Back Pain: Hildebrandt J

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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Lindena G, Diener HC, Hildebrandt J, Klinger R, Maier C, Schöps P, Tronnier V, Anonymous00098. · CLARA Clinical Analysis, Kleinmachnow, Germany. · Schmerz. · Pubmed #12077679 No free full text.

Abstract: The committee for quality assurance of the German IASP chapter (DGSS) evaluated all relevant guidelines concerning pain treatment. Quality of guidelines was analysed according to the checklist "Methodical quality of guidelines" by Ollenschläger and the user manual released by the German Medical Centre for Quality Assurance. The guideline for the treatment of back pain released by the German Medical Association was examined as well as the one released by the German Association for physical therapy and rehabilitation, the guideline on cervical and lumbal nerve root compression syndrome of the German Association of Neurosurgeons, the guideline for cancer pain of the Drug Committee of the German Medical Association was compared with the one of the German Interdisciplinary Association for Pain Treatment. The guideline for the treatment of chronic headache and facial pain of the Medical Association was evaluated and the guideline for the treatment of trigeminal neuralgia of the German Association of Neurosurgery and Neurology, also the guideline for the treatment of acute postoperative and posttraumatic pain. All guidelines show deficiencies in different aspects and of different severity. At first there are deficiencies in interdisciplinary formulation of the guidelines and identification and interpretation of evidence of multimodal pain treatment options. The most prominent deficiency is the lack of implementation and application trials or impulses by all author associations. This way all expenditure on releasing guidelines is given away without improving quality of pain treatment. The authors' recommendation is to adjust to guidelines and, if they are working or not, tell the authors and improve interdisciplinary in pain treatment guidelines.

Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. · Department of Epidemiology and Caphri Research School, Maastricht University, P Debyeplein 1, Maastricht, Netherlands. · Spine (Phila Pa 1976). · Pubmed #19127161 No free full text.

Abstract: STUDY DESIGN: A systematic review of randomized controlled trials (RCTs). OBJECTIVE: To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low back pain. SUMMARY OF BACKGROUND DATA: The effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent, and dosage, generally found in RCTs, point to the need for clinically valid comparisons in a literature synthesis. METHODS: We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases up to March 2007 for relevant trials reported in English, French, German, Dutch, and Nordic languages. We also screened references from trials identified. RCTs on the effects of injection therapy involving epidural, facet, or local sites for subacute or chronic low back pain were included. Studies that compared the effects of intradiscal injections, prolotherapy, or ozone therapy with other treatments were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded. RESULTS: Eighteen trials (1179 participants) were included in this review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender-and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics, and a variety of other drugs. The methodologic quality of the trials was limited with 10 of 18 trials rated as having a high methodologic quality. Statistical pooling was not possible because of clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy. CONCLUSION: There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.

Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P. · Department of Epidemiology and Caphri Research Institute, Maastricht University , P Debyeplein 1, Maastricht, Netherlands, 6200 MD. · Cochrane Database Syst Rev. · Pubmed #18646078 No free full text.

Abstract: BACKGROUND: The effectiveness of injection therapy for low-back pain is still debatable. Heterogeneity of target tissue, pharmacological agent and dosage generally found in randomized controlled trials (RCTs) points to the need for clinically valid comparisons in a literature synthesis. OBJECTIVES: To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low-back pain. SEARCH STRATEGY: We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE databases from January 1999 to March 2007 for relevant trials reported in English, French, German, Dutch and Nordic languages. We also screened references from trials identified. SELECTION CRITERIA: RCTs on the effects of injection therapy involving epidural, facet or local sites for subacute or chronic low-back pain were included. Studies which compared the effects of intradiscal injections, prolotherapy or Ozone therapy with other treatments, were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the quality of the trials. If study data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a best evidence synthesis to summarize the results. The evidence was classified into five levels (strong, moderate, limited, conflicting or no evidence), taking into account the methodological quality of the studies. MAIN RESULTS: 18 trials (1179 participants) were included in this updated review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender- and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics and a variety of other drugs. The methodological quality of the trials was limited with 10 out of 18 trials rated as having a high methodological quality. Statistical pooling was not possible due to clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy. AUTHORS' CONCLUSIONS: There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.

Hildebrandt J. · Schwerpunkt Algesiologie, Klinikum der Georg-August-Universität Göttingen. · Z Orthop Ihre Grenzgeb. · Pubmed #15106057 No free full text.

Abstract: Only 20 % of low back pain or sciatica is of a specific origin. These specific pain conditions include tumours, spondylitis, rheumatic and metabolic diseases as well as radicular syndromes. By far the most pain from discs, facet and sacroiliac joints, ligaments and muscles must be considered as unspecific, because no anamnestic information or clinical signs exist (radiological changes included) to assign pain to structural or functional correlates. In addition, the therapeutic consequences from the assignment of structural changes to pain remain unclear. In acute pain situations the specificity of the pain is not important because of the fast relief of the disease, in chronic pain situations, fear avoidance beliefs and pain behaviour seem to be much more important than structural and functional changes.

Hildebrandt J. · Schwerpunkt Algesiologie, Zentrum Anästhesie, Rettungs- und Intensivmedizin, Universitätsklinik Göttingen. · Schmerz. · Pubmed #14648313 No free full text.

Abstract: Lumbar muscle function is considered to be an important component of chronic low back pain (CLBP). Many studies have documented compromised muscle function in patients with CLBP. Although the mechanism associating muscle insufficiency to CLBP is not clearly understood, it is commonly held that the passive tissues of the spine are increasingly stressed with increasing functional muscle insuffiency. Functional instability of the spine plays a major role in the development of back pain. During the last few years, objective evaluation of the fatigue of back muscles by surface electromyography (EMG) with quantitative spectral techniques, evaluation of fibre type and size of the back muscles and quantifying of postural control of the lumbar spine during different tasks documented the failure of the spine in CLBP patients by a deficit of motor control more objectively. Besides this deficit, many patients show severe psychosocial problems and fear-avoidance beliefs. On this basis, treatment of CLBP with active rehabilitation, which includes educational, psychological, and social components along with the therapeutic exercises, has been increasingly advocated during recent years.

Hildebrandt J. · Zentrum für Anästhesiologie, Universitätsklinik Göttingen. · Med Monatsschr Pharm. · Pubmed #10965695 No free full text.

This publication has no abstract.

Hildebrandt J. · Zentrum Anästhesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität Göttingen. · Ther Umsch. · Pubmed #10483314 No free full text.

Abstract: Back pain is a common disease causing tremendous costs for treatment, work loss and pension payments. The reasons of back pain vary considerably and often remain doubtful. The effectiveness of common treatment concepts has not yet been proved significantly. Active treatment procedures should be preferred. In chronic pain patients only multimodal concepts of treatment seem to be successful as far as they take care of somatic, psychosocial, ergonomic and sport physiological aspects.

Pfingsten M, Leibing E, Harter W, Kröner-Herwig B, Hempel D, Kronshage U, Hildebrandt J. · Department of Algesiology, Center of Anesthesiology, Georg-August-University of Göttingen, Göttingen, Germany. · Pain Med. · Pubmed #15102230 No free full text.

Abstract: OBJECTIVE AND DESIGN: In a randomized controlled study, we investigated whether pain anticipation and fear-avoidance beliefs will lead to behavioral avoidance. PATIENTS: Fifty patients with chronic low back pain (CLBP) performed a simple leg-flexion task. Before the test, members of a control group were informed that the movement would not result in any increase of pain, whereas experimental group participants were told that a slight increase of pain could occur. OUTCOME MEASURES: All patients completed the Fear-Avoidance-Beliefs Questionnaire (FABQ) and the Pain Disability Index (PDI). As dependent variables, different behavioral performance parameters were registered by a computerized protocol: number of flexion movements, mean range of motion, and mean work ratio. Furthermore, patients were asked about their pain intensity as well as their fear (at the moment) and finally were asked to judge the unpleasantness of the experiment (using visual analogue scales for each of the three variables). RESULTS: Inducing pain anticipation (by instruction) led to significantly lower levels of behavioral performance as well as increased pain intensity and fear during the test. Behavioral performance was significantly correlated with fear-avoidance beliefs. CONCLUSIONS: Results confirm that pain anticipation and fear-avoidance beliefs significantly influence the behavior of patients with low back pain in that they motivate avoidance behavior. Therapists must be aware of the powerful effects of cognitive processes, which can give rise to fear of pain and, consequently, avoidance behavior.

Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Hildebrandt J, Basler HD, Baum E, Kochen MM, Pfingsten M. · Department of General Practice parallelDepartment of Anesthesiology, Pain Clinic, University Goettingen, Germany. · Clin J Pain. · Pubmed #18716496 No free full text.

Abstract: OBJECTIVE: Epidemiologic surveys frequently show that women more often and are more affected by low back pain (LBP). The aim of this secondary analysis of a randomized controlled study was to explore whether presentation and course of LBP of women is different from men, and if sex affects the use of healthcare services for LBP. METHODS: Data from 1342 [778 (58%) women] patients presenting with LBP in 116 general practices were collected. Patients completed standardized questionnaires before and after consultation and were contacted by phone 4 weeks, 6 months, and 12 months later for standardized interviews by study nurses. Functional capacity was assessed with Hannover Functional Ability Questionnaire (HFAQ). Logistic regression models-adjusting for sociodemographic and disease-related data-were conducted to investigate the effect of sex for the use of healthcare services. RESULTS: Women had on average a lower functional capacity at baseline and after 12 months. They were more likely to have recurrent or chronic LBP and to have a positive depression score. Being female was associated with a low functional capacity after 12 months (odds ratio: 1.7, 95% confidence interval: 1.2-2.3), but baseline functional capacity, chronicity, and depression were stronger predictors. In univariate analysis, women had a tendency of higher use of healthcare services. Those differences disappeared after adjustment. DISCUSSION: Our findings confirm that women are more severely affected by LBP and have a worse prognosis. Utilization of healthcare services cannot be fully explained by female sex, but rather by a higher impairment by back pain and pain in other parts of the body characteristic of the female population.

Becker A, Leonhardt C, Kochen MM, Keller S, Wegscheider K, Baum E, Donner-Banzhoff N, Pfingsten M, Hildebrandt J, Basler HD, Chenot JF. · Department of General Practice, Preventive and Rehabilitation Medicine, University of Marburg, Marburg, Germany. · Spine (Phila Pa 1976). · Pubmed #18317189 No free full text.

Abstract: STUDY DESIGN: Cluster randomized controlled trial. OBJECTIVE: To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention. SUMMARY OF BACKGROUND DATA: International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen. METHODS: We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders. RESULTS: After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320-6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = -0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls. CONCLUSION: Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Chenot JF, Scherer M, Becker A, Donner-Banzhoff N, Baum E, Leonhardt C, Keller S, Pfingsten M, Hildebrandt J, Basler HD, Kochen MM. · Dpt, of General Practice, University of Göttingen, Humboldtallee 38, 37073 Goettingen, Germany. · Implement Sci. · Pubmed #18257923 links to  free full text

Abstract: ABSTRACT: BACKGROUND: Implementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation. METHODS: Seventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion. RESULTS: Most GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP. CONCLUSION: Promoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system. TRIAL REGISTRATION: BMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 25.

Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Baum E, Pfingsten M, Hildebrandt J, Basler HD, Kochen MM. · Dpt. of General Practice, University of Göttingen, Humboldtallee 38, 37073 Göttingen, Germany. · BMC Complement Altern Med. · Pubmed #18088435 links to  free full text

Abstract: BACKGROUND: Although back pain is considered one of the most frequent reasons why patients seek complementary and alternative medical (CAM) therapies little is known on the extent patients are actually using CAM for back pain. METHODS: This is a post hoc analysis of a longitudinal prospective cohort study embedded in a RCT. General practitioners (GPs) recruited consecutively adult patients presenting with LBP. Data on physical function, on subjective mood, and on utilization of health services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months RESULTS: A total of 691 (51%) respectively 928 (69%) out of 1,342 patients received one form of CAM depending on the definition. Local heat, massage, and spinal manipulation were the forms of CAM most commonly offered. Using CAM was associated with specialist care, chronic LBP and treatment in a rehabilitation facility. Receiving spinal manipulation, acupuncture or TENS was associated with consulting a GP providing these services. Apart from chronicity disease related factors like functional capacity or pain only showed weak or no association with receiving CAM. CONCLUSION: The frequent use of CAM for LBP demonstrates that CAM is popular in patients and doctors alike. The observed association with a treatment in a rehabilitation facility or with specialist consultations rather reflects professional preferences of the physicians than a clear medical indication. The observed dependence on providers and provider related services, as well as a significant proportion receiving CAM that did not meet the so far established selection criteria suggests some arbitrary use of CAM.

Leonhardt C, Keller S, Chenot JF, Luckmann J, Basler HD, Wegscheider K, Baum E, Donner-Banzhoff N, Pfingsten M, Hildebrandt J, Kochen MM, Becker A. · Institute for Medical Psychology, University of Marburg, Germany. · Patient Educ Couns. · Pubmed #18023130 No free full text.

Abstract: OBJECTIVE: To investigate the effectiveness of a TTM-based motivational counselling approach by trained practice nurses to promote physical activity of low back pain patients in a German primary care setting. METHODS: Data were collected in a cluster-randomized controlled trial with three study arms via questionnaires and patient interviews at baseline and after 6 and 12 months. We analysed total physical activity and self-efficacy by using random effect models to allow for clustering. RESULTS: A total of 1378 low back pain patients, many with acute symptoms, were included in the study. Nearly 40% of all patients reported sufficient physical activity at baseline. While there were significant improvements in patients' physical activity behaviour in all study arms, there was no evidence for an intervention effect. CONCLUSION: The outcome may be explained by insufficient performance of the practice nurses, implementation barriers caused by the German health care system and the heterogenous sample. PRACTICE IMPLICATIONS: Given the objective to incorporate practice nurses into patient education, there is a need for a better basic training of the nurses and for a change towards an organizational structure that facilitates patient-nurse communication. Counselling for low back pain patients has to consider more specificated aims for different subgroups.

Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Baum E, Pfingsten M, Hildebrandt J, Kochen MM, Basler HD. · Dpt, of General Practice, University of Göttingen, Humboldtallee 38, 37073 Goettingen, Germany. · BMC Health Serv Res. · Pubmed #17112374 links to  free full text

Abstract: BACKGROUND: Acupuncture is a frequently used but controversial adjunct to the treatment of chronic low back pain (LBP). Acupuncture is now considered to be effective for chronic LBP and health care systems are pressured to make a decision whether or not acupuncture should be covered. It has been suggested that providing such services might reduce the use of other health care services. Therefore, we explored factors associated with acupuncture treatment for LBP and the relation of acupuncture with other health care services. METHODS: This is a post hoc analysis of a longitudinal prospective cohort study. General practitioners (GPs) recruited consecutive adult patients with LBP. Data on physical function, subjective mood and utilization of health care services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months. RESULTS: A total of 179 (13 %) out of 1,345 patients received acupuncture treatment. The majority of those (59 %) had chronic LBP. Women and elderly patients were more likely to be given acupuncture. Additional determinants of acupuncture therapy were low functional capacity and chronicity of pain. Chronic (vs. acute) back pain OR 1.6 (CL 1.4-2.9) was the only significant disease-related factor associated with the treatment. The strongest predictors for receiving acupuncture were consultation with a GP who offers acupuncture OR 3.5 (CL 2.9-4.1) and consultation with a specialist OR 2.1 (CL 1.9-2.3). After adjustment for patient characteristics, acupuncture remained associated with higher consultation rates and an increased use of other health care services like physiotherapy. CONCLUSION: Receiving acupuncture for LBP depends mostly on the availability of the treatment. It is associated with increased use of other health services even after adjustment for patient characteristics. In our study, we found that receiving acupuncture does not offset the use of other health care resources. A significant proportion of patients who received did not meet the so far only known selection criterion (chonicity). Acupuncture therapy might be a reflection of helplessness in both patients and health care providers.

Pfingsten M, Baller M, Liebeck H, Strube J, Hildebrandt J, Schöps P. · Ambulanz für Schmerzbehandlung, Zentrum Anästhesiologie, Rettungs- und Intensivmedizin, Klinikum der Georg-August-Universität Gö · Schmerz. · Pubmed #14513340 No free full text.

Abstract: BACKGROUND: The aim of our study was the analysis of the psychometric properties of the Ransford technique which is a qualitative scoring method of the pain drawing. It has been suggested that this method could be used as a brief screening technique for psychological involvement in pain complaints. METHODS: 109 patients with chronic back pain filled in the pain drawing which was rated according to the technique described by Ransford and colleagues in 1976. As external criterium of validity we chose a differentiated expert rating of psychological interference. RESULTS: The Ransford technique showed moderate to good coefficients of reliability (re-test, inter and intra-rater). On the other hand, the Ransford technique demonstrated very low indices of validity in order to give a prognosis about psychological interference. Sensitivity and specificity of the Ransford technique demonstrated inadequate values, which furthermore were independent from cut-off points. CONCLUSION: The pain drawing and the Ransford technique are not sufficiently sensitive and therefore allow no screening for psychological interference in complaints of back pain.

Hildebrandt J. · Schwerpunkt Algesiologie, Zentrum Anästhesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität Göttingen. · Schmerz. · Pubmed #11793154 No free full text.

Abstract: Diagnostic nerve blocks: The popularity of neural blockade as a diagnostic tool in painful conditions, especially in the spine, is due to features like the unspecific character of spinal pain, the irrelevance of radiological findings and the purely subjective character of pain. It is said that apart from specific causes of pain and clear radicular involvement with obvious neurological deficits and corresponding findings of a prolapsed disc in MRI or CT pictures, a diagnosis of the anatomical cause of the pain can only be established if invasive tests are used [5]. These include zygapophyseal joint blocks, sacroiliacal joint blocks, disc stimulation and nerve root blocks. Under controlled conditions, it has been shown that among patients with chronic nonradicular low back pain, some 10-15% have zygapophyseal joint pain [58], some 15-20% have sacroiliacal joint pain [36, 59] and 40% have pain from internal disc disruption [60]. The diagnostic use of neural blockade rests on three premises. First, pathology causing pain is located in an exact peripheral location, and impulses from this site travel via a unique and consistent neural root. Second, injection of local aneasthetic totally abolishes sensory function of intended nerves and does not affect other nerves. Third, relief of pain after local anaesthetic block is attributable solely to block of the target afferent neural pathway. The validity of these assumptions is limited by complexities of anatomy, physiology, and psychology of pain perception and the effect of local anaesthetics on impulse conduction [28]. Facet joints: The prevalence of zygapophyseal joint pain among patients with low back pain seems to be between 15% and 40% [62], but apparently only 7% of patients have pure facet pain [8, 29]. Facet blockade is achieved either by injection of local anaesthetic into the joint space or around the medial branches of the posterior medial rami of the spinal nerves that innervate the joint. There are several problems with intraarticular facet injections, mainly failure to enter the joint capsule and rupture of the capsule during the injection [11]. There is no physiological means to test the adaequacy of medial nerve block, because the lower branches have no cutaneous innervation. Medial ramus blocks (for one joint two nerves have to be infiltrated) are as effective as intraarticular joint blocks [37]. Reproducibility of the test is not high, the specifity is only 65% [61]. For diagnosis of facet pain fluoroscopic control is always necessary as in the other diagnostic blocks. Sacroiliacal joint: Definitely the sacroiliacal joint can be the source of low back pain. Stimulation of the joint by injection in subjects without pain produces pain in the buttock, in the posterior thigh and the knee. There are many clinical tests which confirm the diagnosis, but the interrater reliability is moderate [53]. Intraarticular injection can be achieved in the lower part of the joint with fluoroscopic guidance only, but an accurate intraarticular injection, which is confirmed by contrast medium, even at this place is often difficult. It is not clear whether intraarticular spread is necessary to achieve efficacy. Discography: Two primary syndromes concerning the ventral compartment have been described: anular fissures of the disc and instability of the motion segment. In the syndrome of anular tear, leakage of nucleus pulposus material into the anulus fibrosus is considered to be the source of pain. The studies of Vaharanta [71] and Moneta [41] show a clear and significant correlation between disc pain and grade 3 fissures of the anulus fibrosus. intervertebral discs are difficult to anaesthetize. Intradiskal injections of local anaesthetics may succeed in relieving the patient's pain, but such injections are liable to yield false negative results if the injected agent fails to adequately infiltrate the nerve endings in the outer anulus fibrosus that mediate the patient's pain. In the majority of cases MRI provide adaequate information, but discography may be superior in early stages of anular tear and in clarifying the relation between imaging data and pain [71]. Selective spinal nerve injection: In patients with complicated radiculopathy, the contribution of root inflammation to pain may not be certain, or the level of pathology may be unclear. Diagnostic root blocks are indicated in the following situations: atypical topography of radicular pain, disc prolapses or central spinal stenosis at more than one level and monoradicular pain, lateral spinal stenosis, postnucleotomysyndrome. Injection of individual spinal nerves by paravertebral approach has to be used to elucidate the mechanism and source of pain in this unclear situations. The premise is that needle contact will identify the nerve that produces the patient's characteristic pain and that local anaesthetic delivered to the pathogenic nerve will be uniquely analgesic. Often, this method is used for surgical planning, such as determining the site of foraminotomy. All diagnostic nerve root blocks have to be done under fluoroscopic guidance. Pain relief with blockade of a spinal nerve cannot distinguish between pathology of the proximal nerve in the intervertebral foramen or pain transmitted from distal sites by that nerve. Besides, the tissue injury in the nerve's distribution and neuropathic pain (for instance as a result of root injury) likewise would be relieved by a proximal block of the nerve. Satisfactory needle placement could not be achieved in 10% of patient's at L4, 15% at L5 and 30% at S1 [28]. The positive predictive value of indicated radiculopathy confirmed by surgery ranged between 87-100% [14, 22]. The negative predictive value is poorly studied, because few patients in the negative test group had surgery. Negative predictive values were 27% and 38% of the small number of patients operated on despite a negative test. Only one prospective study was published, which showed a positive predictive value of 95% and an untested negative predictive value [66]. Some studies repeatedly demonstrated that pain relief by nerve root block does not predict success by neuroablative procedures, neither by dorsal rhyzotomy nor by dorsal gangliectomy [46]. Therapeutic nerve blocks - facet joints: Intraarticular injection of steroids offer no greater benefit than injections of normal saline [8, 15] and long lasting success is lacking. In this case, a denervation of the medial branches can be considered. To date three randomized controlled studies of radiofrequency facet denervation have been published. One study [20] reported only modest outcomes and its results remained inconclusive, another study [72] with a double blind controlled design showed some effects in a small selected group of patients (adjusted odds ratio 4.8) 3, 6 and 12 months after treatment, concerning not only reduction of pain but alleviating functional disability also. The third study (34a) showed no effect 3 months after treatment. Discogenic pain: Intradiscal radiofrequency lesions, intradiscal injections of steroids and phenol have been advocated, but there are no well controlled studies. Just recently, intradiscal lesion and denervation of the anulus has been described with promising results, but a randomized controlled study is lacking up to now [31, 55]. Epidural Steroids: Steroids relieve pain by reducing inflammation and by blocking transmission of nociceptive C-fiber input. Koes et al. [33] reviewed the randomized trials of epidural steroids: To date, 15 trials have been performed to evaluate the efficacy, 11 of which showed method scores of 50 points (from 100) ore more. The trials showed inconsistent results of epidural injections. Of the 15 trials, 8 reported positive results and 7 others reported negative results. Consequently the efficacy of epidural steroid injections has not yet been established. The benefits of epidural steroid injections seem to be of short duration only. Future efficacy studies, which are clearly needed, should take into account the apparent methological shortcomings. Furthermore, it is unclear which patients benefit from these injections. In our hands the injection technique can be much improved by fluoroscopic guidance of the needle, with a prone position of the patient, and lateral injection at the relevant level and with a small volume (1-2 ml) and low dose of corticosteroid (20 mg triamcinolone in the case of a monoradicular pain, for example). In the case of epidural adhesions in postoperative radicular pain [50], the study of Heafner showed that the additional effect of hyaloronidase and hypertonic saline to steroids was minimal. In our hands there was no effect in chronic radicular pain 3 months after the injection.

Bigos SJ, McKee JE, Holland JP, Holland CL, Hildebrandt J. · Department of Orthopedics, Harborview Medical Center, Seattle, USA. · Schmerz. · Pubmed #11793147 No free full text.

Abstract: Back problems are common, expensive, and the few patients who are the crux of the problem are uncomfortable but also an uncomfortable frustration for clinicians and employers alike. We now know that clinicians can greatly improve the patient's response to back symptoms by admitting our diagnostic limitations, demedicalizing the issue, providing assurance, and encouraging a more reasonable approach to improving comfortable activity tolerance.

Pfingsten M, Hildebrandt J. · Ambulanz für Schmerzbehandlung, Schwerpunkt Algesiologie, Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Klinikum der Georg-August-Universität Göttingen. · Anasthesiol Intensivmed Notfallmed Schmerzther. · Pubmed #11577358 No free full text.

Abstract: AIM OF THE STUDY: Treatment of chronic low back pain is a difficult problem and usually of low effectiveness. Aim of the study was to analyse the effectiveness of a multimodal treatment procedure. METHODS: From the basis of functional restoration concepts primarily established in the USA we conceptualized a treatment program which initially was funded by the German ministry of research. Over the years the regimen was modified in several respects (programs of different intensity). From 1990 to 2000 762 patients were treated in this way with one-year follow-up examination. RESULTS: Patients who were off work had significant differences in psychosocial and pain-related variables in comparison to those patients who were still working. Treatment procedures were in general very effective, although a modification of the program with less treatment (no work-hardening) failed in repeating the same effects. Pain intensity, disability, amount of depression and psychological distress improved significantly as well as work capability and use of the health care system. Nearly all results were seen to stabilize at the 12-month evaluation. DISCUSSION: Functional restoration programs for treatment of chronic low back pain have demonstrated effectiveness in several countries. By early use of these programs the high amount of costs due to back pain disability may be consequently reduced. Up to now in Germany these concepts are not well-known and insurance companies as well as the health system do not yet acknowledge them.

Pfingsten M, Kröner-Herwig B, Leibing E, Kronshage U, Hildebrandt J. · Department of Algesiology, Center of Anesthesiology, Georg-August-University of Göttingen, Germany. · Eur J Pain. · Pubmed #10985869 No free full text.

Abstract: Fearful avoidance of physical activities is a major factor in low back pain (LBP) and disability. In 1993 Waddell et al. developed the Fear-Avoidance Beliefs Questionnaire (FABQ) focusing on patients' beliefs about how physical activity and work affect LBP. The focus of our study was to analyse and validate the German version of the FABQ. Three-hundred and two consecutive LBP outpatients participating on a functional restoration programme filled in the FABQ. Factor analysis yielded three factors which accounted for nearly 65% of the total variance of the questionnaire. Whereas the factor 'physical activity' (8.9% of the variance) remained the same as in the English version, the second factor of the original version split into two: one related to, 'work as cause of pain' (43.4% of the variance) and the other to patients' assumptions of their probable return to work (11.8% of the variance). Both work-related subscales showed a good internal consistency (alpha = 0.89, resp. alpha = 0.94), whereas the consistency of the subscale 3 'physical activity' was only modest (alpha = 0.64). Test-re-test reliability score was fair to good for the whole scale (r = 0.87;n = 30). Regression analysis demonstrated that fear-avoidance beliefs account for the highest proportion of variance (35%) regarding disability in activities of daily living and work loss. Patients out of work demonstrated more fear-avoidance beliefs in comparison to those who were still working. It can be concluded that the German version of the FAQB is a reliable and valid instrument, but it shows a different factor structure from the original English version. The FABQ has been proven to identify patients with maladaptive beliefs which have to be focused on in proper treatment.

Hildebrandt J. · No affiliation provided · MMW Fortschr Med. · Pubmed #11194268 No free full text.

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