Previous systematic reviews have reported positive associations between Modic changes (MCs) and low back pain (LBP), but due to their narrow scope and new primary studies, there is a need for a ...comprehensive systematic review. Our objectives were to investigate if MCs are associated with non-specific LBP and/or activity limitation and if such associations are modified by other factors.
A protocol for this review was registered at PROSPERO prior to commencing the work (PROSPERO record: CRD42015017350). The MEDLINE, CINAHL and EMBASE databases were searched for relevant studies from first record to June 15th 2016. Prospective or retrospective cross-sectional cohort studies and case-control studies including people of all ages from general, working and clinical study populations were eligible for inclusion. Risk of bias assessment and data extraction for associations and potential modifiers were completed independently by pairs of reviewers. Meta-analysis was performed for homogeneous studies and presented as odds ratios (OR) with 95% CI.
In all, 5210 citations were identified and 31 studies were included. One study had low risk of bias. Fifteen studies (48%) reported statistically significant positive associations between MCs and LBP and one study found a statistically significant negative association. Meta-analysis performed for studies using concordant pain with provocative discography as the clinical outcome resulted in an OR of 4.01 (1.52-10.61). One of seven studies reported a statistically significant positive association between MCs and activity limitation. Lumbar disc level and disc degeneration were found to modify the association between MCs and LBP.
The results from this comprehensive systematic review indicate that the associations between MCs and LBP-related outcomes are inconsistent. The high risk of bias and the heterogeneity in terms of study samples, clinical outcomes and prevalence estimates of MCs and LBP may explain these findings. It is likely that new studies with low risk of bias will affect the direction and strength of these associations.
Objective: To investigate the causal effect of sense of coherence on long-term work participation after rehabilitation, including stratification by age and diagnoses.
Design: Longitudinal cohort ...study.
Participants: Patients aged ≤ 60 years, employed and accepted for somatic interprofessional rehabilitation in 2015 (n = 192).
Methods: Patients reported sense of coherence before rehabilitation in 2015 and mental and physical functioning in 2016. Register data were used to measure work participation during 2018 and days working without social security benefits during 2016–18. Regression models were used to explore the total effect of sense of coherence and the possible mediation of functioning. Results are reported as odds ratios (95% confidence intervals).
Results: During 2018, 77% of the total study cohort participated in work activities. The subgroup with musculoskeletal diagnoses had the fewest days of working without social security benefits. A causal relationship was found between sense of coherence and long-term work participation. Some of the effect of sense of coherence was mediated by mental functioning. The total effect of sense of coherence was strongest for patients with musculo-skeletal diagnoses (work participation: 1.11 (1.05, 1.17), days working without social security benefits: 1.05 (0.01, 109)).
Conclusion: Improving coping resources may be beneficial to facilitate long-term work participation after injury or illness, especially for individuals with musculoskeletal diagnoses.
To investigate changes and predictors of change in physical and mental function over a 3-year period after rehabilitation.
Prospective cohort.
Patients, across diseases, living in western Norway, ...accepted for somatic specialized interprofessional rehabilitation (n = 984).
Physical and mental function were assessed at admittance (baseline), and after 1 and 3 years using the Medical Outcome Study Short Form 36 (SF-36). Associations between changes in SF-36 component summary scores and sense of coherence, pain, disease group (musculoskeletal, neoplasm, cardiovascular, neurological, other), exercise habits and demographic variables were analysed using linear mixed modelling.
In the total group, mean (standard deviation) physical component summary scores improved by 2.9 (8.4) and 3.4 (9.3) points at 1 and 3 years, respectively. Mental component summary scores improved by 2.1 (9.7) and 1.6 (10.8) points. Improvement in physical component summary was significantly greater for patients with higher sense of coherence (b = 0.09, p = 0.001) and for the neoplasm disease group (b = 2.13, p = 0.046). Improvement in mental component summary was significantly greater for patients with low sense of coherence (b = -0.13, p = < 0.001) and higher level of education (b = 3.02, p = 0.0302). Interaction with age (physical component summary: b = 0.22, p = 0.039/mental component summary b = 0.51, p = 0.006) indicated larger effect at 1 year than at 3 years.
Physical and mental function improved in the total study group over the 3-year period. Sense of coherence at baseline was associated with improved physical and mental function, suggesting that coping resources are important in rehabilitation.
Objective:
To compare the effect of modified constraint-induced movement therapy (mCIMT) to bimanual task-related training for patients in the subacute phase post stroke.
Design:
A single-blinded ...randomized controlled trial.
Settings:
Inpatient and outpatient rehabilitation clinics and the patient’s home.
Subjects:
Thirty patients in the subacute phase post stroke (2–16 weeks) were randomized to modified constraint-induced movement therapy with an emphasis on unimanual tasks, or bimanual task-related training, emphasizing bimanual tasks. All trained with a therapist 4 hours a week for four weeks, followed by a 2–3 hours daily self-training program. Patients in the modified constraint-induced movement therapy group were supposed to wear a restraining mitt on the unaffected hand for 4 hours a day for four weeks.
Main measures:
Blinded assessments at pre and post treatment and after three months with Action Research Arm Test as a primary outcome measure, Nine-Hole Peg Test and Motor Activity Log.
Results:
Power calculations suggested an inclusion of 60 patients, but due to recruitment difficulties the trial was stopped after an interim analysis at 30 patients. There was no difference in change (P > 0.05) between the groups on any of the measures, neither at post treatment nor at follow-up assessments. From pre-intervention to follow-up assessment the modified constraint-induced movement therapy group obtained a mean change score of 17.77 (14.66) on Action Research Arm Test, the bimanual group 15.47 (13.59).
Conclusion:
Bimanual training was as effective as modified constraint-induced movement therapy in improving arm motor function. Wearing a mitt seems unnecessary for most patients in the subacute phase post stroke when focused affected arm training is provided.
Objectives
A tool for measuring neck pain in patients with dizziness is needed to further investigate the relationship between the two symptoms. The objective of this study was to examine the ...reliability and validity of a hand‐held pressure algometer in measuring pressure pain threshold (PPT) in different cervical regions of dizzy patients.
Methods
PPT was measured at two bilateral standardized sites of the neck by a trained physiotherapist in 50 patients with dizziness. Intraclass correlation coefficients (ICC) were calculated for intrarater and test–retest reliability. Concurrent validity was assessed by measuring the association between PPT and the American College of Rheumatology (ACR) tender points at each site and with the numeric pain rating scale (NPRS).
Results
Almost perfect intrarater (ICC = 0.815–0.940) and within‐session test–retest (ICC = 0.854–0.906) reliability was found between the measures. On each site, a low PPT predicted a positive ACR tender point at each site (OR = 0.864–0.922). Last, we found a statistical inverse relationship between the PPT and the NPRS (R = −0.52 to −0.66).
Conclusion
The study shows that a pressure algometer is a reliable tool for measuring PPT in the neck of dizzy patients. Further, the PPT correlates significantly with other subjective measures of pain indicating that it may be a useful tool for further research.
To predict psychological distress at 2 months for patients with mild traumatic brain injury.
A prospective cohort study of 162 patients with mild traumatic brain injury (MTBI) admitted consecutively ...to an outpatient clinic at Haukeland University Hospital, Norway. Demographic data were obtained from Statistics Norway and injury characteristics were obtained from the hospital records. Sick leave data from the last year before the injury were obtained from The Norwegian Labor and Welfare Service. Self-report questionnaires were used to obtain history about earlier disease and symptom profiles. The Hospital Anxiety and Depression Scale (HAD) detecting states of depression and anxiety were used as the dependent variable in a stepwise linear regression. Pre-injury factors and injury-related factors were examined as potential predictors for HAD.
In the first steps we observed a significant association between HAD at 2 months and education, whiplash associated disorder (WAD), and earlier sick listed with a psychiatric diagnosis. In the final step there was an association only between HAD and self-reported anxiety and WAD. There were no associations between HAD and injury-characteristics like severity at Glasgow Coma Scale or intracranial injury.
Patients with low education, earlier psychiatric diagnosis, self-reported earlier anxiety and WAD were more likely to develop a psychological distress after a MTBI. These findings should be taken into consideration when treating patients with MTBI.
Objective. To predict return to work (RTW) at 12 months for patients who either were sick-listed or were at risk to be sick-listed with persistent postconcussion symptoms (PCS) at six to eight weeks ...after injury. Method. A prospective cohort study of 151 patients with mild traumatic brain injury (MTBI) admitted consecutively to outpatient clinics at two University Hospitals in Norway. The study was conducted as part of a randomised clinical trial. Injury characteristics were obtained from the medical records. Sick leave data from one year before to one year after MTBI were obtained from the Norwegian Labour and Welfare Service. Self-report questionnaires were used to obtain demographic and symptom profiles. Results. We observed a significant negative association between RTW at 12 months and psychological distress, global functioning, and being sick-listed at two months after MTBI, as well as having been sick-listed the last year before injury. Conclusion. Psychological distress, global functioning postinjury, and the sick leave trajectory of the subjects were negative predictors for RTW. These findings should be taken into consideration when evaluating future vocational rehabilitation models.
Few studies have examined the responsiveness of physical tests.
The purpose of this study was to explore the responsiveness of 10 physical tests used for patients with back pain in order to ...illuminate the significance of changes in scores.
Cross-sectional and longitudinal designs within a prospective cohort study were applied.
Distribution-based and anchor-based methods were used. Ninety-eight patients (18-65 years of age) with long-lasting back pain were recruited consecutively at an outpatient spine clinic. Measurements The participants were assessed using 10 physical tests and 2 questionnaires (Hannover Functional Ability Questionnaire and Roland-Morris Disability Questionnaire) at inclusion and after rehabilitation. Six predefined hypotheses for each test were examined regarding the association between changes in scores on the physical tests and the self-report measures of functioning and regarding the relationship of changes in scores on the physical tests and external anchors of important change.
Five physical tests demonstrated responsiveness by both distribution-based and anchor-based methods: spondylometry, lateral flexion test, fingertip-to-floor test, lift test, and Back Performance Scale (4 hypotheses confirmed). The minimal important change values were all within the range of the smallest detectable change for individual patients. Responsiveness by distribution-based methods only (3 hypotheses confirmed) was shown for the Biering-Sørensen test and the loaded reach test, whereas little evidence of responsiveness (1 hypothesis confirmed) was shown for the Global Physiotherapy Examination flexibility subscale, the Progressive Isoinertial Lifting Evaluation, and the 15-m (50-ft) walk test. Limitations The smallest detectable change values were examined in a small sample of patients and need further exploration.
Responsiveness varied among the 10 physical tests.
Objectives
This randomized controlled trial investigated the efficacy of cognitive functional therapy (CFT) compared with manual therapy and exercise (MT‐EX) for people with non‐specific chronic low ...back pain (NSCLBP) at 3‐year follow‐up.
Methods
Hundred and twenty‐one patients were randomized to CFT (n = 62) or MT‐EX (n = 59). Three‐year data were available for 30 (48.4%) participants in the CFT group, and 33 (55.9%) participants in the MT‐EX group. The primary outcomes were disability (Oswestry disability Index ODI) and pain intensity (numerical rating scale) and secondary outcomes were anxiety/depression (Hopkins Symptoms Checklist) and pain‐related fear (Fear‐Avoidance Belief Questionnaire). A full intention to treat analysis was conducted using linear mixed models.
Results
Significantly greater reductions in disability were observed for the CFT group, with ODI scores at 3 years 6.6 points lower in the CFT than the MT‐EX group (95%CI:‐10.1 to −3.1, p < 0.001, standardized effect size = 0.70). There was no significant difference in pain intensity between the groups at 3 years (0.6 points 95%CI:‐1.4–0.3, p = 0.195). Significantly greater reductions were also observed for the CFT group for Hopkins Symptoms Checklist and Fear‐Avoidance Belief Questionnaire (Work).
Conclusions
CFT is more effective at reducing disability, depression/anxiety and pain‐related fear, but not pain, at 3‐year follow‐up than MT‐EX.
Significance
Cognitive functional therapy (CFT) was more effective than manual therapy and exercise (MT‐EX) in reducing disability at 3‐year follow‐up, in people with non‐specific chronic low back pain. The sustained reduction in disability without concomitant reductions in pain intensity in the CFT group suggests a de‐coupling of the pain—disability relationship.
CFT resulted in long‐lasting reductions in anxiety and depression, and pain‐related fear regarding work compared to MT‐EX. The findings support the long‐term benefits of a individualized behaviourally orientated intervention that targets pain beliefs, functional restoration and lifestyle factors.
A previous randomised controlled trial (RCT) of patients with chronic low back pain (LBP) and vertebral bone marrow (Modic) changes (MCs) on magnetic resonance imaging (MRI), reported that a 3-month, ...high-dose course of antibiotics had a better effect than placebo at 12 months' follow-up. The present study examines the effects of antibiotic treatment in chronic LBP patients with MCs at the level of a lumbar disc herniation, similar to the previous study. It also aims to assess the cost-effectiveness of the treatment, refine the MRI assessment of MCs, and further evaluate the impact of the treatment and the pathogenesis of MCs by studying genetic variability and the gene and protein expression of inflammatory biomarkers.
A double-blinded RCT is conducted at six hospitals in Norway, comparing orally administered amoxicillin 750 mg, or placebo three times a day, over a period of 100 days in patients with chronic LBP and type I or II MCs at the level of a MRI-confirmed lumbar disc herniation within the preceding 2 years. The inclusion will be stopped when at least 80 patients are included in each of the two MC type groups. In each MC type group, the study is designed to detect (β = 0.1, α = 0.05) a mean difference of 4 (standard deviation 5) in the Roland Morris Disability Questionnaire score between the two treatment groups (amoxicillin or placebo) at 1-year follow-up. The study includes cost-effectiveness measures. Blood samples are assessed for security measures and for possible inflammatory mediators and biomarkers at different time points. MCs are evaluated on MRI at baseline and after 12 months. A blinded intention-to-treat analysis of treatment effects will be performed in the total sample and in each MC type group.
To ensure the appropriate use of antibiotic treatment, its effect in chronic LBP patients with MCs should be re-assessed. This study will investigate the effects and cost-effectiveness of amoxicillin in patients with chronic LBP and MCs at the level of a disc herniation. The study may also help to refine imaging and characterise the biomarkers of MCs.
ClinicalTrials.gov, ID: NCT02323412 . Registered on 21 November 2014.
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