From: Eur J Pain. 2008 Aug 7; [Epub ahead of print]

Chronic neck pain is a common complaint in the Netherlands with a point prevalence of 14.3%. Patients with chronic neck pain are often referred to physiotherapy and, nowadays, are mostly treated with exercise therapy. It is, however, unclear which type of exercise therapy is to be preferred. Therefore, this study evaluates the effectiveness of behaviour graded activity compared with conventional neck exercises for patients with chronic neck pain. Eligible patients with non-specific chronic neck were randomly allocated to either behaviour graded activity or conventional neck exercises. Primary treatment outcome is the patient’s global perceived effect concerning recovery from complaint and daily functioning. Outcome assessment was performed at baseline, and at 4, 9, 26, and 52 weeks after randomization. Effectiveness was examined with general estimating equations analyses. Baseline demographics and patient characteristics were well balanced between the two groups. Mean age was 45.7 years and the median duration of complaints was 60 months. The mean number of treatments was 6.6 in behaviour graded activity and 11.2 in conventional neck exercises.

No significant differences between treatments were found in their effectiveness of managing patients with chronic neck pain. In both behaviour graded activity and conventional neck exercises some patients reported recovery from complaints and daily function but the proportion of recovered patients did not exceed 50% during the 12-month follow-up period. Both groups showed clinically relevant improvements in physical secondary outcomes.

From: Eur Spine J. 2008 Jul 29; [Epub ahead of print]

Intensive group training using principles of graded activity has been proven to be effective in occupational care for workers with chronic low back pain. Objective of the study was to compare the effects of an intensive group training protocol aimed at returning to normal daily activities and guideline physiotherapy for primary care patients with non-specific chronic low back pain. The study was designed as pragmatic randomised controlled trial with a setup of 105 primary care physiotherapists in 49 practices and 114 patients with non-specific low back pain of more than 12 weeks duration participated in the study. In the intensive group training protocol exercise therapy, back school and operant-conditioning behavioural principles are combined. Patients were treated during 10 individual sessions along 20 group sessions. Usual care consisted of physiotherapy according to the Dutch guidelines for Low Back Pain. Main outcome measures were functional disability (Roland Morris disability questionnaire), pain intensity, perceived recovery and sick leave because of low back pain assessed at baseline and after 6, 13, 26 and 52 weeks. Both an intention-to-treat analysis and a per-protocol analysis were performed. Multilevel analysis did not show significant differences between both treatment groups on any outcome measures during the complete follow-up period, with one exception. After 26 weeks the protocol group showed more reduction in pain intensity than the guideline group, but this difference was absent after 52 weeks. We finally conclude that an intensive group training protocol was not more effective than usual physiotherapy for chronic low back pain.

In 2001 the physiotherapy guideline for the assessment and treatment of patients with non-specific low back pain was published in The Netherlands. The recommendations in this guideline were based on scientific evidence where available; otherwise they were based on consensus. The guideline recommends that the diagnostic process should focus on disability and participation problems resulting from back pain. The treatment should consist of an active approach, in which patients learn to take control of their back pain. The main treatment interventions are systematic patient education and exercise therapy aimed at improvement of functioning (Bekkering et al 2003). For patients with a normal course (in whom activities and participation gradually increase)
reassurance, adequate information, and advice to stay active are the most important recommendations. One treatment session should be sufficient; if necessary a second appointment may be made. For patients with an abnormal course, in whom activities and participation do not improve, exercise therapy should be provided, with a behavioural approach if necessary. The guideline does not include a recommendation about the number of sessions in patients with an abnormal course (Bekkering et al 2003).

From: J Orthop Sports Phys Ther. 2007;35(9):567-571. Epub 2007 Feb 5

To compare the performance of the deep cervical flexor muscles on the craniocervical flexion test in individuals with and without neck pain. Significant weakness of the superficial neck muscles is often found in patients with neck pain. However, there is scant work on deep cervical flexors performance in subjects with chronic nonspecific neck pain. Twenty asymptomatic subjects and 20 subjects with chronic neck pain (duration, >3 months) were recruited. The craniocervical flexion test was performed with the subject supine and required performing a gentle head-nodding action of craniocervical flexion (indicating yes) for 5 incremental stages of increasing difficulty. Each stage was held for 10 seconds, as guided by the pressure biofeedback unit. The data used for analysis were the highest pressure level each subject was able to hold for 10 seconds, up to a maximum of 30 mmHg.
Reliability data obtained on 10 asymptomatic subjects indicated that the craniocervical flexion test was reliable, with a kappa coefficient equal to 0.72.

Subjects with chronic neck pain had significantly poorer performance on the craniocervical flexion test (median pressure achieved, 24 mmHg) when compared with those in the asymptomatic group (median pressure achieved, 28 mmHg). The results of this study demonstrated that patients with chronic neck pain had a poorer ability to perform the craniocervical flexion test when compared with asymptomatic subjects. The study adds to the evidence that poor ability to perform the craniocervical flexion test may be clinical evidence of an impairment that characterizes neck pain, regardless of origin.

From: Isr Med Assoc J. 2008 May;10(5):365-9

Balneotherapy is an established treatment modality for musculoskeletal disease, but few studies have examined the efficacy of spa therapy in elderly patients with degenerative spine and joint diseases. To assess the effects of balneotherapy on chronic musculoskeletal pain, functional capacity, and quality of life in elderly patients with osteoarthritis of the knee or with chronic low back pain. The 81 patients in the study group underwent a 1 day course of 30 minute daily baths in mineral water. Changes were evaluated in the following parameters: pain intensity, functional capacity, quality of life, use of non-steroidal anti-inflammatory or analgesic drugs, subjective disease severity perceived by the patients, investigator-rated disease severity, and severity of pain perceived by the patients. We analyzed the results of 76 subjects as 5 did not complete the study.

Compared to baseline, all monitored parameters were significantly improved by balneotherapy in both investigated groups. Moreover, the favorable effect was prolonged for 3 months after treatment. This study showed that balneotherapy is an effective treatment modality in elderly patients with osteoarthritis of the knee or with chronic low back pain, and its benefits last for at least 3 months after treatment.

From: Cogn Behav Ther. 2008 Jun 13;:1-14 [Epub ahead of print]

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash associated disorders were recruited from a patient organization and randomized to either a treatment or a wait-list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10-session protocol emphasizing values-based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants’ abilities to behave in accordance with values in the presence of interfering pain and distress - psychological flexibility. After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the chronic pain and whiplash groups was seen in pain intensity. Improvements in the treatment group were maintained at 7-month follow-up. The authors discuss implications of these findings and offer suggestions for further research in chronic pain and whiplash with cognitive behaviour therapy.

From: J Pain. 2008 Jul 3; [Epub ahead of print]

Although there is a growing body of research concerning the prevalence and correlates of chronic pain conditions and their association with mental disorders, cross-national research on age and gender differences is limited. The present study reports the prevalence by age and gender of common chronic pain conditions (headache, back or neck pain, arthritis or joint pain, and other chronic pain) in 10 developed and 7 developing countries and their association with the spectrum of both depressive and anxiety disorders. It draws on data from 18 general adult population surveys using a common survey questionnaire (N = 42,249).

Results show that age-standardized prevalence of chronic pain conditions in the previous 12 months was 37.3% in developed countries and 41.1% in developing countries, with back pain and headache being somewhat more common in developing than developed countries. After controlling for comorbid chronic physical diseases, several findings were consistent across developing and developed countries. There was a higher prevalence of chronic pain conditions such as; headaches, back pain, neck pain, arthritis or joint pain among females and older persons; and chronic pain was similarly associated with depression and anxiety spectrum disorders in developed and developing countries. However, the large majority of persons reporting chronic pain did not meet criteria for depression or anxiety disorder. We conclude that common pain conditions affect a large percentage of persons in both developed and developing countries.

Chronic pain conditions including headache, back or neck pain, arthritis or joint pain are common in both developed and developing countries. Overall, the prevalence of pain is greater among females and among older persons. Although most persons reporting pain do not meet criteria for a depressive or anxiety disorder, depression and anxiety spectrum disorders are associated with pain in both developed and developing countries.

From: BMC Musculoskelet Disord. 2008 Jun 28;9(1):97 [Epub ahead of print]

The causes of chronic low back pain remain obscure and effective treatment of symptoms remains elusive. A mechanism of relieving chronic pain based on the consequences of conflicting unpleasant sensory inputs to the central nervous system has been hypothesised. As a result a device was generated to deliver sensory discrimination training (FairMed), and this randomised controlled trial compared therapeutic effects with a comparable treatment modality, TENS.

60 patients with chronic low back pain were recruited from physiotherapy referrals to a single-blinded, randomised controlled, non-inferiority trial. They were randomised to receive either FairMed or TENS and asked to use the allocated device for 30 minutes, twice a day, for 3 weeks. The primary outcome variable measured at 0 and 3 weeks was pain intensity measured using a visual analogue scale averaged over 7 days. Secondary outcome measures were Oswestry Disability Index, 3 timed physical tests, 4 questionnaires assessing different aspects of emotional coping and a global measure of patient rating of change.

Baseline characteristics of the two groups were comparable. The primary outcome, change in pain intensity at 3 weeks showed a mean difference between groups of -0.1. The mean difference in change in ODI scores was 0.4. Differences in change of physical functioning showed that no significant difference in change of scores for any of these test. Changes in scores of aspects of emotional coping also demonstrated no significant difference in change scores between the groups.

FairMed was not inferior to TENS treatment. The findings have implications for further research on current chronic pain theories and treatments. Further work to explore these mechanisms is important to expand our understanding of chronic pain and the role of neuro-modulation.

Device treatment for pain has some obvious advantages over pharmaceutical treatments, particularly that nothing has to be ingested and the side effect profile is likely to be much less. It is also likely to be cheaper than pharmaceutical management and can be used in conjunction with those rehabilitation treatments for which there is evidence of efficacy. Device treatment is likely to have a potent placebo effect. There are many devices that purport to treat back pain. The current “market leader” is transcutaneous electrical nerve stimulation (TENS), estimated to be 1% of the analgesic market for back pain The treatment effect of TENS is attributed to influencing the “gate” proposed by Melzack and Wall in their Gate Control Theory of Pain. TENS has been commercially successful. However, the clinical benefits of TENS remain controversial and there is lack of consensus regarding its efficacy. Some studies suggest a lack of evidence to support its use in the treatment of chronic low back pain, while others found evidence of benefit, or have concluded that there is a lack of evidence of effect, rather than evidence of a lack of effect. The recent Cochrane Review concluded that there was limited or inconsistent evidence for TENS. However, no other device has any better evidence of efficacy and for this reason TENS was chosen as a comparator treatment for a new device (FairMed) that has been developed to deliver sensory discrimination training in patients with chronic back pain

The FairMed is a novel device and as such there are no existing data on effectiveness. It is difficult to establish what is a fair comparator to use in a trial with a new device. Whilst the Cochrane review of TENS concluded that there was limited evidence for TENS, there are no other devices that provide any better evidence of efficacy, nor any which have stood the test of time as well as TENS. For this reason TENS was chosen as a comparator treatment for a new device designed to help those patients with chronic back pain who continue to have serious difficulties, despite not being a treatment endorsed by current guidelines.

The findings of this trial demonstrate no significant difference in pain intensity reduction between the FairMed and TENS. This is in keeping with other trials investigating sensory changes, such as the findings of Guieu et al. and Lundeberg who also found no significant difference in pain reduction between vibratory stimulation and TENS in patients suffering with chronic musculoskeletal pain. Both trials used a control of a similar high frequency TENS and vibration protocol to the ones in the trial. There is a plethora of different outcome measures that can be used in the assessment of low back pain. In this study the physical outcome measures chosen were a walk test, timed stair climb and sit to stand. These physical tests have been advocated by other trial designs and reported for reliability in a similar clinical population to the one in this study, hence the rationale for their use. However, it is possible that selection of physical performance measures that stressed the spine more specifically, such as loaded forward reach may have been more responsive to change in this patient population.

The theory for the analgesic effect of TENS is suggested to be as a result of counter stimulation of the nervous system modifying the perception of pain. There is evidence to suggest that this same theory could be applied to the FairMed. Studies have demonstrated that superficial and deep mechanoreceptors exist with a high sensitivity to vibratory stimulation. With a surface area of almost 500cm2, the FairMed stimulates a large region of the lumbar spine and underlying tissues, indicating that pain alleviation could be attributed to the activation of these receptors. Functional magnetic resonance imaging (fMRI) of subjects has revealed reduced activity in the anterior cingulated, insula and thalamus; some of the key pain processing areas of the brain. There is evidence to suggest that the same is true for cognitively demanding distraction. Bantick et al reported decreased perception of painful stimuli in subjects receiving noxious thermal stimulus whilst engaged in a cognitively demanding task. Using fMRI, decreased activation in the same key components of the pain matrix have been reported. Although these results are based on acute experimentally induced pain, modulation of chronic pain could conceivably be achieved by the FairMed through interference from vibratory stimulation and cognitive regulation of attention. Furthermore, Flor et al demonstrated a reduction in phantom limb pain following a treatment programme using sensory discrimination training, demonstrated to be as a result of cortical reorganisation in the primary somatosensory cortex.

From: Clinical Rehabilitation. 2008 Jul;22(7):592-600

To compare the effectiveness of a 12-month home-based combined strength training and stretching programme against stretching alone in the treatment of chronic neck pain. A randomized follow-up study with one hundred and one patients with chronic non specific neck pain were randomized in two groups. The strength training and stretching group was supported by 10 group training sessions and the stretching group was instructed to perform stretching exercises only as instructed in one group session. Neck pain, disability, neck muscle strength and mobility of cervical spine were measured before and after the intervention.

No significant differences in improvement in neck pain and disability were found between the two training groups. Mean pain decreased from 64 (17) mm by 37 mm in the strength training and stretching group, and from 60 (17) mm by 32 (39 to 25) mm in the stretching group. The improvements in disability were significant in both neck pain groups, while the changes in neck strength and mobility were minor. Training adherence decreased over time from the targeted three sessions a week, ending up at 1.1 (0.7) times a week for strength training and stretching group and 1.4 (0.8) times a week for stretching group.

No statistically significant differences in neck pain and disability were observed between the two home-based neck training regimens. Combined strength training and stretching or stretching only for neck pain were probably as effective in achieving a long-term improvement although the training adherence was rather low most of the time.

From: Psychosomatic Medicine. 2008 Jan;70(1):125-31. Epub 2007 Dec 24

Comparison of the muscular reactivity of patients with chronic back pain to different psychological stressors with the reactions of healthy controls. We also investigated the specificity of muscular reaction near the site of pain in comparison to distal sites. The symptom-specificity model of chronic pain postulates that increased muscle tension in chronic back pain patients may be responsible for the development and maintenance of chronic pain.

Studied were a total of 54 chronic back pain patients with musculoskeletal pain of the lower back, midback, or neck and 62 healthy controls, matched with chronic back pain patients. Muscle tension and skin conductance level (SCL) were assessed. The four experimental conditions included back focusing, a personally relevant stressor, a cognitive stressor, and a social stressor.

Chronic back pain patients showed patterns of higher muscular reactivity in the lower back region for chronic low back pain patients during the exposure to a personally relevant stressor, a cognitive stressor, and a social stressor. Additionally, chronic low back pain patients showed specific muscular responses in the lower back. The results support the assumptions made by the symptom-specificity model of chronic back pain, but only for lower back, not for midback and neck. Treatment programs of chronic low back pain should include specific combined relaxation and stress management components.

From: European Spine Journal. 2008 Apr 4. [Epub ahead of print]

Animal experiments and studies in humans clearly show that the relation between pain (acute and chronic) and sleep quality is two-way: sleep disorders can increase pain, which in turn may cause sleep disorders. Sleep disorders and chronic low back pain are frequent health problems and it is unsurprising that the two can co-exist. This study was conducted to evaluate if sleep disorders and chronic pain associated are more frequently than one would expect. The objective of the study was to compare sleep quality in a population of patients with chronic low back pain and a control population. Sleep quality was assessed in 101 patients with chronic low back pain (chronic low back pain) and in 97 sex and age matched healthy control subjects using the Pittsburgh Sleep Quality Index [score from 0 (no disorder) to 21]. The French version of the Dallas Pain Questionnaire was used to assess the impact of low back pain on patients’ quality of life. This impact was taken as nil in the healthy controls. The patients with chronic low back pain and the controls were comparable in age, sex, and height, but mean bodyweight was higher in the chronic low back pain group. The patients with chronic low back pain were also more frequently on sick leave than the controls. Coffee, tea, and cola intakes were comparable in the two groups. Patients with chronic low back pain had statistically higher scores in all items of the Pittsburgh Sleep Quality Index than the healthy controls. The mean Pittsburgh Sleep Quality Index was 4.7 +/- 3.2 for the healthy controls and 10.9 +/- 7.9 for the patients with chronic low back pain. Sleep disorders were greater when the impact of chronic low back pain on daily life (the four aspects of the Dallas Pain Questionnaire) was greater. The sleep of the patients with chronic low back pain was significantly altered compared with that of the healthy controls, in proportion to the impact of low back pain on daily life. Our findings do not indicate whether sleep disorders are a cause or a consequence of chronic low back pain.