Asymmetry of lumbar lateral flexion and treatment outcome in chronic low-back pain patients.

In a study on the treatment of chronic low-back pain (n = 456 patients; 58% men, 35-54 years of age), 3-month treatment outcome was assessed by back pain questionnaires and physical measurements including spinal and hip mobility and trunk muscle strength. Changes in differences between ranges of right and left lumbar lateral flexion and rotation of > 5 degrees from pretreatment to follow-up were recorded. A relative increase in left lumbar lateral flexion was associated with a better treatment outcome according to both back pain and physical performance (p < 0.05-0.001). With spinal rotation measurements no similar connections were observed. The results point to a connection between back pain and asymmetric spinal function, which may have pathogenetic and therapeutic significance.

Outcome of a multimodal treatment including intensive physical training of patients with chronic low back pain.

A comprehensive 4-week inpatient treatment including intensive physical training was evaluated in 194 chronic low back pain patients of whom 101 were working and 79 were on sick leave. Physical performance was assessed by measurements of spinal mobility, isometric trunk flexion and extension strength, and isokinetic lifting strength. Outcome was evaluated by a functional capacity index and work status changes reported at a 12-month follow-up. There was a 30-50% average increase in physical performance during treatment. At the 12-month follow-up the functional capacity index showed an average increase from 35.4 to 39.3 points (score range 24-48). At follow-up 28% of the sicklisted patients had returned to work and of those employed before treatment 14% were on sick leave. Associations between outcome and the improvement in physical measurements and their level at discharge were determined by stepwise multiple and logistic regression analyses. Among the physical measurements only increase in spinal mobility was associated with functional capacity index in women and return to work in both men and women at the 12-month follow-up. The overall results showed that intensive physical training and improved physical performance did not play crucial roles in the rehabilitation of chronic low back pain patients, at least when return to work was used as the outcome criterion.

Outcome of two multimodal back treatment programs with and without intensive physical training.

We compared the results of two multimodal back treatment programs (program A: n = 134; program B: n = 175) using pain, functional capacity, sickness absence, subjective state of health, depression, and work status as outcome variables. Whereas in program A exercise was guided by pain, in program B a "no pain, no gain" rationale was used as a basis for intensive physical training. Neither of the programs included direct attempts to influence the patient's environment (i.e., to find employment or to modify working conditions). In both programs, a clear decrease in pain and an increase in functional capacity was found from the pretreatment phase to the 12-month follow-up. These changes were, however, stronger in program B. Days of absence decreased significantly in group B, but the change was not significantly different from that in group A. On the whole, the more intensive training showed somewhat better results, even though the difference was not substantial. In contrast to some earlier results, there was no statistically significant increase in the proportion of those employed after treatment in either group. The results indicate that intensive physical exercise does not, as such, solve the problem of back disability in a country that has a highly developed social security system. More active interventions in work and work-life are needed.

Spinal mobility and posture in adolescent idiopathic scoliosis at three stages of curve magnitude.

Spinal posture and mobility were studied in 71 girls with progressive adolescent idiopathic thoracic scoliosis. Measurements were carried out by inclinometers and a compass in three planes; sagittal, frontal, and horizontal. The patients were divided into three groups according to the curve magnitude. Group 1 had curves smaller than 25 degrees, group 2 had curves between 25 and 35 degrees, and group 3 had curves greater than 35 degrees. The positional inclines of sacrum, upper lumbar and upper thoracic areas became more vertical as the curve size increased resulting in smaller lumbar lordosis and thoracic kyphosis. In the thoracic spine flexion and bending to the right was smaller in group 3 than in the other groups. Rotations in both clockwise and counterclockwise directions decreased as the curve size increased. In the lumbar spine only bending to the left decreased significantly with the curve size increase. All thoracic and lumbar movements except lumbar rotations had a general tendency to stiffening as the curve size increased. Of the mobility measurements thoracic rotation most clearly decreased with increased curves, which together with straightening of the spine can be important features in the pathomechanism of a progressive idiopathic thoracic curve.

Spinal mobility and posture in 8- to 16-year-old children.

Spinal mobility and posture were measured in 294 8-16-year-old boys and girls, divided into five age groups. The upper thoracic sagittal alignment was more vertical among girls, but the postural curves showed no significant age-related differences for either sex. Among both boys and girls thoracic extension, lateral flexion, and rotation decreased significantly between the ages of 12 and 13, but with the exception of extension they returned to the previous level by age 16. Girls were significantly different from boys at 13 years of age. In the thoracic spine, girls had less kyphosis, and were stiffer in forward and lateral flexion, with more rotation to the right than to the left. In the lumbar spine, lateral flexion increased after the age of 10 in both sexes. Between the ages of 8 and 14 lumbar lateral flexion was significantly greater among girls than among boys, whereas extension and rotation was greater only at the ages of 8 and 10 years. With increasing age, a shift from left to right dominance in lumbar lateral flexion was found in girls only.

Influence of repeated measurements on isokinetic lifting strength.

The aim of the study was to evaluate the effect of repeated measurements on isokinetic lifting strength in a smaple of patients with low back pain. The measures were performed in series of five consecutive lifts on two occasions 1-13 days apart, and the patients continued their normal living during this period. A group of healthy subjects was used as a control. The hypothesis was that a mere repetition of the lifting procedure would increase the performance, and that the increase would be bigger in the patient group that in the non-patient group. In addition, grip strength was measured on both occasions. It was supposed that grip strength would not change from trial 1 to trial 2. The results showed an increase in lifting strength from first to second trial in the patient group by an average of 28%, and in the control group by an average of 16%. Grip strength did not increase in either group. The last of five consecutive lifts was the best one in a majority of the cases in both trials. Neither five consecutive lifts nor measurements on two different occassions seem enough to define a reliable baseline for maximal lifting capacity. Other factors than an increase in muscle strength influence the performance, one being a repetition of the lifting procedure. This must be accounted for when defining a baseline for isokinetic lifting capacity.

Effects of subject position on measurements of flexion, extension, and lateral flexion of the spine.

Effects of subject positions on range and repeatability of thoracic and lumbar forward flexion, extension, and lateral flexion were studied. Inclinometric methods were used, and 27 subjects were measured by two trained testers. No great differences in repeatability and range of movements were found between measurements in different positions, but according to the results and convenience of performance, the following positions could be recommended: forward flexion in a sitting position, extension while lying on an examination table with arms braced ahead, and lateral flexion close to a wall and facing it.

Aerobic capacity among chronic low-back-pain patients.

The role of aerobic capacity (maximal oxygen uptake, VO2max) in connection with chronic low-back pain was assessed in a study mainly designed to evaluate the outcome of inpatient and outpatient treatment of low-back pain. A total of 245 subjects (ages 35-54 years, 71% men)--81 inpatients, 88 outpatients, and 76 controls--who had chronic low-back pain but who were still working, performed maximal graded bicycle ergometer tests four times during the follow-up of 30 months. In every group the estimated VO2max was on the level of the reference values of healthy persons. There were no significant changes in the VO2max in any of the intervention groups during the follow-up period. The correlation analyses showed no connection between aerobic capacity and pain or disability caused by chronic low-back pain. Among several components of physical fitness, aerobic capacity had no predictive value in the course of low-back pain.

Effects and follow-up of a multimodal treatment program including intensive physical training for low back pain patients.

The results of a comprehensive 4-week treatment program including intensive physical training were evaluated in 65 chronic low back pain patients. Marked increases in measures of spinal mobility, trunk muscle strength and lifting capacity were found during the treatment, but no average increase in pain ratings. At 3-week and 12-month follow-ups a statistically significant decrease in subjective disability and pain was found, but the percentage of patients who were working was unchanged. This points to a need for more work-oriented rehabilitation efforts in the treatment.

Decreased joint and spinal mobility associated with low back pain in young adults.

Anthropometric factors, spinal and limb-joint mobility, and trunk strength were measured in young students--55 men and 48 women (mean age 21.4 years, SD 1.6). Twenty-six of the men and 29 of the women had had back pain during the preceding year and they were compared with those without back pain. In the male back-pain group, extension, lateral flexion and the sum of mobility in the lumbar spine, and hip flexion and external rotation of the shoulders were significantly smaller. In the female back-pain group, extension and the sum of mobility in the thoracic spine, and extension, external rotation, and the sum of mobility in the hips were significantly diminished. Anthropometric factors and trunk strength had no significant relationship with a history of back pain except for a pronounced lordosis in women. The results suggest that ligamentous or capsular stiffness of the joints may be associated with low back pain in young adults.

Referred limb symptoms in chronic low back pain.

Referred limb symptoms (RLS) in chronic low back pain patients without signs of root affections were studied in 212 men and 126 women, aged 36-55 years, who were at work, but suffered from chronic or recurrent low back pain. RLS during the past few months were experienced by 17% daily and 22% occasionally. Previous RLS were reported by 34%, whereas 27% had never had such symptoms. There was a 3:4 distribution between symptoms in right and left legs, and 30% claimed symptoms in both legs. The distal extension of RLS into the limbs was as follows: thigh 18%, leg 37%, foot 20%, and toes 26%. The nature of RLS comprised the following: pain 56%, numbness 50%, cramps 22%, sharp pain 15%, and weakness 10%. Occurrence of RLS was not related to age. In both men and women, RLS correlated with subjective disability as well as with pain on bendings and palpation of lumbar spine and muscles. Men with previous and present RLS had greater external rotation of the hips, but otherwise no specific physical measurements were related with RLS. RLS of both legs in women and of distal extension in men showed more findings related with back pain.

Increased spinal mobility in adolescents with bronchial asthma.

Spinal mobility was measured in thirty-five adolescents (21 boys and 14 girls) with bronchial asthma. Comparisons were carried out with an equal number of healthy controls matched for sex, age, weight, and height. Thoracic spinal movements of rotation and lateral flexion in girls and of rotation in boys were significantly greater in asthmatics as were the sagittal lumbar movements with the exception of forward flexion in the boys. Sagittal spinal curvatures of the asthmatics did not significantly differ from those of the controls. The results indicate that there are no need of explicit mobilization of thoracic spine in asthmatic children.

A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part IV. Long-term effects on physical measurements.

Effects of inpatient and outpatient treatment on physical measurements in chronic low back pain patients (n = 476) were analyzed at 1.5- and 2.5-year follow-ups as well as 3 months after a refresher programme which was carried out 1.5 years after the first treatment. Physical measurements consisted of hip and lumbar spinal mobility, and trunk muscle strength. At the 1.5-year follow-up the two treatment groups did not differ from the control group, but at the 2.5-year follow-up inpatients showed better improvements in physical functions from the pretreatment level. The refresher treatment was found to improve physical functions more effectively than the first treatment program, especially in the outpatients. Self-care with heavy exercising was related with the improvement of physical functions, but back exercises and light exercising were not. Statistically significant but modest correlations were found between improved physical functions and subjective progress during the long-term follow-ups.

A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part III. Long-term follow-up of pain, disability, and compliance.

The long-term outcome results of inpatient and outpatient treatment of low back pain (LBP) were studied in 476 subjects (aged 35-54, 63% men) randomly assigned to three study groups: inpatients (n = 157), outpatients (n = 159), and controls (n = 160). The study included changes in the severity of low back pain, grade and disability, compliance with self-care, data on disability pensions, and days of sickness allowance during a 2.5-year follow-up period. These variables were used as outcome criteria. Pain and disability had decreased significantly in the two treated groups up to the 3-month follow-up. LBP was still a little slighter in the inpatients at the 1.5-year and 22-month follow-ups, but there were no significant differences between the groups in disability caused by LBP. The refresher programme carried out 1.5 years after the first one did not bring about as clear short-term improvement in pain and disability as the first treatment. During the whole 2.5-year follow-up compliance with self-care was better in the two treated groups, especially in the inpatients. Days of sickness allowance had increased somewhat more in the controls than in the inpatients during the follow-up. No differences between the groups were found in the number of disability pensions granted.

Spinal mobility in adolescent girls with idiopathic scoliosis and in structurally normal controls.

Spinal mobility and posture were studied in 29 adolescent girls (mean age, 13.9 years) with thoracal idiopathic scoliosis, and in 30 healthy girls (mean age, 14.0 years) of the same age. Measurements of the mobility were conducted by inclinometers and a compass in three planes; sagittal, frontal, and horizontal. The structurally healthy girls were taller and heavier than the scoliotics; the difference was statistically significant for weight (P less than 0.01). The positional inclines of sacrum, upper lumbar and thoracic areas were significantly smaller in the scoliotics, resulting in smaller lumbar lordosis and thoracic kyphosis in them (P less than 0.001). In the thoracic spine, forward flexion was smaller (P less than 0.01), whereas extension (P less than 0.001) and the total sagittal mobility (P less than 0.01) were greater in the scoliotics. In the healthy controls, the thoracic clockwise rotation was significantly (P less than 0.05) larger than the counterclockwise. This side difference had disappeared in the scoliotics, and their total thoracic rotation was indicatively smaller than in the controls. In the lumbar spine, extension was smaller (P less than 0.01) in the scoliotics than in the controls. All spinal mobility measurements noted there was no change of general spinal flexibility in the scoliotics.

A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part I. Pain, disability, compliance, and reported treatment benefits three months after treatment.

Outcome of inpatient and outpatient treatment of low back pain was studied in 459 patients (aged 35-54 years, 63% men); 156 inpatients, 150 outpatients and 153 controls. Changes in low back pain and in disability caused by it, and adherence and accomplishment of back exercises were used as short-term outcome criteria. The overall results showed a significant decrease in pain and disability and better compliance in the two treated groups when compared to the controls. There was also a significant difference in treatment gains between the inpatients and outpatients; i.e. the decrease in pain was greater and the frequency of back exercises higher in the inpatients. The inpatients also estimated their treatment benefits more positively than the outpatients.

A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part II. Effects on physical measurements three months after treatment.

Inpatient and outpatient treatments were compared with a control intervention in 288 men and 168 women, aged 35-54, who were at work, but suffered from chronic or recurrent low back pain. Physical measurements and back pain assessments were carried out before the intervention and at a 3-month follow-up. Physical fitness improved most in the inpatients, but the outpatients did not differ from the controls. Correlations between back pain and physical measurements indicated that increase of lumbar and hip mobility was more important than increase of trunk strength for subjective progress in these patients. Increased trunk extension strength correlated significantly with subjective progress in women, who also had higher correlations between improved physical fitness and progress than men.