Resumos

The treatment of acute low back pain - Bed rest, exercises, or ordinary activity?

ANTTI MALMIVAARA, M.D., PH.D., UNTO HÄKKINEN, M.SC., PH.D., TIMO ARO, M.D., PH.D., MAJ-LEN HEINRICHS, R.N., LIISA KOSKENNIEMI, M.D., EEVA KUOSMA, M.SC., SEPPO LAPPI, M.D., RAILI PALOHEIMO, M.D., CARITA SERVO, M.D., VESA VAARANEN, M.D., PH.D., AND SVEN HERNBERG, M.D., PH.D.

Abstract Background. Bed rest and back-extension exercises are often prescribed for patients with acute low back pain, but the effectiveness of these two competing treatments remains controversial.

Methods. We conducted a controlled trial among employees of the city of Helsinki, Finland, who presented to an occupational health care center with acute, nonspecific low back pain. The patients were randomly assigned to one of three treatments: bed rest for two days (67 patients), back-mobilizing exercises (52 patients), or the continuation of ordinary activities as tolerated (the control group; 67 patients). Outcomes and costs were assessed after 3 and 12 weeks.

Results. After 3 and 12 weeks, the patients in the control group had better recovery than those prescribed either bed rest or exercises. There were statistically significant differences favoring the control group in the duration of pain, pain intensity, lumbar flexion, ability to work as measured subjectively, Oswestry back-disability index, and number of days absent from work. Recovery was overall costs of care did not differ significantly among the three groups.

Conclusions. Among patients with acute low back pain, continuing ordinary activities within the limits permitted by the pain leads to more rapid recovery than either bed rest or back-mobilizing exercises. (N Engl J Med 1995;332:351-5.)

From the Departments of Occupational Medicine (A.M., T.A., V.V.) and Epidemiology and Biostatistics (E.K., S.H.), Finnish Institute of Occupational Health; the National Research and Development Health Center for Welfare and Health (U.H.); and the City of Helsinki Occupational Health Care Centers (M.-L.H., L.K., S.L., R.P., C.S.) - all in Helsinki, Finland, Address reprint requests to Dr. Malmivaara at the Department of Occupational Medicine, Finnish Institute of Occupational Health, Topeliuksenkatu 41 aA, FIN-00250 Helsinki, Finland.

RICHARD A. DEYO, MD, MPH

BACK PAIN ranks second only to upper respiratory tract complaints as a symptomatic reason for visits to office-based physicians, and seventh as a reason for visits to internists. At least in some settings, fewer than 2% of these patients need surgery Since an earlier review, several important findings have emerged concerning the diagnostic evaluation of low back pain. While much of the direct cost of treating patients who have back pain is related to diagnostic tests, recent data suggest that selective parsimonious testing may be appropriate, especially in primary care. This conclusion has emerged as the roles of the clinical examination and plain radiography have been refined and clarified.

Received from the Department of Medicine, Division of General Internal Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas.

Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, conclusions, and proposals in the text are those of the author and do not necessarily represent the views of the Robert Wood Johnson Foundation.

Address correspondence and reprint requests to Dr. Deyo: Department of Medicine, University of Texas Health Science Center, 7703 Floyd Curi Drive, San Antonio, TX 78284. 

Epidemiology and impact of low-back pain

JENNIFER L. KELSEY, PhD, and AUGUSTUS A. WHITE III, MD, Dr Med Sci

Disorders of the lumbar spine are among the most common medical problems in western countries, affecting up to 80% of people at some time during their lives. The epidemiology and impact of six specific disorders of the lumbar spine are reviewed. These include prolapsed discs, discs degeneration, osteoarthrosis of the apophyseal joints, fractures and dislocations of vertebrae, osteoporosis, and spondylolisthesis. Various mechanical factors contribute to the causation of most of these disorders, but other underlying pathologic mechanisms are important as well. In light of the great impact of these conditions on society and on individuals, it is concluded that there is a considerable need for a greater allocation of resources for improvement in methods of prevention, diagnosis, and treatment. [Key words: low-back pain, epidemiology, prolapsed disc, disc degeneration, osteoarthrosis, fractures, osteoporosis, spondylolisthesis.

From the Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, and the Department of Orthopedic Surgery, Beth Israel Hospital and Harvard Medical School, Boston, Massachusetts.
Submitted for publication May 23, 1979. 

A randomized controlled trial of flexion exercises, education, and bed rest for patients with acute low back pain

CATHY EVANS, J.R. GILBERT, WAYNE TAYLOR, ANN HILDEBRAND

A randomized control trial of back flexion exercises, education and bed rest was carried out to determine the effects on subjects with low back pain. Two hundred and sixty subjects and 22 family physicians participated in the study. Subjects were randomly allocated to one of four treatment groups: back flexion exercises and education program; exercise/education plus bed rest; bed rest alone; or a control group. Subjects in the bed rest groups were instructed to remain in bed for a minimum of four days. Subjects in the exercise/education groups were taught a standardized back flexion exercise program by a physiotherapist and instructed in back care techniques. Results demonstrated that subjects who received flexion exercises and education were able to stop their medication sooner than the bed rest and control groups. No other statistically significant difference in degree of pain, activities of daily living, straight leg raise (SLR), or lumbar flexion was observed among the four treatment groups.

KEY WORDS: Back, bed rest, exercise therapy.

C. Evans, Co-ordinator of Physiotherapy, Credit Valley Treatment Centre for Children, Mississauga, Ontario.
J.R. Gilbert, M.D., Professor of Family Medicine and Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, Hamilton, Ontario.
D.W.Taylor, M.A., Associate Professor of Clinical Epidemiology and Biostatistics, McMaster University Medical Centre, Hamilton, Ontario.
A. Hildebrand, medical student, McMaster University Medical Centre, Hamilton, Ontario.
Mailing address: C. Evans, Credit Valley Treatment Centre, 2277 South Millway, Mississauga, Ontario. L5L 2M5
This project was supported by a grant from the Ontario Ministry of Health (DM 500).

Muscular performance after a 3 month progressive physical exercise program and 9 month follow-up in subjects with low back pain. A controlled study.

Scand J Med Sci Sports 1996;6;112-121. Munksgaard, 1996

The purpose of this study was to assess, in subjects with low back pain, the changes and their permanence in muscular performance after a 3 month progressive physical exercise program. Ninety subjects with chronic low back pain participated in the study. The study design was controlled and it was carried out in three groups: intensive training, home exercise, and control group. Isometric and dynamic muscle strength of the trunk and lower limb were measured, at the beginning of the study and after the 3 months exercise program, and then during each of the follow-up sessions. The Oswestry Index and back pain intensity were also determined. Both exercise groups received benefit from the progressive exercise program. Their muscular performance improved and their back pain intensity decreased significantly. Among the home exercise group, the Oswestry Index also changed positively. The results demonstrate that the home exercise program could be as effective as the intensive training program in increasing muscle strength, as well as decreasing back pain and functional disability among low back pain patients with mild functional limitations.

T.Kuukkanen, E. Mälkia - Central Finland College of Health, Jyväskylä, Finland, Department of Health Sciences University of Jyväskylä, Jyväskylä, Finland
Key words: back pain; muscle strength; muscular performance; physical exercise
Tina Kuukkanen, Central Finland College of Health, Keskussairaalantie 21, 40620 Jyväskylä, Finland
Accepted for publication November 24, 1995

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice

J Coste, G Delecoeuillerie, A Cohen de Lara, J M Le Parc, J B Paolaggi

Objective - To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes.

Design - Inception cohort study.

Setting - Primary care.

Patients - 103 patients with acute localised non-specific back pain lasting less than 72 hours.

Main outcome measures - Complete recovery (disappearance of both pain and disability) and return to work.

Results - 90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 405 of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender.

Conclusions - The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with exacerbation of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.

INSERM Unité U 292, Hôpital de Bicêtre, 94275
Le Kremlin-Bicêtre Cedex, France
J Coste, medical statistician
Laboratoires CASSENNE 1, 92800 Puteaux, France
G Delecoeuillerie, consultant rheumatologist
Service de Rhumatologie, Hôpital Ambroise Paré, 92104 Boulogne Cedex, France
A Cohen de Lara, consultant rheumatologist
J M Le Parc, professor of rheumatology
J B Paolaggi, professor of rheumatology
Correspondence to: Dr J Coste. 

Exercise and Spinal Manipulation in the Treatment of Low Back Pain

Current research clearly the importance of exercise and mobility in the treatment of low back pain and also that bed rest and inactivity should play a relatively small part in treatment. The use of intensive, physical exercise and "work hardening" routines have been shown to be necessary for treating chronic low back pain and returning individuals to work. Evidence derived from valid clinical studies of the use of manipulation in the acute treatment of "mechanical" low back disorders These studies have demonstrated that manipulative relief compared with other conservative therapies. Over a longer time frame, this advantage disappears. [Key words: exercise, low back pain, manipulation, mobilization] Spine 1995;20:615-619.

From the Curtin University of Technology, Perth, Western Australia. Accepted for publication September 28, 1994.

 A Controlled, Multicentre Trial of Manual Therapy in Low-Back Pain

STEFAN BLOMBERG, KURT SVÄRDSUDD and FRANZ MILDENBERGER

Blomberg S, Svärdsudd K, Mildenberger F. A controlled, multicentre of manual therapy in low-back pain: initial status, sick-leave and pain score during follow-up. Scand J Prim Health Care 1992; 10: 170-8

101 outpatients with care or subacute low-back pain were randomly allocated to one of two treatment groups. One group was given standardized conventional but optimal activating treatment by primary healthcare teams. The other group received manual treatment such as manipulation, specific mobilization, muscle stretching, auto-traction, and cortisone injections. The two groups were similar in most of the pretrial variables, including age, sex, previous low-back pain problems, sick-leave, previous treatment, findings at the physical examination, quality-of-life score, disability rating, and pain score.After one month in the study, the proportion of patients on sick-leave was six times larger in the conventionally treated group than in the group receiving the specific manual treatment. The difference diminished over time but was still significant after eight months. Two slightly different pain scores ("pain at the moment" and "pain during the last weeks"), initially similar in the two groups, diminished in both groups but were significantly lower in the manual treatment group during the study.

The group receiving specific manual treatment thus had a significantly better outcome than the group receiving conventional treatment as far as sick-leave and pain score are concerned.

Key words: low-back pain, manual therapy, controlled randomized trial, primary health care, sick-leave, pain score.

Stefan Blomberg, MD, Department of Family Medicine, Academic Hospital, S-751 85 Upp-sala, Sweden.

1987 Volvo Award in Clinical Sciences

A New Clinical Model for the Treatment of Low-Back Pain 

GORDON WADDELL, BSc, MD, FRCS

Because there is increasing concern about low-back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low-back pain should be a bening, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic, and that the role of traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low-back disorders. Studies of the mathematical relationship between the elements of illness in chronic low-back pain suggest that the biophysichosocial concept can be used as an operational model that explains many clinical observations. This model is used to compare rest and active rehabilitation for low-back pain. Rest is the commonest treatment prescribed after analgesics but is based on a doubtful rationale, and there is little evidence of any lasting benefit. There is, however, little doubt about the harmful effects- especially of prolonged bed rest. Conversely, there is no evidence that activity is harmful and, contrary two common belief, it does not necessarily make the pain worse. Experimental studies clearly show that controlled exercises not only restore function, reduce distress and illness behavior, and promote return to work, but actually reduce pain. Clinical studies confirm the value of active rehabilitation in practice. To achieve the goal of treating patients rather than spines, we must approach low-back disability as an illness rather than low-back pain as a purely physical disease. We must distinguish pain from disability, the symptoms and signs of distress and illness behavior from those of physical disease, and nominal from substantive diagnoses. Management must change from a negative philosophy of rest for pain to more active restoration of function. Only a new model and understanding of illness by physicians and patients alike makes real change possible. [Key words: low-back pain, clinical model, treatment, psychosocial factors]

From the Orthopaedic Department, Western Infirmary, Glasgow, Scotland.

Submitted for publication December 15, 1986.

The author thanks David Allan, Michael Bond, Bill Fordyce, David Hamblen, Bill Hrudey, John Loeser, Chris Main, Alf Nachemson, Henrik Weber, and Philip Wood for their ideas, information, and assistance. Original data and detailed analyses were supplied by the Consumer's Association, London, the Department of Health and Social Security Headquarters Division SR8B, Newcastle upon Tyne, and the Workmen's Compensation Board of British Columbia.

Management of Exercise in the Elderly

R. J. Shephard
School of Physical and Health Education
Dept. of Preventive Medicine & Biostatistics,
Faculty of Medicine,
and
Instituteof Medical Sciences,
University of Toronto.

SHEPHARD, R. J., Management of Exercises in the Elderly. Can. J. Appl. Spt. Sci. 9:3 109-120,1984. The principles of exercise management in the elderly are reviewed from the standpoint of the practicing physician. The fitness needs of the older individual are defined, and practical methods of assessment are suggested for both the healthy and the partially disabled senior citizen. Attention should be directed to clinical status, aerobic power, body composition, muscular strength, flexibility, and the electrocardiographic response to vigorous exercise. Fitness standards for the elderly are discussed, and arguments are advanced for improving their personal fitness. Greater activity should prolong independence, improve lifestyle, upgrade moodstate, and help in the prevention of many medical disorders. The exercise prescription must include an adequate warm up and warmdown. As condition permits, the aerobic component should be extended to 30 minutes of activity at 60% or more of maximum oxygen intake. Reasons for strengthening specific muscle groups, and methods of reducing the percentage of body fat are considered. Techniques of developing flexibility are presented, and adapted prescriptions are suggested for those with various disabilities. Methods of sustaining motivation are reviewed, and the need for immediate medical supervision of programs is discussed. Finally, the gains from a training program are evaluated. Although absolute physiological responses are less than in a younger individual, a suitably graded exercise prescription does much to improve both the physical ability and the mood state of a senior citizen.