Welcome
to Chiropractic OnLine Today's Journal Corner's Literature Review of
the Month. This month's topic centers on Chiropractic's effectiveness
in the treatment of low back pain.
Dr. Donald Murphy Reviews The Literature ....
1. The prediction of chronicity of patients with an acute attack of
low back pain in a general practice setting. Klenerman L, Slade PD, Stanely
IM, Pennie B, Reilly JP, Atchison LE, Troup JDG, Rose MJ. Spine 1995; 20(4):478-484.
2. Identifying patients at risk of becoming disabled because of low
back pain. The Vermont Rehabilitative Engineering Center predicitive model.
Cats-Baril WL, Frymoyer JW. Spine 1991; 16(6):605-607.
3. Effects of physical training and ergonomic counseling on the psychophysical perception of work and on the subjective assessment of low back insufficiency. Dehlin O, Andersson GBH, Grimby G. Scand J Rehab Med 1981; 13:1-9.
In today's health care world it is becoming increasingly important
for doctors to develop the ability to predict which patients with low back
pain (LBP) are likely to become chronic and thus be able to apply aggressive
treatment approaches to help minimize or prevent that chronicity. The three
papers reviewed here represent attempts to both determine how this prediction
can be made and apply that treatment approach that is most likely to effectively
intervene in the chronic pain process. The first study looks at 300 patients
with LBP and, through questionnaires and interviews, as well as physical
exam, attempt to determine the predictive ability of these measures for
progression to chronic stages. It shows that fear-avoidance variables were
the most predictive of the progression to chronicity. It appears that the
first 2 months is the critical period in determining the progression to
chronicity. If the patient is not recovered by 2 months, the likelihood
of progression to chronic stages becomes much greater. After 2 months the
prediction of further chronicity is best done by a combination of psychosocial
and physical variables. Using this methodology, 50% of eventual chronic
sufferers can be predicted from the beginning and 85-88% at 2 months.
It is hypothesized that 4 psychosocial factors are considered likely
to determine whether a patient is likely to be a "confronter"
or "avoider" with an acute LBP episode, the confronters being
expected to do far better than the avoiders.
1. Stressful life events - experienced just before the onset of acute
LBP.
2. Personality - Over concern with body and physical symptoms.
3. Previous Pain History - a history of previous severe pain experience.
4. Pain Coping Strategies - coping with pain in a passive rather than
active way.
The second study looked at 232 patients with acute LBP and compared
specialist opinions as to whether they will become chronically disabled
with a predictive questionnaire. They found that the questionnaire more
accurately identified chronics (89%) then the specialists (83%). The questionnaire
showed that characteristics of the job, the perception of fault, whether
the injury fell under workers' comp., past hospitalizations and educational
level were strong predictors of LBP disability. It showed that "people
who were able to continue working through the acute phase of a LBP episode
or those who go back to work even if the pain has not disappeared after
a period of rest are unlikely to become disabled."
It also showed that psychological variables were not predictive of
disability, contrary to other studies.
The third study was performed in 1981 and separated LB injured nurse's
aides into 3 groups: physical training, ergonomic counseling and control.
The physical training group showed improvement in 2 of the 7 variables
of the psychological perception of work whereas the ergonomics and control
groups showed no change. Little difference in physical capacity or symptoms
was shown between the groups. This is an important study as a negative
perception of work has been shown to be the primary predisposing factor
to LB injury (Bigos 1991) and exercise was more effective than counseling
at improving this perception in this study.
It is becoming increasingly clear in the literature that acute LBP
and chronic LBP are entirely different entities and that they should not
be treated in like manners. One of the most important factors that differentiates
these two conditions is the presence of psychosocial issues such as fear
avoidance behavior and abnormal illness behavior. Also, it is becoming
clear that preventing the progression of acute LBP to chronic LBP is at
least as important, and probably more important, than effectively treating
the chronic LBP patient. Exercise can be an important factor in addressing
both the physical and psychosocial aspects of the disorder and should be
incorporated as a major part of the treatment plan for both the chronic
sufferer and the acute patient who exhibits risk factors for progression
to chronic stages.
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