WITHDRAWN: Lumbar supports for prevention and treatment of low-back pain.

BACKGROUND: Lumbar supports are used in the treatment of low back pain patients to make the impairment and disability vanish or decrease. Lumbar supports are also used to prevent the onset of low back pain (primary prevention) or to prevent recurrences of a low back pain episode (secondary prevention). OBJECTIVES: The objective of this systematic review was to assess the effects of lumbar supports for prevention and treatment of non-specific low back pain. SEARCH STRATEGY: We searched the Medline, Cinahl and Current Contents databases and the Cochrane Controlled Trials Register up to September 1999, and the Embase database up to September 1998. We also screened references given in relevant reviews and identified controlled trials, and used Science Citation Index to identify additional controlled trials. SELECTION CRITERIA: Controlled clinical trials that reported on any type of lumbar supports as preventive or therapeutic intervention for non-specific low back pain were included. DATA COLLECTION AND ANALYSIS: One author extracted data from the trials considering characteristics of the study population, characteristics of the interventions and the final results for each outcome measure. The author compared these findings to data regarding the same characteristics of the same studies published already in other reviews. The methodological quality was independently assessed by two authors. Because it was not possible to perform a quantitative analysis, a qualitative meta-analysis was performed in which the strength of evidence on the effectiveness of lumbar supports was classified as being strong, moderate, limited or conflicting, and no evidence. MAIN RESULTS: Five randomized and two nonrandomized controlled preventive trials and six randomized therapeutic trials were included in our review. Overall the methodological quality of the studies included in our review was rather low. Only four of the thirteen studies scored positive on 50% or more of the the internal validity items. There was moderate evidence that for primary prevention lumbar supports are not more effective than other types of treatment or no intervention. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, while it is still unclear if lumbar supports are more effective than other interventions for treatment of low back pain. AUTHORS' CONCLUSIONS: There is still a need for high quality randomised trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realisation of an adequate compliance.

Health-related quality of life in patients with adolescent idiopathic scoliosis: a matched follow-up at least 20 years after treatment with brace or surgery.

No results on long-term outcome in terms of health-related quality of life (HRQL) have previously been presented for patients treated for adolescent idiopathic scoliosis. A consecutive series of patients with adolescent idiopathic scoliosis, treated between 1968 and 1977 before the age of 21, either with distraction and fusion using Harrington rods [surgical treatment group (ST), n=156; 145 females and 11 males] or with a brace [brace treatment group (BT), n=127; 122 females and 5 males] were followed at least 20 years after completion of the treatment. Ninety-four percent of ST and 91% of BT patients filled in a questionnaire comprising the SF-36, Psychological General Well-Being Index (PGWB), Oswestry Disability Back Pain Questionnaire, parts of SRS/MODEM'S questionnaire and study-specific questions concerning the treatment, as a part of an unbiased personal follow-up examination including radiography and clinical examination. An age- and sex-matched control group of 100 persons was randomly selected and subjected to the same examinations. The results showed no differences in terms of sociodemographic data between the groups. Both ST and BT patients had a slightly, but significantly, reduced physical function using the SF-36 subscales, SF-36/Physical Component Summary (PCS) score as well as the Oswestry Disability Back Pain Questionnaire compared to the controls. Neither the mental subscales and the Mental Component Summary (MCS) score of SF-36 nor the PGWB index showed any significant difference between the groups. Forty-nine percent of ST, 34% of BT and 15% of controls admitted limitation of social activities due to their back [P<0.001 ST vs controls, P=0.0010 BT vs controls, and n.s. (P=0.024) ST vs BT], mostly due to difficulties with physical participation in activities or self-consciousness about appearance. Pain was a minor reason for limitation. No correlation was found between the outcome scores and curve size after treatment, curve type, total treatment time or age at completed treatment. Patients treated for adolescent idiopathic scoliosis were found to have approximately the same HRQL as the general population. A minority of the patients (4%) had a severely decreased psychological well-being, and a few (1.5%) were severely physically disabled due to the back.

Childbearing, curve progression, and sexual function in women 22 years after treatment for adolescent idiopathic scoliosis: a case-control study.

STUDY DESIGN: A consecutive series of female patients with adolescent idiopathic scoliosis treated between 1968 and 1977, either with distraction and fusion using Harrington rods (n = 145) or with a brace (n = 122), were followed for at least 20 years after completion of the treatment. OBJECTIVES: To determine the long-term outcomes of childbearing and sexual life in women treated for adolescent idiopathic scoliosis, as compared with matched control subjects who did not have scoliosis. SUMMARY OF BACKGROUND DATA: The effect of pregnancy on curve progression is not established, and results are contradictory. Few reports exist on the social life (marriage, childbearing, and sexual function) of formerly treated individuals with scoliosis. METHODS: In this study, 136 surgically treated women (94%) and 111 brace-treated women (91%) completed the Scoliosis Research Society (SRS)/MODEM's questionnaire concerning childbearing and sexual life as a part of an unbiased personal follow-up examination. Of these, 129 surgically treated and 105 brace-treated women also underwent a radiographic examination. The Cobb method was used to measure curve size in present and earlier examinations. An age-matched control group of 90 women was randomly selected and subjected to the same examinations. RESULTS: The mean age for all the groups was 40 years. Of the surgically treated and brace-treated women, 85% were or had been married, as compared with 82% of the control women. In the total cohort, 628 pregnancies had occurred. No significant mean difference existed between the groups in the number of children born (1.8 for the surgically treated, 1.9 for the brace-treated, and 2 for the control women) (P = 0.25). The patients in the brace-treated group had a significantly higher mean age at first pregnancy (28 years) than the control subjects (25.9 years) (P = 0.011), whereas the age for the surgically treated women (26.6 years) did not differ significantly from that for the brace-treated women. There were no significant differences between the groups in rates for low back pain (35% for the surgically treated, 43% for the brace-treated, and 28% for the control group) or for cesarean section (19% for the surgically treated, 14% for the brace-treated, and 18% for the control group) during the first pregnancy. The rate of vacuum extractions was higher in the surgically treated group (16%) than in the control group (5%) (P = 0.036) or the brace-treated group(8%). Limitation of sexual function from the back was admitted by 33% of the surgically treated, 28% of the brace-treated, and 15% of the control women: surgically treated vs control subjects (P = 0.0042), brace-treated vs control subjects (P = 0.026), and brace-treated vs surgically treated subjects (P = 0.57, a nonsignificant difference). These limitations were largely because of difficulties participating physically in activities or self-consciousness about appearance. Pain was a minor reason for limitation. There was no correlation between progression of the major or lumbar curve and number of pregnancies, or between curve progression and age at first pregnancy. CONCLUSIONS: Patients treated for adolescent idiopathic scoliosis appeared to function well with regard to marital status and number of children. The scoliotic curve did not seem to increase as a result of childbearing. Minor problems occurred during pregnancy and delivery. Some patients, however, experienced a slight negative effect in their sexual life.

The prevalence of disc aging and back pain after fusion extending into the lower lumbar spine. A matched MR study twenty-five years after surgery for adolescent idiopathic scoliosis.

PURPOSE: To determine the long-term outcome after fusion for adolescent idiopathic scoliosis in terms of degenerative disc findings diagnosed using MR imaging and to elucidate the clinical consequences. MATERIAL AND METHODS: Thirty-two patients with adolescent idiopathic scoliosis, who had undergone spinal fusion using Harrington rods to the lower lumbar spine with one or two unfused discs below the fusion, were re-examined 25 years after the fusion. The re-examinations included validated questionnaires, clinical examination, full standing frontal and lateral radiographs and MR examination of the lower lumbar region. Curve size and degenerative findings on MR images were evaluated by two unbiased radiologists, blinded to the clinical findings. A matched control group of 32 persons without scoliosis was subjected to the same examinations. RESULTS AND CONCLUSION: There were significantly more degenerative disc changes (p<0.0001), disc height reduction (p=0.0010) and end-plate changes (p<0.0001 for both upper and lower end-plates) in the lowest unfused disc in the patient group compared with the control group. The MR findings in the lowest unfused disc, but not the one above, in the patient group correlated to lumbar pain intensity as well as to the diminished lumbar lordosis.

Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group.

STUDY DESIGN: A systematic review of randomized and nonrandomized controlled trials. SUMMARY OF BACKGROUND DATA: Lumbar supports are used in the treatment of low back pain, but also to prevent the onset (primary prevention) or recurrences of a low back pain episode (secondary prevention). OBJECTIVES: To assess the effects of lumbar sup-ports for prevention and treatment of nonspecific low back pain. METHODS: The Medline, Cinahl, and Current Contents databases; the Cochrane Controlled Trials Register up to September 1999; and the Embase database up to September 1998 were all searched. References of identified trials and systematic reviews were reviewed and the Science Citation Index used to identify additional trials. Methodologic quality assessment and data extraction were performed by two reviewers independently. A quantitative analysis was performed in which the strength of evidence was classified as strong, moderate, limited or conflicting, and no evidence. RESULTS: Five randomized and two nonrandomized preventive trials and six randomized therapeutic trials were included in the review. Only 4 of the 13 studies were of high quality. There was moderate evidence that lumbar supports are not effective for primary prevention. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, whereas it is still unclear whether lumbar supports are more effective than other interventions for treatment of low back pain. CONCLUSIONS: There continues to be a need for high quality randomized trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance.

Lumbar supports for prevention and treatment of low back pain.

BACKGROUND: Lumbar supports are used in the treatment of low back pain patients to make the impairment and disability vanish or decrease. Lumbar supports are also used to prevent the onset of low back pain (primary prevention) or to prevent recurrences of a low back pain episode (secondary prevention). OBJECTIVES: The objective of this systematic review was to assess the effects of lumbar supports for prevention and treatment of non-specific low back pain. SEARCH STRATEGY: We searched the Medline, Cinahl and Current Contents databases and the Cochrane Controlled Trials Register up to September 1999, and the Embase database up to September 1998. We also screened references given in relevant reviews and identified controlled trials, and used Science Citation Index to identify additional controlled trials. SELECTION CRITERIA: Controlled clinical trials that reported on any type of lumbar supports as preventive or therapeutic intervention for non-specific low back pain were included. DATA COLLECTION AND ANALYSIS: One reviewer extracted data from the trials considering characteristics of the study population, characteristics of the interventions and the final results for each outcome measure. The reviewer compared these findings to data regarding the same characteristics of the same studies published already in other reviews. The methodological quality was independently assessed by two reviewers. Because it was not possible to perform a quantitative analysis, a qualitative meta-analysis was performed in which the strength of evidence on the effectiveness of lumbar supports was classified as being strong, moderate, limited or conflicting, and no evidence. MAIN RESULTS: Five randomized and two nonrandomized controlled preventive trials and six randomized therapeutic trials were included in our review. Overall the methodological quality of the studies included in our review was rather low. Only four of the thirteen studies scored positive on 50% or more of the the internal validity items. There was moderate evidence that for primary prevention lumbar supports are not more effective than other types of treatment or no intervention. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, while it is still unclear if lumbar supports are more effective than other interventions for treatment of low back pain. REVIEWER'S CONCLUSIONS: There is still a need for high quality randomised trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realisation of an adequate compliance.

Pain sensitivity as a correlate of clinical status in individuals with chronic low back pain.

STUDY DESIGN: A cross-sectional study of baseline correlates of clinical pain and functional status in consecutive patients being treated for chronic low back pain. OBJECTIVES: To determine if an individual's global pain sensitivity, measured by experimental pain threshold to pressure at various regions of the body, is associated with baseline measures of clinical pain and physical functioning. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated that in individuals with chronic low back pain, clinical pain and functional status are significantly associated with demographic, structural, and psychosocial factors. However, a large portion of variance remains unexplained. Because pain sensitivity (tenderness) has been shown to occur as a continuum in the population, the authors sought to determine if such sensitivity might be associated with clinical status in chronic low back pain, beyond what is known regarding demographic, structural, and psychosocial factors. METHODS: Forty-five patients with chronic low back pain were assessed for a variety of demographic, structural, and psychosocial factors, which previously have been shown to contribute to clinical status. In addition, all patients underwent testing for pain tolerance and threshold at various areas of the body. RESULTS: Age, degree of structural abnormality observed on magnetic resonance imaging, and depressive symptoms were all significantly correlated with either clinical pain or functional status. Pain sensitivity, the target of this investigation, accounted for significant proportions of variance in functional status and pain, even after controlling for demographic, structural, and psychosocial variables. CONCLUSIONS: These pilot data suggest that an individual's experimental pain threshold (a measure of tenderness) is associated with baseline functional status and pain in cases of chronic low back pain and may represent an important domain warranting further investigation.

Health care providers should use a common language in relation to low back pain patients.

Uncertainty is the rule rather than the exception when it comes to the underlying causes of 'common' or 'non-specific' low back pain. It may be called many names, depending on whether the diagnostic term is descriptive, anatomopathological or physiopathological. Classifications have been devised, including various criteria: symptoms and signs, duration, treatment, consequences of low back pain on the patients' daily life, etc. Because back pain frequently runs a recurrent course, functional and pain outcomes need to be considered separately: chronic disability and chronic pain may not be parallel. Thus, pain duration (e.g. acute, transient, recurrent, chronic) is only one element in the definition of chronicity. These difficulties in defining and classifying non-specific low back pain may lead to communication problems among health professionals as well as between patients and health professionals. These difficulties raise questions such as: what kind of diagnostic term should we use to avoid dramatization of non-specific low back pain? how can we improve the definition of long-term low back pain? and how can we assure and reassure the patient that this condition is benign in the majority of the population?

The crankshaft phenomenon after posterior Harrington fusion in skeletally immature patients with thoracic or thoracolumbar idiopathic scoliosis followed to maturity.

STUDY DESIGN: This retrospective study evaluated the progression of deformity after posterior fusion by reviewing 63 consecutive patients with idiopathic scoliosis who were all in Risser sign 0 at the time of surgery. All patients were observed beyond the time of skeletal maturity. Average follow-up time was 9 years and 8 months (range, 5-16 years). OBJECTIVES: To investigate the risk factors for the crankshaft phenomenon after posterior fusion and to build a model for predicting the probability of curve progression until maturation of growth. SUMMARY OF BACKGROUND DATA: There remains considerable controversy concerning the incidence, risk factors, and necessity of combined anterior fusion to prevent the crankshaft phenomenon in patients who are skeletally immature. METHODS: Serial radiographs were measured for Cobb angle, apical rotation according to Perdriolle, and apical rib-vertebra angle of Mehta. Multivariate and univariate logistic regression analysis was performed using seven potential predictors as independent variables and Cobb angle progression and rotational progression as dependent variables. RESULTS: Average progression of deformity was 3 degrees Cobb angle (range, -8-16 degrees) and 3 degrees Perdriolle rotation (range, -9-17 degrees). Progression of deformity more than 5 degrees of either Cobb angle or rotation was observed in 22 (35%) of 63 curves with 7 (11%) of 63 curves greater than 10 degrees. Chronologic age and skeletal age were found to be significantly associated with progression of deformity in univariate analysis. In multivariate analysis, only skeletal age seemed to be independently prognostic. The authors tried to build the logistic model using the three factors of chronologic age, skeletal age, and apical rib-vertebra angle. This model correctly classified 81% of all patients as progressive or nonprogressive. The positive predictive value was 90%. CONCLUSIONS: The results showed that patients with chronologic age of 11 years of younger, especially those with a skeletal age of 10 years or younger, had a high estimated probability of progression of deformity. The progression was fairly moderate, however, with an average Cobb angle of 9 degrees and average rotation of 7 degrees, which neither the patients nor the surgeon believed was of such magnitude as to warrant routine combined anterior fusion.

Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society.

In a prospective study by the Scoliosis Research Society, 286 girls who had adolescent idiopathic scoliosis, a thoracic or thoracolumbar curve of 25 to 35 degrees, and a mean age of twelve years and seven months (range, ten to fifteen years) were followed to determine the effect of treatment with observation only (129 patients), an underarm plastic brace (111 patients), and nighttime surface electrical stimulation (forty-six patients). Thirty-nine patients were lost to follow-up, leaving 247 (86 per cent) who were followed until maturity or who were dropped from the study because of failure of the assigned treatment. The end point of failure of treatment was defined as an increase in the curve of at least 6 degrees, from the time of the first roentgenogram, on two consecutive roentgenograms. As determined with use of this end point, treatment with a brace failed in seventeen of the 111 patients; observation only, in fifty-eight of the 129 patients; and electrical stimulation, in twenty-two of the forty-six patients. According to survivorship analysis, treatment with a brace was associated with a success rate of 74 per cent (95 per cent confidence interval, 52 to 84) at four years; observation only, with a success rate of 34 per cent (95 per cent confidence interval, 16 to 49); and electrical stimulation, with a success rate of 33 per cent (95 per cent confidence interval, 12 to 60).(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of progression of the curve in girls who have adolescent idiopathic scoliosis of moderate severity. Logistic regression analysis based on data from The Brace Study of the Scoliosis Research Society.

In a study conducted by the Scoliosis Research Society, 159 girls with a mean age of thirteen years (range, ten to fifteen years) who had adolescent idiopathic scoliosis were followed prospectively until skeletal maturity or until the curve had increased 6 degrees or more. All patients had had an initial curve of 25 to 35 degrees and an apical level between the eighth thoracic and first lumbar vertebrae, inclusive. Of the 159 patients, 120 were observed without treatment and thirty-nine were managed with lateral electrical surface stimulation. The curve progressed at least 6 degrees in eighty patients. There was no apparent difference in the outcome between the patients who were managed with observation only and those who were given electrical stimulation. Logistic regression analysis was performed to determine which of eleven factors were predictive of progression of the scoliotic curve. A Risser sign of 0 or 1, an apical level cephalad to the twelfth thoracic vertebra, and an imbalance of ten millimeters or less were found to be independently prognostic of progression of more than 6 degrees. A prognostic model that included these three factors and chronological age allowed correct classification of the curve as either progressive or non-progressive in 81 per cent of these patients who had a thoracic or thoracolumbar adolescent idiopathic scoliosis. The positive predictive value was 82 per cent, the negative predictive value was 80 per cent, and the sensitivity and specificity were each 81 per cent.