Back Pain: Brox JI

Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G, Anonymous00003. · No affiliation provided · Eur Spine J. · Pubmed #16550448 No free full text.

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Brox JI. · No affiliation provided · Scand J Med Sci Sports. · Pubmed #15546327 No free full text.

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Brox JI, Storheim K, Grotle M, Tveito TH, Indahl A, Eriksen HR. · Orthopedic Department, Rikshospitalet University, 0027 Oslo, Norway. · Spine J. · Pubmed #18164451 No free full text.

Abstract: The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Brox JI, Storheim K, Grotle M, Tveito TH, Indahl A, Eriksen HR. · Orthopedic Department, Rikshospitalet-Radiumhospitalet Medical University Center, 0027 Oslo, Norway. · Spine J. · Pubmed #18024224 No free full text.

Abstract: BACKGROUND: Seven previous systematic reviews (SRs) have evaluated back schools, and one has evaluated brief education, with the latest SR including studies until November 2004. The effectiveness of fear-avoidance training has not been assessed. PURPOSE: To assess the effectiveness of back schools, brief education, and fear-avoidance training for chronic low back pain (CLBP). STUDY DESIGN: A SR. METHODS: We searched the MEDLINE database of randomized controlled trials (RCT) until August 2006 for relevant trials reported in English. Assessment of effectiveness was based on pain, disability, and sick leave. RCTs that reported back schools, or brief education as the main intervention, were included. For fear-avoidance training, evaluation of domain-specific outcome was required. Two reviewers independently reviewed the studies. RESULTS: Eight RCTs including 1,002 patients evaluated back schools, three studies were of high quality. We found conflicting evidence for back schools compared with waiting list, placebo, usual care, and exercises, and a cognitive behavioral back school. Twelve trials including 3,583 patients evaluated brief education. Seven trials, six of high quality, evaluated brief education in the clinical setting. We found strong evidence of effectiveness on sick leave and short-term disability compared with usual care. We found conflicting or limited evidence for back book or Internet discussion (five trials, two of high quality) compared with waiting list, no intervention, massage, yoga, or exercises. Three RCTs of high quality, including 364 patients, evaluated fear-avoidance training. We found moderate evidence that there is no difference between rehabilitation including fear-avoidance training and spinal fusion. CONCLUSIONS: Consistent recommendations are given for brief education in the clinical setting, and fear-avoidance training should be considered as an alternative to spinal fusion, and back schools may be considered in the occupational setting. The discordance between reviews can be attributed differences in inclusion criteria and application of evidence rules.

Grotle M, Brox JI, Vøllestad NK. · Section for Health Science, University of Oslo, Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #15626993 No free full text.

Abstract: STUDY DESIGN: A systematic literature review of outcome questionnaires designed for assessing functional status or disability in patients with low back pain. OBJECTIVES: To provide a comprehensive overview of all functioning/disability questionnaires used in recent years and to explore how the main concept(s) was described or defined in the original paper, the content or the domains of disability, and the measurement properties of the questionnaires. SUMMARY OF BACKGROUND DATA: A number of clinical tools designed for evaluating the functional status of patients with low back pain have been developed. Only a few have been reviewed earlier, and there has been little focus on the content reflected in the questionnaires. METHODS: Papers including questionnaires for assessing disability, function, activity limitations, or participation restrictions in adult patients with low back pain were searched in the MEDLINE and CINAHL databases for the period from January 1996 to January 2002. Two independent and blinded researchers read and selected abstracts and questionnaires. The content of the included questionnaires was classified according to World Health Organization's International Classification of Functioning, Disability and Health. The measurement properties were analyzed according to recommended guidelines. RESULTS: A total of 36 back-specific questionnaires were identified. When distinguishing among a bodily, personal, and social perspective of functioning, 4 main types of content were identified. Most of the outcome questionnaires had a mixed content reflecting various constructs such as pain and symptoms, sleep disturbances, psychological dysfunctions, physical impairments, and social functions. Nine questionnaires assessed solely activities of daily living. For one-third of the questionnaires, the measurement properties were reported in only the original study. CONCLUSIONS: Although most questionnaires had their main focus on activity limitations, a considerable variation with respect to the main concept and content was found. Only a few of the questionnaires can be considered acceptably validated.

Brox JI, Hagen KB, Juel NG, Storheim K. · Rikshospitalet, Senter for ortopedi, Oslo. · Tidsskr Nor Laegeforen. · Pubmed #10394281 No free full text.

Abstract: We evaluated the effectiveness of exercises and manipulation on pain, disability and sick leave in a systematic review of randomized controlled trials including patients with low back pain. Low back pain is commonly a self-limiting illness and most patients are free of symptoms within 14 days. On the basis of 11 studies, no additional benefits from exercises and manipulation were found in patients with acute complaints (0-4 weeks); thus, our results do not support guidelines that prescribe manipulation in the acute stage. One study found reduced disability and sick leave in the subacute stage (4-12 weeks) when patients were told that it was safe to move and this strategy was reinforced by a graded exercise program and visits to the workplace. Seven studies evaluated manipulation; the effectiveness was no better than other treatments or placebo. Based on seven studies in patients with chronic low back pain (> 12 weeks), there is strong evidence that exercises reduce disability and pain, but their effectiveness on sick leave is not documented. Four studies compared different exercise regimens, but found no evidence in favour of one particular method. The effectiveness of manipulation in patients with chronic pain is poorly documented.

Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O. · Department of Physical Medicine and Rehabilitation, Ullevaal University Hospital, N-0407 Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #14699268 No free full text.

Abstract: STUDY DESIGN: A randomized study. OBJECTIVES: To compare muscle strength, cross-sectional area, and density of the back muscles in two categories of patients with chronic low back pain, randomized to either lumbar fusion or cognitive intervention and exercises. SUMMARY OF BACKGROUND DATA: In two clinical trials, patients with chronic low back pain plus disc degeneration and postlaminectomy syndrome, respectively, were randomized to either lumbar fusion or cognitive intervention and exercises. We have previously reported that results for the primary outcome were similar at the 1-year follow-up examination. METHODS: As the treatment alternatives and test procedures were identical, the two trials were merged into one. A total of 124 patients 25 to 60 years of age were included. Muscle strength, measured by isokinetic test device and by the Biering-Sørensen Test, was measured in 112 patients, and the cross-sectional area and density of the back muscles were measured in 61 patients at the inclusion and at the 1-year follow-up examination. RESULTS: The exercise group performed significantly better in muscle strength than did the lumbar fusion group, with the mean difference at 184 Nm (95% confidence interval, 64-303 Nm; P = 0.003) and for the Biering-Sørensen Test 21 seconds (95% confidence interval, 6-36 seconds; P = 0.006). The density at L3-L4 decreased in the lumbar fusion group but remained unchanged in the exercise group. The mean difference was 5.3 HU (95% confidence interval, 1.1-9.5 HU; P = 0.01). The cross-sectional area was unchanged in both groups. CONCLUSIONS: Patients with chronic low back pain who followed cognitive intervention and exercise programs improved significantly in muscle strength compared with patients who underwent lumbar fusion. In the lumbar fusion group, density decreased significantly at L3-L4 compared with the exercise group.

Brox JI, Sørensen R, Friis A, Nygaard Ø, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikerås O. · Department of Orthopedic Surgery, National Hospital, Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #12973134 No free full text.

Abstract: STUDY DESIGN: Single blind randomized study. OBJECTIVES: To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. SUMMARY OF BACKGROUND DATA: To the authors' best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician. PATIENTS AND METHODS: Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index. RESULTS: At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%. CONCLUSION: The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion.

Storheim K, Brox JI, Holm I, Koller AK, Bø K. · Norwegian University of Sport and Physical Education, Oslo, Norway. · J Rehabil Med. · Pubmed #12809196 No free full text.

Abstract: OBJECTIVE: To evaluate the short-term effect of physical exercise and a cognitive intervention in low back pain. DESIGN: Randomized controlled trial. SUBJECTS: Ninety-three patients sick-listed for 8-12 weeks for sub-acute low back pain were randomized to an exercise regime (n = 30), a cognitive intervention (n = 34) or a control group (n = 29). METHODS: Primary outcome measures were pain, disability, sick-listing and satisfaction with care. Secondary outcome measures were self-efficacy for pain and for function, fear-avoidance beliefs, emotional distress, generic health status and life satisfaction. RESULTS: Eighteen percent of subjects dropped out. Drop-out was most frequent in the exercise group. At 18 weeks after inclusion fear-avoidance beliefs were reduced in both intervention groups. The cognitive group demonstrated significant improvement in disability, self-efficacy for pain, emotional distress, general health and life satisfaction. Patients in the exercise group were significantly more satisfied with the treatment, and patients following the exercise protocol reduced pain significantly. No effect on sick-listing was seen. CONCLUSION: Cognitive intervention improved disability and may be feasible for most patients sick-listed in the sub-acute phase. Physical exercise reduced patients' symptoms, but requires high motivation by patients. Despite positive effects in intervention groups on variables considered as negative prognostic factors for long-term disability and sickness absence, interventions had no effect on sick-listing.

Storheim K, Holm I, Gunderson R, Brox JI, Bø K. · Norwegian University of Sport and Physical Education, and dagger National Hospital, Oslo, Norway. · J Spinal Disord Tech. · Pubmed #12792342 No free full text.

Abstract: The effect of exercise on back muscle cross-sectional area (CSA), density, and strength was evaluated in patients sick-listed for subacute low back pain. Twenty-four patients were randomized into an exercise (n = 11) or a control (n = 13) group. Patients in the exercise group followed a biweekly exercise protocol for 15 weeks. Control patients received usual care. Muscle CSA and density were measured by computed tomography before and after intervention. Isokinetic test of back extensors was conducted simultaneously. Results showed a tendency to increased muscle CSA and density in patients in the exercise group, a significant decrease in muscle CSA at L4-L5 in control group patients, and a significant difference in change between groups in muscle CSA at L4-L5. Back extension strength increased in patients in the exercise group, but the improvement was not significant compared with control group patients. In conclusion, there was a tendency for reversal of muscle atrophy after exercise.

Juel NG, Brox JI, Thingnaes K, Bjørnerheim R, Bryde P, Villersø K, Aakhus S. · Avdeling for fysikalsk medisin og rehabilitering Ullevål universitetssykehus 0407 Oslo. · Tidsskr Nor Laegeforen. · Pubmed #19079414 links to  free full text

Abstract: BACKGROUND: Ultrasound-based techniques are frequently used in cardiology, gynecology and radiology. Work-related symptoms are reported for ultrasound operators, but controlled studies have not been published. We wanted to map symptoms and clinical diagnoses in ultrasound operators, compare them to matched controls and evaluate a possible relation between symptoms and exposure. MATERIAL AND METHODS: All ultrasound operators working at Rikshospitalet and Ullevaal University hospitals and matched controls who had other work at the hospitals were invited to participate. They answered questions about pain, well-being at the workplace, physical activity, smoking and validated function scores for the back (Oswestry Disability Index-ODI), shoulder and arm (Quick-DASH), and health- related quality of life (EQ-5D and EQ-VAS, as well as exposure time for ultrasound examinations. All participants underwent a blinded, systematic clinical examination. RESULTS: 81 persons participated (43 women, 38 men); 44 operators and 37 controls. The ultrasound operators reported significantly more work-related pain from the wrist, elbow and shoulder and scored significantly worse on Quick-DASH (difference 6.1 [95 % CI 2.0 to 10.2, p < 0.001) and health-related function (EQ-5D). There was no difference in health-related quality of life (EQ-VAS) or back function (ODI). The number of persons with one or more clinical diagnosis was significantly higher for ultrasound operators (26/44 [59 %]) than controls (7/37 [19 %]), odds ratio 5.2; 95 % CI 2,0 to 14.0, p < 0.001. For subacromial pain the numbers were 11/44 (25 %) and 2/37 (5 %), odds ratio 5,8; CI 1.2 to 28.3, p = 0.034. For the ultrasound operators there was a significant association between exposure > 1000 min/week and Quick-DASH, subacromial pain and lateral epicondylagia. INTERPRETATION: Ultrasound operators reported significantly more shoulder and arm complaints and clinical diagnosis than controls.

Keller A, Brox JI, Reikerås O. · Department of Physical Medicine and Rehabilitation, Ullevål University Hospital, Oslo, Norway. · Pain Med. · Pubmed #18828199 No free full text.

Abstract: OBJECTIVES: We have previously reported in two randomized controlled trials that cognitive intervention and exercises more effectively improved isokinetic trunk muscle strength than lumbar fusion and postoperative rehabilitation in patients with chronic low back pain. The aim of the present study was to predict changes in muscle strength as regard to changes in pain, function, fear-avoidance beliefs (self-rated questionnaires), changes in cross-sectional area and density of the back muscles and treatment. METHODS: We assessed 1) isokinetic trunk muscle strength; 2) cross-sectional area and density of back muscles by computer-tomography (CT); and 3) pain, function, fear-avoidance beliefs, and self- efficacy for pain in the included patients at baseline and 1-year follow-up. Multiple regression analysis was performed with change in muscle strength as dependent variables, and changes in area/density and self-rated symptoms and treatment as independent variables. RESULTS: The correlations between the change in muscle strength and change in both cross-sectional area and density were weak (r < 0.1) and nonsignificant and these variables were not included in the multiple regression analysis. The change in pain, change in fear-avoidance beliefs, change in self-efficacy for pain and treatment explained 46% of the change in muscle strength, with change in pain and treatment as significant predictors. CONCLUSION: Our results emphasize the central role of pain and treatment for the improvements in muscle strength in patients with chronic low back pain.

Grøvle L, Haugen AJ, Keller A, Natvig B, Brox JI, Grotle M. · Department of Rheumatology, Østfold Hospital Trust, Norway. · Spine (Phila Pa 1976). · Pubmed #18827701 No free full text.

Abstract: STUDY DESIGN: Cross-sectional and prospective study of patients with sciatica and disc herniation. OBJECTIVE: To describe the process of translation of the Norwegian versions of the Maine Seattle Back Questionnaire (MSBQ), the Sciatica Bothersomeness Index (SBI) and the Sciatica Frequency Index (SFI), and to test the reliability, construct validity and responsiveness of these Norwegian versions. SUMMARY OF BACKGROUND DATA: The instruments have been validated in English only. METHODS: Reliability was assessed by internal consistency (Cronbach alpha), test-retest reliability (ICC) and measurement error (MDC and Bland and Altman's limits of agreement). Construct validity was assessed by comparing the 3 measures with subscales of SF-36, ratings of back and leg pain, and clinical findings. Responsiveness was assessed by standardized response means and Receiver Operating Characteristic curve analyses. RESULTS: Four hundred sixty six patients were included in the study, of whom 87 participated in the test-retest study. Completion time for the MSBQ was 1-2 minutes and 30 seconds for the SBI and the SFI, respectively. ICCs varied between 0.86 and 0.90. Cronbach alpha was 0.74, 0.70, and 0.65 for the MSBQ, SBI, and SFI, respectively. The measurement errors constituted 26% of the total MSBQ score range, 22% of the SBI and 27% of the SFI score range. Compared to the MSBQ the 2 Sciatica Indexes discriminated better between patients with normal versus abnormal clinical findings, but correlated less strongly with pain and physical functioning. Responsiveness was assessed by 2 external criteria at 3 months, a global change score (improved vs. unchanged) and surgical treatment status (operated vs. nonoperated). All standardized response means were >or=1.3 and all AUCs >or=0.75. Differences between the 3 measures were generally small. CONCLUSION: The Norwegian versions of the MSBQ and the Sciatica Frequency and Bothersomeness Indexes were rapidly administered, with acceptable internal consistency, test-retest reliability, measurement error, construct validity and responsiveness.

Bjerkreim I, Steen H, Brox JI. · Rikshospitalet-Radiumhospitalet Medical Center, Orthopaedic Department, University of Oslo, Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #17762812 No free full text.

Abstract: STUDY DESIGN: Prospective cohort study with 10-year follow-up. OBJECTIVE: To evaluate long-term results after operative treatment with Cotrel-Dubousset (CD) instrumentation for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Limited knowledge exists in the evaluation of long-term function with quality of life measures after CD instrumentation in patients with AIS. METHODS: A total of 100 (76 females and 24 males) consecutive AIS patients all with single primary curves were included. Radiologic measures and pain were registered at baseline and at 1- to 5-year follow-up. Quality of life and back specific measures, including EuroQol (EQ) and Oswestry Disability Index (ODI), were obtained by a questionnaire mailed to the patients at 10 years after surgery. RESULTS: Mean age at operation was 16.8 (SD, 5.3) years, mean Risser sign was Grade 3.2 (SD, 1.5). All patients were observed for 2 years. The average primary curve was reduced from 56 degrees to 19 degrees, and this correction was maintained during follow-up. Fourteen patients had minor complications, and 5 patients had implants removed because of late clinically suspected infections. A total of 86 patients answered the 10-year questionnaire; 97% of the patients considered back function as excellent, good, or fair, and 96% would have done the operation again. Scores for EQ-5D and ODI were slightly worse than in the normal population. Despite this observation, 45% of the patients reported to have consulted a physician or received physiotherapy for back pain during the last year before the 10-year follow-up. CONCLUSION: Radiologic results, patient satisfaction, and mean scores for quality of life and back function were excellent after CD instrumentation for AIS, but a considerable number of patients had treatment for back problems.

Grotle M, Brox JI, Vøllestad NK. · Department of Orthopaedics, Section for Physical Medicine and Rehabilitation, National Hospital, Oslo, Norway. · J Rehabil Med. · Pubmed #17067967 No free full text.

Abstract: OBJECTIVE: To evaluate reliability, validity and responsiveness of the Fear-Avoidance Beliefs Questionnaire (FABQ) for use in Norwegian patients with low back pain. DESIGN: A prospective cohort study with 2 groups. PATIENTS: The questionnaire was tested in 123 patients with acute low back pain and 50 patients with chronic low back pain. METHODS: A translation and cross-cultural adaptation was performed. Test-retest reliability was assessed in 28 patients with chronic low back pain. Responsiveness was assessed in acute low back pain. RESULTS: Two factors for the FABQ were confirmed; fear-avoidance beliefs about work (FABQ-Work) and physical activity (FABQ-PA), accounting for 60% and 54% of the total variance in acute and chronic low back pain, respectively. For FABQ-Work and FABQ-PA internal consistency was 0.90 and 0.79, intra-class correlation coefficients 0.82 and 0.66, minimal detectable changes 12 and 9 points, and coefficients of variation were 16% and 23%. The FABQ correlated weakly to moderately with pain, disability, distress, and clinical variables. Standardized response means were low for FABQ-Work (0.32) and moderate (0.56) for FABQ-PA. Both FABQ subscales showed initially floor and/or ceiling effects. CONCLUSION: The Norwegian FABQ version had acceptable factor structure, internal consistency, test-retest reliability and construct validity. The responsiveness of the FABQ-Work was low, and for the FABQ-PA moderate, in the acute sample.

Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. · Section for Health Science, University of Oslo, P.O. Box 1153, Blindern, N-0318 Oslo, Norway. <> · Man Ther. · Pubmed #16843031 No free full text.

Abstract: The objective of the study was to assess inter-rater reliability of one palpation and six pain provocation tests for pain of sacroiliac origin. The sacroiliac joint (SIJ) is a potential source of low back and pelvic girdle pain. Diagnosis is made primarily by physical examination using palpation and pain provocation tests. Previous studies on the reliability of such tests have reported inconclusive and conflicting results. Fifty-six women and five men aged 18-50 years old were included in the study. Fifteen patients had ankylosing spondylitis; 30 women had post partum pelvic girdle pain for more than 6 weeks; and 16 people had no low back or pelvic girdle pain. All participants were examined twice on the same day by experienced manual therapists. Percentage agreement and kappa statistic were used to evaluate the tests reliability. Results showed percentage agreement and kappa values ranged from 67% to 97% and 0.43 to 0.84 for the pain provocation tests. For the palpation test the percent agreement was 48% and the kappa value was -0.06. Clusters of pain provocation tests were found to have good percentage agreement, and kappa values ranged from 0.51 to 0.75. In conclusion this study has shown the reliability of the pain provocation tests employed were moderate to good, and for the palpation test, reliability was poor. Clusters out of three and five pain provocation tests were found to be reliable. The cluster of tests should now be validated for assessment of diagnostic power.

Grotle M, Vøllestad NK, Brox JI. · National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway. · Clin J Pain. · Pubmed #16772801 No free full text.

Abstract: OBJECTIVES: The purpose of this study was to evaluate the reliability and construct and predictive validity of the Norwegian version of the Acute Low Back Pain Screening Questionnnaire (ALBPSQ). METHODS: A prospective study with a 12-month follow-up was conducted on 123 patients with acute low back pain (LBP) seeking help in primary health care for the first time and 50 patients with chronic LBP for more than 3 months. RESULTS: Test-retest reliability was high with intraclass correlation coefficients of 0.90, minimal detectable change of 12 points (of a total score of 210), and coefficient of variation of 4%. Internal consistency was 0.95. Principal-components analysis revealed 3 factors explaining 49% of the variance. The ALBPSQ score correlated highly (r> or =0.60) with disability variables, moderately (0.30<r<0.60) with age, pain intensity, and psychologic, questionnaires, and weakly (r< or =0.30) with most sociodemographic and clinical variables. The ALBPSQ were significantly lower in acute compared with chronic LBP at all follow-up visits (P<0.001). Significant associations were found between high-risk and low-risk subgroups on the ALBPSQ and pain and disability variables during follow-up. Different cut-off points on the accuracy of predicting outcomes at 6 and 12 months' follow-up showed high specificity and low sensitivity with a best cut-off of 90 points. DISCUSSION: The findings of this study provide further evidence of the utility of the ALBPSQ in clinical studies and in primary care settings (general practitioners, chiropractors, and physiotherapists) to help identify patients at risk of developing chronic LBP and disability.

Grotle M, Brox JI, Glomsrød B, Lønn JH, Vøllestad NK. · National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway. · Eur J Pain. · Pubmed #16677837 No free full text.

Abstract: There is limited knowledge on prognostic factors for developing chronic low back pain (LBP) at an early stage of LBP. The objectives of this study were to investigate the clinical course of pain and disability, and prognostic factors for non-recovery after 1-year, in patients seeking help for the first time due to acute LBP. An inception cohort study included 123 patients with acute LBP lasting less than 3 weeks and consulting primary care for the first time. Main outcome measures were pain intensity, Roland-Morris disability questionnaire (RMQ), and sickness absence. Eleven patients (9%) did not return for the 12-month follow-up. There were large and significant reductions in pain intensity (P<0.001) and RMQ scores (P<0.001) during follow-up. Patients with neurological signs showed significantly less improvement in pain (P=0.001) and RMQ (P=0.004) compared with those without neurological signs. The proportions with sickness absence due to LBP at 6, 9, and 12 months were 7%, 8%, and 9%, respectively. At 12 months, 17% of patients had not fully recovered. Multivariate logistic regression analyses showed that high scores on a psychosocial screening (acute low back pain screening questionnaire) and emotional distress (Hopkin's symptom check list) were significantly associated with non-recovery at 12 months, with odds ratios of 4.4 (95% confidence interval 1.1-17.4) and 3.3 (1.1-10.2), respectively.

Grotle M, Vøllestad NK, Brox JI. · National Resource Center for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #16641782 No free full text.

Abstract: STUDY DESIGN: Prospective inception cohort study. OBJECTIVES: To compare the clinical course of fear-avoidance beliefs in acute and chronic low back pain (LBP) and investigate the contribution of fear-avoidance beliefs to predict pain and disability after 1 year. SUMMARY OF BACKGROUND DATA: Fear-avoidance beliefs are involved in disability development. There is little knowledge on the development of fear-avoidance beliefs among different LBP subgroups. METHODS: Patients with acute (n = 123) and chronic (n = 50) LBP completed a comprehensive assessment, including the Fear-Avoidance Beliefs Questionnaire (FABQ), and were followed at 3, 6, 9, and 12 months. RESULTS: At baseline, patients with chronic LBP had significantly higher FABQ-scores for work (FABQ-Work) than patients with acute LBP (P < 0.001), and this difference remained unchanged over 1 year (P > 0.21). At baseline, there was no statistical significant difference in FABQ-scores for physical activity (FABQ-PA) between the two groups (P = 0.57). FABQ-PA scores decreased significantly over the first 4 weeks among patients with acute LBP during follow-up and remained unchanged thereafter, whereas in the chronic sample the FABQ-PA scores were unchanged throughout the first year (time effect, P < 0.001; and interaction effect, P < 0.001). In the acute sample, FABQ-Work predicted pain (P < 0.05) and disability at 12 months (P = 0.01). In the chronic sample, FABQ-PA predicted disability at 12 months (P = 0.03). The associations between the FABQ and pain/disability disappeared with distress included in the models. CONCLUSION: Patients with chronic LBP had more fear-avoidance beliefs for work than patients with acute LBP. There were small changes in fear-avoidance beliefs during the year of follow-up, except for a rapid decrease during the first month in the FABQ-PA in the acute sample. Fear-avoidance beliefs predicted pain and disability at 12 months after adjusting for socio-demographic and pain variables. Distress was a stronger predictor than fear-avoidance beliefs.

Brox JI, Reikerås O, Nygaard Ø, Sørensen R, Indahl A, Holm I, Keller A, Ingebrigtsen T, Grundnes O, Lange JE, Friis A. · Department of Orthopedics and Physiotherapy, Rikshospitalet University Hospital and Medical Faculty University in Oslo, Norway. · Pain. · Pubmed #16545523 No free full text.

Abstract: The effectiveness of lumbar fusion for chronic low back pain after surgery for disc herniation has not been evaluated in a randomized controlled trial. The aim of the present study was to compare the effectiveness of lumbar fusion with posterior transpedicular screws and cognitive intervention and exercises. Sixty patients aged 25-60 years with low back pain lasting longer than 1 year after previous surgery for disc herniation were randomly allocated to the two treatment groups. Experienced back surgeons performed transpedicular fusion. Cognitive intervention consisted of a lecture intended to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The primary outcome measure was the Oswestry Disability Index (ODI). Outcome data were analyzed on an intention-to-treat basis. Ninety-seven percent of the patients, including seven of eight patients who had either not attended treatment (n=5) or changed groups (n=2), completed 1-year follow-up. ODI was significantly improved from 47 to 38 after fusion and from 45 to 32 after cognitive intervention and exercises. The mean difference between treatments after adjustment for gender was -7.3 (95% CI -17.3 to 2.7, p=0.15). The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group. For patients with chronic low back pain after previous surgery for disc herniation, lumbar fusion failed to show any benefit over cognitive intervention and exercises.

Storheim K, Brox JI, Holm I, Bø K. · Department of Sport Medicine, Norwegian School of Sport Sciences, PB 4014 Ullevål Station, N-0806 Oslo, Norway. · J Rehabil Med. · Pubmed #16287668 No free full text.

Abstract: OBJECTIVE: To investigate whether personal and work-related factors, physical performance and back-specific questionnaires predict return to work. A prospective study identifying prognostic factors for return to work. SUBJECTS: Ninety-three patients sick-listed for 8-12 weeks for non-specific sub-acute low back pain included in a randomized controlled trial. METHODS: Patients were examined with regard to demographic variables, a battery of back-specific questionnaires and physical tests before entering a randomized controlled trial. A stepwise backward Cox regression model was established to identify the most powerful predictors. RESULTS: During follow-up 78.5% of the patients have returned to full-time work. Fear-avoidance beliefs for work (relative risk (RR) for 1 SD change 0.49; 95% confidence interval (CI) 0.38-0.64), disability (RR 1.39, 95% CI 1.02-1.88) and cardiovascular fitness (RR 1.42, 95% CI 1.12-1.79) were identified as the best predictors for return to work. The prevalence of correct predictions was 69.3%. CONCLUSION: The predictors identified in the present study may reflect personal risk factors in a patient who gets acute low back pain. On the other hand, they may support that fear of pain and injury may be more disabling than pain itself, and that deconditioning is a result of altered behaviour reflecting attitudes towards low back pain in society, and information and advice given in primary healthcare.

Grotle M, Brox JI, Veierød MB, Glomsrød B, Lønn JH, Vøllestad NK. · Section for Health Science, University of Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #15834343 No free full text.

Abstract: STUDY DESIGN: Inception cohort study. OBJECTIVES: To examine the clinical course of acute low back pain and to evaluate prognostic factors for nonrecovery. SUMMARY OF BACKGROUND DATA: Few studies have explored clinical course and prognostic factors in patients who consult primary care for their first time because of an episode of low back pain of <3 weeks duration. METHODS: A total of 123 patients with acute low back pain <3 weeks consulting primary care for the first time were included, and 120 completed 3 months follow-up. Baseline assessments included sociodemographic characteristics, back pain history and current status, psychological questionnaires and clinical examination. Main outcome measures were pain intensity, disability by Roland Morris Disability Questionnaire, and recovery of disability. Potential prognostic factors for recovery or not were analyzed by multivariate logistic regression. RESULTS: At 4 weeks and 3 months 76% of the patients had recovered. Mean pain intensity and mean disability scores dropped 58% and 68%, respectively, of initial levels during the 3 months. The proportion with sickness absence was 8% at 4 weeks and 6% at 3 months. Several sociodemographic, clinical, and psychological factors were of prognostic value. Compared with their respective reference categories, age above 45 years (odds ratio 4.4, 95% confidence interval 1.4-14.0), smoking (3.0, 1.1-8.5), two or more neurological signs (4.6, 1.4-14.9), a score of >or=90 on the psychosocial screening (3.1, 1.0-9.4), and high levels of distress (4.1, 1.3-12.8) were the best prognostic factors of nonrecovery at 3 months. CONCLUSION: During a period of 3 months, 24% of the patients had not recovered. Psychological factors and neurological signs were strongly associated with nonrecovery at 3 months. In addition to the traditional examination of neurological symptoms and signs, psychological factors should be considered already at the initial visit of an episode of low back pain.

Brox JI, Storheim K, Holm I, Friis A, Reikerås O. · Department of Orthopaedic Surgery, Section for Back Surgery and Physical Medicine and Rehabilitation, National Hospital, Oslo, Norway. · J Rehabil Med. · Pubmed #15788344 No free full text.

Abstract: OBJECTIVE: To compare measures of disability, psychological factors, pain and physical performance in healthy controls, and patients with sub-acute and chronic low back pain. To evaluate the concept of the deconditioning syndrome and to explore factors that may contribute to chronicity. DESIGN: Case-control study. SUBJECTS: Three age- and gender-matched groups were included in the study; healthy controls (n = 45), patients sick-listed 8-12 weeks (n = 46) and patients with chronic low back pain on a waiting list for lumbar instrumented fusion (n = 45). METHODS: Measures of disability, pain, psychological factors, and physical performance were obtained from the 3 groups using validated measures. RESULTS: Gender, age, body weight and height were not significantly different between the groups. Comparable scores were found for self-rated working ability, fear-avoidance beliefs for physical activity and aerobic capacity in the 2 patient groups. Oswestry Disability Index, pain, emotional distress, abdominal and back muscle endurance were significantly different between the 3 groups. Self-efficacy for pain and fear-avoidance beliefs for work was significantly different between the 2 patient groups. CONCLUSION: The results suggest a stepwise deterioration of impairment and disability from healthy controls to patients with chronic low back pain. Most variables distinguished between healthy controls and patients with sub-acute or chronic low back pain. Deconditioning was more related to psychophysical measures of abdominal and back muscle endurance than to cardiovascular fitness. Comparable scores for fear-avoidance and working ability in the 2 patient categories suggest that these factors appear at an early stage and contribute to the transition from acute to chronic low back pain.

Grotle M, Vøllestad NK, Veierød MB, Brox JI. · Section for Health Science, University of Oslo, P.O. Box 1153 Blindern, N-0316 Oslo, Norway. · Pain. · Pubmed #15561390 No free full text.

Abstract: Patients with chronic low back pain (LBP) frequently demonstrate high scores for fear-avoidance beliefs and distress. We need better knowledge about fear-avoidance beliefs and distress in early stages of LBP. The objectives of this study were to compare the level of fear-avoidance beliefs and distress in patients with acute LBP to patients with chronic LBP, and to assess the relationship of fear-avoidance beliefs and distress to disability in acute and chronic LBP. Two different back pain groups including 123 patients with acute and 233 patients with chronic LBP were studied. Main outcome measures were Oswestry Disability Index and work loss. The scores for fear-avoidance beliefs and distress in patients with acute LBP were significantly lower than among patients with chronic LBP. The results of the multivariate regression analyses, adjusting for sociodemographic, pain and clinical variables, demonstrated that whereas fear-avoidance beliefs for physical activity and distress were significantly associated with the Oswestry Disability Index, fear-avoidance beliefs for work and distress were significantly associated with work loss. The associations showed the same pattern in acute and chronic LBP. In addition, several of the pain and clinical variables were significantly associated with the Oswestry Disability Index and fingertip-floor distance was associated with work loss. In conclusion, fear-avoidance beliefs and distress influence pain-related disability both in early acute and long-term chronic LBP. The results replicate previous reports on the association between pain experience, fear-avoidance beliefs, distress, and disability in chronic LBP, and extend the findings to patients at an early stage of acute LBP.

Grotle M, Brox JI, Vøllestad NK. · Section for Health Science, University of Oslo, Norway. · Spine (Phila Pa 1976). · Pubmed #15507789 No free full text.

Abstract: STUDY DESIGN: Prospective study of two samples of patients with acute and chronic low back pain, respectively. OBJECTIVES: To compare the responsiveness of four functional status questionnaires, Roland Morris Disability Questionnaire (RMDQ), Oswestry Disability Index (ODI), Disability Rating Index (DRI), and Physical Functioning scale of the SF-36 (PFSF-36), and two pain scales, a Numerical Pain Rating Scale (NRS) and Visual Analogue Scale (VAS). SUMMARY OF BACKGROUND DATA: Concurrent comparisons of different outcome measurements in back patients have been requested. METHODS: Norwegian versions of the scales and questionnaires were completed by 54 patients with acute (<3 weeks) and 50 patients with chronic low back pain (>3 months). Clinical change was estimated on a global change index. An alternative external criterion was the expected clinical course in the two cohorts. Mean changes, standardized response mean (SRM), and area under the receiver operating characteristic (ROC) curves with cutoff point for highest sensitivity and specificity were calculated. RESULTS: At the follow-up, 63% of the acute and 41% of the chronic sample reported improvement on the global change index. Large SRMs (1.3-2.0) and areas under the ROC curves (0.84-0.93) were found for the measurements in the acute sample. In the chronic sample, the SRMs (0.4-1.1) and areas under the ROC curves (0.65-0.83) were lower, in particular for the PFSF-36 and the VAS. There was no statistically significant difference between the responsiveness in the measurements, except for higher responsiveness in the NRS compared with the VAS when using expected clinical course as the external criterion for change. CONCLUSION: The results suggest that all the outcome measures were appropriate for measuring changes in functional status and pain in patients with acute low back pain, whereas among chronic patients the RMDQ, ODI, DRI, and NRS were most appropriate.