuscript. Controversial topics are discussed in commentaries and rebuttals. Associated areas such as medical-legal, worker's compensation and practice guidelines are included.
The journal publishes original research papers, review articles, programme descriptions and cast studies. Letters to the editors, commentaries, and editorials are also welcomed. Manuscripts are peer reviewed. Constructive critiques are given to each author. Suggestions for thematic issues and proposed manuscripts are welcomed.
Abstract: Objective: To evaluate the clinical and electrophysiological effects of local depo-methylprednisolone injection in patients with carpal tunnel syndrome (CTS) over a 6-months period. Methods: Twenty one patients, of whom 7 were lost for follow-up (mean age 57.9 ± 8.4) with clinical and electrophysiological evidence of CTS were treated by injection of depo-methylprednisolone 40 mg proximal to the carpal tunnel. Severity of pain (VAS), rates of numbness/paresthesias and nocturnal awakening, motor and sensory nerve conduction studies were used as outcomes. All tests were performed before, 1, 3 and 6 months after the injection. Results: Severity of pain…was significantly reduced at all follow-up time points (p < 0.001). Prior to injection all patients complained of night pain and awakening. On the first, third and sixth months, 0(0%), 4 (29%) and 7 (50%) of the patients, respectively, had night awakening. All patients complained of numbness before the treatment. This symptom disappeared in 81% of the patients after one month and reappeared in all after three months. Significant improvement was shown in the mean distal motor latency (DML) of the median nerve: 5.2 ± 0.9 msec. before, 4.6 ± 0.6 msec. and 4.7 ± 0.6 msec. 1 and 3 months after the injection, respectively (p < 0.05). Mean values of motor muscle potential amplitudes, sensory latency and sensory amplitude did not change significantly after the treatment. Conclusions: Local corticosteroid injection for the treatment of CTS provides significant symptom improvement for three months. No electrophysiological parameters were improved after injection, except the improvement in distal motor latency of the median nerve.
Abstract: Introduction: Workers with chronic low back pain (LBP) mean a heavy human and social-economic burden. Their medical histories often include different treatments without attention to work-relatedness or communication with occupational health providers, leaving them passive and medicalized in (outpatient) health care. So we developed and implemented an innovative, patient-activating alternative: the multidisciplinary outpatient care (MOC) programme, including work(place) intervention and graded activity. It aims at function restore (instead of pain elimination), return to work (RTW) and coordinated communication. Objectives: To qualitatively explore how patients and health care providers perceive the programme effectiveness and which factors influence its implementation.…Methods: In-depth, semi structured interview with patients and focus groups of health care providers are used, all recorded, transformed into verbatim transcript and analysed. Results: This qualitative study shows that although patients’ expectations were low at the start of the program, and despite long LBP histories, including many different therapies, (primarily) directed at pain reduction, the MOC programme was successful in changing patients’ goal setting from pain oriented towards function restore and RTW. The programme was therefore perceived as applicable and effective. Patient compliance was influenced by barriers – despair, supervisory and subordinate resistance at work, waiting period, medicalisation in health care – and facilitators: disciplinary motivation, protocolled communication, information supply, tailor-made exercises. For some patients the barriers were too high. Several improvement suggestions were given. Conclusions: This qualitative study shows that generally, patients and professionals perceived the multidisciplinary outpatient care programme as applicable and effective. After incorporating improvement suggestions this program seems promising for further, broader application and hypothesis testing. For those, negatively evaluating the programme, alternatives should be explored.
Keywords: Qualitative research, return to work, low back pain
Abstract: Objective: To assess the changes in static and dynamic balance and movement strategies in patients with severe osteoporotic vertebral compression fracture while wearing and not wearing the Knight-Taylor (K-T) spinal brace. Subjects: 47 patients with severe osteoporotic vertebral compression fracture, which was confirmed on radiographs and with bone density measurements obtained by dual energy X-ray absorption. Intervention: Patients were randomly subjected to computerized dynamic posturography, which contained sensory organization tests, motor control balance test at 75% limit of stability (LOS) in 8 movement directions, and left/right rhythmic weight shift test (L/R RWS), while wearing and not…wearing the K-T spinal brace, respectively. Results: Patients wearing the spinal brace had significantly increased average stability, significantly increased average maximal stability under the swayed vision with fixed support surface condition and under the eye open with swayed support surface condition, significantly increased ankle strategy and decreased average velocity of COG target sway under the eye open with swayed support surface condition, significantly reduced the frequency of falls under the eye closed with swayed support surface condition and swayed vision with swayed support surface condition, and significantly decreased in the percentage of directional control with no difference of reaction time in the LOS test, and an increase in the on-axis velocity in the L/R RWS test. Conclusions: The K-T spinal brace efficiently enables the subjects to maintain static and dynamic motor balance. Its use decreases the fall frequency but limits the directional control in severe osteoporotic patients with vertebral compression fracture.
Abstract: Purpose: This study was to compare the effectiveness of the translaminar, caudal, and transforaminal technique with small and large volume of injectate in the treatment of lumbosacral herniation of intervetebral disc (HIVD) or spinal stenosis (SS). Method: Medical records reviewed retrospectively were of patients with radicular pain over 3 months and had diagnosed as HIVD or SS. Patients who underwent four weeks of treatments such as analgesics, anti-inflammatory drugs, or physical therapy for radicular pain with no improvement and afterwards received ESI were selected. Exclusion criteria was those who had suffered trauma, patients with other serious diseases, patients…demonstrating adverse reactions to the medications, and patients with more than two levels of disease. The number of HIVD and SS group is 95 and 138, respectively. Visual Analog Scale (VAS) pain score, Patient Satisfaction Index (PSI), and Roland 5-point pain score were compared between different epidural approaches at pretreatment, 2 weeks, 1 month, and 2 months after treatment. Results: Higher ratio of successful results was found in translaminar and transforaminal techniques than caudal technique in VAS in the HIVD group and in VAS and PSI in the SS group. Reduction of Roland score was maintained until 2 months in all techniques in HIVD and SS groups. In SS group, transforaminal groups showed more reduction of Roland score than caudal approach. No difference was found between small and large volume of transforaminal techniques. Conclusion: Translaminar and transforaminal approach were more effective than caudal approach in HIVD and SS groups. Especially, effectiveness of transforaminal approach was more prominent in SS group as compared with HIVD group.
Keywords: Epidural steroid injection, herniation of intervertebral disc, spinal stenosis
Abstract: Objective: The study describes the clinical spectrum of patients with low back pain due to sacroiliac joint (SIJ) involvement with the proposition of a diagnostic scheme. Methods: In this retrospective review, 61 patients with SIJ pain (unilateral or bilateral) greater than six weeks duration were evaluated by pain history, clinical examination including SIJ provocative tests, laboratory investigations and skeletal imaging. Results: Fifty two patients (M: F, 31:21) were diagnosed to have specific SIJ pathologies amongst 61 patients presenting between 2002 to 2004. Forty patients (65%) were diagnosed with rheumatic conditions – ankylosing spondylitis (AS) – 21,…undifferentiated spondyloarthropathy (UspA) – 11, psoriatic arthropathy (PS) – 5, reactive arthropathy (ReA) – 1 and juvenile spondyloarthropathy (JS)-2. Non rheumatic conditions were involved in 12 patients (20%) – osteitis condensus ilii (OCI) – 4, osteomalacia – 2, tuberculosis – 2, pyogenic arthritis – 1, pregnancy related sacroiliac joint pain – 2 and malignancy in 1 patient. The diagnosis could not be confirmed in 9 patients (15%). Conclusions: Medical history, clinical examination including SIJ tests, plain radiography and laboratory investigations were helpful in diagnosing SIJ pathology in 39% cases (n = 24), 46% (n = 28) needed CT or MRI. A diagnostic scheme of dividing the SIJ pathologies into rheumatic and non-rheumatic conditions was helpful in evaluating patients with suspected SIJ pathologies.
Abstract: The objective of this study was to assess the long- and short-term effects of a multimodal program, specifically designed to be carried out by fibromyalgia syndrome (FMS) patients themselves, after a 12-week period of learning. Thirty female FMS patients volunteered for the study. The learning phase consisted on twelve weekly sessions of an hour, combining muscular resistance and flexibility exercises with techniques of breathing and relaxing, plus a half-hour incentive physiotherapy session. Flexibility, illness impact and pain were assessed at the beginning of the study, at the end of the learning phase and six months afterwards (follow-up). Twenty-one patients completed…the programme. At the end of the learning phase, the improvement in the patients' physical condition was significant, as was the impact of the illness. Thirty-three percent of the patients continued training during the follow-up period and kept up the improvements achieved. The self-controlled multimodal programme was efficient in improving flexibility and reducing the impact of the illness in women fibromyalgia patients. However, adherence was poor when patients had to exercise on their own.
Abstract: Objective: The treatment of thoracolumbar burst fracture is a controversial issue. Although spinal fusion has been a touchstone of spinal fixation, nonfusion technique have become raising its popularity recently. Some studies suggested that nonfusion had several advantages over fusion. The aim of this prospective study was to compare long segment posterior instrumentation with fusion versus long-segment posterior instrumentation without fusion. Methods: For this purpose, 42 consecutive patients were assigned to two groups. Group 1 included 21 patients treated by long segment instrumentation with fusion (WF), whereas Group 2 included 21 patients treated by long segment instrumentation without fusion…(WOF). Long segment instrumentation was hook fixation (claw hooks attached to second upper vertebra and infralaminar hooks attached to first upper vertebra) above and pedicle fixation (pedicle screws attached to first and second lower vertebrae) below the fractured vertebra. Results: Measurements of local kyphosis, sagittal index and anterior vertebral height compression showed that both group had similar outcome at final follow-up. Moreover, there was no difference between the two groups according to low back outcome score. Also, implant failure rate (4.7%) was quite low in both groups. However, WF group had prolonged operative time, increased blood loss and donor site morbidity. Conclusions: Radiological and clinical parameters demonstrated that spinal fusion is not necessary in long segment posterior instrumentation for the management of thoracolumbar burst fractures.
Abstract: Background: Studies of measurement of maximal aerobic uptake in patients with chronic low back pain have shown inconsistent results and none has focused on clinical endpoints of ergometry tests. Objective: To determine the level of cardiorespiratory fitness and to establish factors limiting the maximal effort during the ergometry. Methods: Patients with chronic low back pain performed a graded maximal exercise test. Clinical endpoints of the test were determined and grouped as “maximal effort” and “symptom-limited effort” endpoints. Results: 101 patients aged 29.8 ± 7.5 achieved a VO2 max value of 30.0 (± 7.27) ml.kg-1….min-1 . In men and women independently, a linear regression analysis demonstrated that VO2 max was inversely and weakly related to age. When compared to normative categories of VO2 max, men and women were situated in the fair category. Quadriceps/leg fatigue was reported by 47.5% of patients and was the most frequent limiting factor of the tests. “Symptom limited effort” endpoints were reported by 54.4% of the subjects. Conclusions: Clinical limiting factors of maximal exertion interfere the achievement of maximal oxygen uptake in patients with low back pain during ergometry. Further, there exists an association among the clinical endpoints of the tests and the VO2 value achieved. CLBP patients have a lower level of aerobic fitness than healthy controls.
Keywords: Chronic low back pain, fitness, ergometry, physiology
Abstract: We have presented a patient of 71-year-age with brucellar spondylodiscitis, involving the cervical spine, especially the C3–C4 segment. The patient had painful percussion of the cervical spine and passive mobilization of the neck, decreased range of motion, and cervical paravertebral tenderness; but no abnormalities observed on neurological examination. Wright agglutination test for brucella was positive at 1/320. Cervical localization for brucellar spondylodiscitis is an unusual case and should be detected and treated as early as possible. In endemic regions, spinal involvement of brucellosis should be considered in cases with fever, neck and low back pain.
Abstract: Objective: Acrodysostosis is a rare syndrome characterized by peripheral dysostosis, nasal hypoplasia and frequently mental retardation. Only one adult case of acrodysostosis has been reported to have neurologic symptoms. We report one further adult case of acrodysosotosis with severe neurologic findings including myelopathy and spastic paraparesis due to diffuse spinal stenosis and recurrent deep vein thrombosis possibly caused by neurologic deficits. Results: We report a 43-year-old woman who had back and neck pain with weakness in the extremities of several years. 1 year before admission to our hospital, she had been treated with a missed diagnosis of sero…(–) spondyloarthropathy but had not benefited. She became unable to walk, thereafter she underwent decompression surgery with a diagnosis of degenerative spinal stenosis. She presented at our outpatient department complaining of lowback pain and difficulty walking. She had marked facial and peripheral appearance of acrodysostosis. Spinal MRI revealed extensive spinal stenosis. A diagnosis was made through the genetic investigation, clinical and radiological findings. Spastic paraparesis were detected. There was widespread neuropathic pain. 15 days after admission, she developed swelling and redness of the left lower extremity and the venous doppler ultrasonography showed left acute and right past DVT. We treated DVT with anticoagulant therapy. Gabapentin and Baclofen were initiated for neuropathic pain and spasticity. A conventional rehabilitation program was performed. She left walking with a walker without pain and spasticity. Conclusions: We would like to remind physicians to be aware of peripheral malformations as signs of skeletal dysplasias and to consider acrodysostosis in the differential diagnosis. Although it is a rare condition, if diagnosed early, possible complications can be treated and outcomes may be improved.
Keywords: Adult case of acrodysostosis, neurologic involvement, recurrent DVT