Back Pain: Mannion AF

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.

This publication has no abstract.

Mannion AF, Balagué F, Pellisé F, Cedraschi C. · Spine Center, Schulthess Klinik, Zürich, Switzerland. · Nat Clin Pract Rheumatol. · Pubmed #17968331 No free full text.

Abstract: Pain is a multidimensional experience that is a prominent feature of many musculoskeletal disorders. Despite its subjective nature, pain is a highly relevant complaint; hence, nothing should deter physicians from attempting to formally assess it. This Review summarizes the main aspects of pain measurement from a practical standpoint, with a specific focus on low back pain. On balance, for the assessment of pain intensity, categorical scales with verbal descriptors or numerical rating scales seem to be preferable to traditional visual analogue scales, although no single best measure can be recommended. Pain per se should be assessed, rather than surrogate measures such as analgesic use. Back and leg pain should be evaluated separately in patients in whom these conditions coexist. For assessing change, prospective measurements are preferable to retrospective reports. Pain is not synonymous with function or quality of life, and other tools covering these important outcome dimensions should complement the assessment of pain, especially in patients with chronic symptoms. Clinicians should be aware of the psychometric properties of the tool to be used, including its level of imprecision (random measurement error) and its minimum clinically important difference (score difference indicating meaningful change in clinical status).

Mannion AF, Elfering A. · Spine Unit, Schulthess Klinik, Lengghalde 2, 8008, Zürich , Switzerland. · Eur Spine J. · Pubmed #16320033 No free full text.

Abstract: The relatively high rate of failed back surgery has prompted the search for "risk factors" to predict the result of spinal surgery in a given individual. However, the literature reveals few unequivocal predictors and they often explain a relatively low proportion of variance in outcome. This suggests that we have a long way to go before being able to rest easily, having refused someone surgery on the basis of unfavourable baseline characteristics. The best recommendation is to ensure, firstly, that the indication for surgery is absolutely clear-cut (i.e. that surgically remediable pathology exists) and then to consider the various factors that may influence the "typical" outcome. Consistent risk factors for a poor outcome regarding return-to-work include long-term sick leave/receipt of disability benefit. Hence, every effort should be made to keep the individual in the workforce, despite the ongoing symptoms and plans for surgery. In patients with a particularly heavy job, consultation with occupational physicians might later ease the patient's way back into the workplace. Patients with degenerative disorders and/or comorbidity should be counselled that few of them will have complete/lasting pain relief or a complete return to pre-morbid function. Patients with a high level of distress may benefit from psychological treatment, before and/or accompanying the surgical treatment. The opportunity (time), encouragement (education and positive messages), and resources (referral to appropriate support services) to modify risk factors that are indeed modifiable should be offered, and realistic expectations should be discussed with the patient before the decision to operate is made.

Moffett JK, Mannion AF. · Institute of Rehabilitation, University of Hull, 215 Anlaby Road, Hull HU3 2PG, UK. · Best Pract Res Clin Rheumatol. · Pubmed #15949780 No free full text.

Abstract: Some would say that the value of physical therapies for low back pain patients is the provision of pain relief; others argue that it is all about helping the person to get on with his or her life. There is an on-going debate amongst practitioners as to whether a hands-on or a hands-off approach is likely to be most effective for these patients. This chapter reviews these positions through an exploration of the literature. It examines the evidence for the effectiveness of a range of commonly used physical therapies.

Junge A, Mannion AF. · Schulthess-Klinik Zürich. · Orthopade. · Pubmed #15007549 No free full text.

Abstract: Self-assessment questionnaires are becoming increasingly important in the evaluation and outcome-assessment of low back pain patients, both in the research environment and in everyday clinical practice. Questionnaires allow a standardised, patient-orientated examination of the symptoms and effects of the disease as well as the assessment of change following treatment. The aim of the current review was to provide a summary of the questionnaires that are currently available in the German language for the assessment of patients with low back pain; the review focuses on those that have been shown to be reliable and valid and widely-used on an international basis. The following topics are considered: (1) current pain experience and pain history, (2) disability due to low back pain, (3) coping with pain and psychological disturbance, (4) general health status and (5) outcome. Depending on the aim of the study, the evaluation of outcome may involve disease-specific symptoms (pain and disability), general health status, the ability to work, and the utilisation of health care resources (medical consultations, treatment, use of medication). For the analysis of treatment effects, prospective assessment of the relevant characteristics is recommended - that is, assessments should be made before the treatment and again with identical questionnaires at follow-up. Especially within the context of scientific studies, instruments should be chosen that enable an international comparison of the data generated. In everyday clinical routine, a short standardised documentation of the most important dimensions is recommended.

Mannion AF. · Department of Neurology, Schulthess Clinic, Zürich, Switzerland. · J Electromyogr Kinesiol. · Pubmed #10597049 No free full text.

Abstract: This review focuses on the role of the paraspinal muscles in relation to the development and existence of low back pain. It begins with a discussion of the deficits in paraspinal muscle strength and fatigue-resistance observed in low back pain patients and addresses the issue of 'cause or effect' with respect to muscle dysfunction and back pain. Our current knowledge regarding the 'normal' fibre type characteristics of the human erector spinae is then presented and the influence of these fibre type characteristics on the muscle's performance capacity is discussed. Alterations in the 'microanatomy' of the musculature in connection with low back pain, and the associated implications for the performance capacity of the patient, are then considered. Finally, a number of outstanding issues in relation to the clinical significance of back muscle dysfunction are identified, leading to the proposal of areas for future research.

Mannion AF, Dvorak J, Taimela S, Müntener M. · Schulthess Klinik Zürich, Schweiz. · Schmerz. · Pubmed #11793153 No free full text.

Abstract: INTRODUCTION: Active treatments are advocated for the management of non-specific chronic low back pain (CLBP), although few studies have documented the relative efficacy of differing types of programme. A number of the available treatments comprise exercise routines on specially designed training machines, which are ostensibly better disposed to reverse the compromised trunk muscle function displayed by these patients than are 'free exercise' programmes. However, in using these muscle-training programmes, the physiological or anatomical adaptations that might account for the improved performance are rarely investigated, let alone identified. This is an important issue, because if the 'newly-acquired strength' is mostly specific to performance on the devices on which the patient has trained and been tested, and reflects the skill in executing these particular tasks, this will not necessarily assist the patient during performance of his/her everyday activities. The aims of the present study were (1) to quantify the changes in back muscle performance in chronic LBP patients following 3 months active therapy, and (2) to analyse the corresponding changes in activation and cross-sectional area of the paraspinal muscles. METHODS: 148 individuals (57% women) with CLBP (age 45.0+/-10.0 years; duration of LBP 10.9+/-9.5 years) were randomised to a treatment which they attended 2/week for 3 months: active physiotherapy, muscle reconditioning on training devices, or low-impact aerobics. Pre- and post-therapy, assessments were made of isometric trunk muscle strength in each plane of movement and of erector spinae activation (using surface electromyography) during back extension. In a sub-group of 56 patients, the cross-sectional area of the paravertebral muscles was determined using magnetic resonance imaging (MRI). In all patients, self-rated pain intensity, pain frequency and disability were assessed before and after therapy. RESULTS: 132/148 patients completed the therapy. Isometric strength in each movement plane increased significantly in all groups post-therapy. Apart from trunk extension, the changes were significantly greater in the devices group than in the other two groups (Fig 1). Activation of the paraspinal muscles during back extension also increased significantly in all groups (Fig 2) and was weakly, but significantly (r = 0.37; p = 0.0001) correlated with increased strength in back extension. Although, at baseline, highly significant correlations were observed between the size of the paraspinal muscles (at L3/4 and at L4/5) and isometric back extension strength (r=0.75; p< 0.0001), post-training increases in strength were not accompanied by corresponding changes in muscle size. None of the improvements in strength showed any relationship with the clinical changes in pain and disability, regardless of whether the latter were examined on an individual basis or in relation to 'outcome groups'. CONCLUSION: The superior trunk strength shown by the devices group post-therapy was considered to be attributable, in part, to a 'learning effect', of the type often seen when training and testing are carried out on the same machines. These gains are considered to be mostly 'task-specific'. However, part of the improvement in strength after active therapy (in all groups) also appeared to be due to an increased neural activation of the trunk muscles. These positive effects should be transferable to the performance of everyday activities for which the same muscles are employed, although the percentage improvement is probably not as high as the measured increase in strength might suggest. Possible roles for improved co-ordination and changes in motivation and/or pain tolerance after therapy cannot be excluded. No differences in the clinical outcome were observed between the three therapy groups, and the changes in physical performance after therapy did not correlate with the clinical outcome. It is therefore questionable whether strength measurements have any clinical significance in documenting the success of rehabilitation programmes, other than on a motivational basis. The results of the present study suggest that the value of supervised active therapy programmes does not reside in the reversal of specific muscular deficiencies, but rather in the provision of a source of confirmation/encouragement for the patient, that movement is not harmful, and a foundation upon which to further build. Whether the utilisation of specific training devices, or individual instruction, is necessary to elicit these particular effects is questionable.

Mannion AF, Müntener M, Taimela S, Dvorak J. · Department of Neurology, Schulthess Clinic, Zürich, Switzerland. · Rheumatology (Oxford). · Pubmed #11477282 links to  free full text

Abstract: OBJECTIVES: To examine the relative efficacy of three active therapies for patients with chronic low back pain. METHODS: One hundred and forty-eight subjects with chronic low back pain were randomized to receive, twice weekly for 3 months, (i) active physiotherapy, (ii) muscle reconditioning on training devices, or (ii) low-impact aerobics. Questionnaires were administered to assess pain intensity, pain frequency and disability before and after therapy and at 6 and 12 months of follow-up. RESULTS: One hundred and thirty-two of the 148 patients (89%) completed the therapy programmes and 127 of the 148 (86%) returned a questionnaire at all four time-points. The three treatments were equally efficacious in significantly reducing pain intensity and frequency for up to 1 yr after therapy. However, the groups differed with respect to the temporal changes in self-rated disability over the study period (P=0.03): all groups showed a similar reduction after therapy, but for the physiotherapy group disability increased again during the first 6 months of follow-up whilst the other two groups showed a further decline. In all groups the values then remained stable up to the 12-month follow-up. The larger group size and minimal infrastructure required for low-impact aerobics rendered it considerably less expensive to administer than the other two programmes. CONCLUSIONS: The introduction of low-impact aerobic exercise programmes for patients with chronic low back pain may reduce the enormous costs associated with its treatment.

Mannion AF, Junge A, Taimela S, Müntener M, Lorenzo K, Dvorak J. · Institute of Anatomy, University of Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #11317114 No free full text.

Abstract: DESIGN: Cross-sectional analysis of the factors influencing self-rated disability associated with chronic low back pain and prospective study of the relationship between changes in each of these factors and in disability following active therapy. OBJECTIVES: To examine the relative influences of pain, psychological factors, and physiological factors on self-rated disability. SUMMARY OF BACKGROUND DATA: In chronic LBP, the interrelationship between physical impairment, pain, and disability is particularly complicated, due to the influence of various psychological factors and the lack of unequivocal methods for assessing impairment. Investigations using new "belief" questionnaires and "sophisticated" performance tests, which have shown promise as discriminating measures of impairment, may assist in clarifying the situation. Previous studies have rarely investigated all these factors simultaneously. METHODS: One hundred forty-eight patients with cLBP completed questionnaires and underwent tests of mobility, strength, muscle activation, and fatigability, and (in a subgroup) erector spinae size and fiber size/type distribution. All measures were repeated after 3 months active therapy. Relationships between each factor and self-rated disability (Roland and Morris questionnaire) at baseline, and between the changes in each factor and changes in disability following therapy, were examined. RESULTS: Stepwise linear regression showed that the most significant predictors of disability at baseline were, in decreasing order of importance: pain; psychological distress; fear-avoidance beliefs; muscle activation levels; lumbar range of motion; gender. Only changes in pain, psychological distress, and fear-avoidance beliefs significantly accounted for the changes in disability following therapy. CONCLUSION: A combination of pain, psychological and physiological factors was best able to predict baseline disability, although its decrease following therapy was determined only by reductions in pain and psychological variables. The active therapy program-in addition to improving physical function-appeared capable of modifying important psychological factors, possibly as a result of the positive experience of completing the prescribed exercises without undue harm.

Käser L, Mannion AF, Rhyner A, Weber E, Dvorak J, Müntener M. · Department of Neurology, Schulthess Klinik, Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #11317113 No free full text.

Abstract: DESIGN: Randomized prospective study to compare the effects of three types of active therapy on the back muscle structure of chronic low back pain patients. OBJECTIVES: To analyze the effects of 3 months active therapy on gross back muscle size and muscle fiber type characteristics and their relationship to changes in muscle function. SUMMARY OF BACKGROUND DATA: Many studies have documented a diminished muscular performance capacity in cLBP patients, but few have supported this with evidence of alterations in either the macro- or microscopic structure of the paraspinal muscles. Investigations of the changes in muscle structure following active rehabilitation are even rarer. METHODS: Assessments of trunk muscle cross-sectional area (using MRI), erector spinae fiber size/type distribution and pathology (percutaneous biopsy), and muscle function (see Part 1) were made in a group of 59 individuals with cLBP, who were participating in a randomized trial of active therapies for cLBP (physiotherapy, muscle training on devices, aerobics). RESULTS: Fifty-three out of 59 patients (90%) completed the therapy. At baseline, significant correlations were observed between the size of the paraspinal muscles and isometric back extension strength (P=0.0001), and between the proportional area of the muscle occupied by each fiber type and the fatigability of the muscle (P=0.012). Following therapy, there were small (few percent) increases in trunk muscle size in the aerobics and physiotherapy groups and a similarly slight decrease in the devices group. Changes in erector spine size correlated only weakly and nonsignificantly with changes in back extension strength. There were no major changes in fiber type proportion or fiber size in any group following therapy. CONCLUSION: Three months active therapy is not sufficient to reverse the typical "glycolytic" profile of the muscles of cLBP patients or to effect major changes in backmuscle size. The alterations in muscle performance observed (increased strength and endurance; Part 1) werenot explainable on the basis of structural changes within the muscle.

Mannion AF, Taimela S, Müntener M, Dvorak J. · Schulthess Klinik Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #11317112 No free full text.

Abstract: DESIGN: Randomized prospective study of the effects of three types of active therapy on back muscle function in chronic low back pain patients. OBJECTIVES: To quantify the effects of 3 months active therapy on strength, endurance, activation, and fatigability of the back entensor muscles. SUMMARY OF BACKGROUND DATA: Many studies have documented an association between chronic low back pain and diminished muscular performance capacity. Few studies have quantified the changes in these measures following interventions using objective measurement techniques or related them to changes in clinical outcome. METHODS: A total of 148 individuals (57% women) with chronic low back pain (age, 45.0 +/- 10.0 years; duration of low back pain, 10.9 +/- 9.5 years) were randomized to a treatment that they attended for 3 months: active physiotherapy, muscle reconditioning on devices, or low-impact aerobics. Before and after therapy, assessments were made of the following: trunk muscle strength (in flexion, extension, lateral bending, and axial rotation), erector spinae activation (maximal, and during forward bending movements), back extensor endurance (Biering-Sørensen test), and erector spinae fatigability (determined from changes in the median frequency of the surface electromyographic signal) during isometric and dynamic tests. RESULTS: A total of 132 of 148 patients (89%) completed the therapy. Isometric strength in each movement direction increased in all groups post-therapy (P < 0.0008), most notably in the devices group. Activation of the erector spinae during the extension tests also increased significantly in all groups and showed a weak, but significant, relationship with increased maximal strength (P = 0.01). Pretherapy 55% of the subjects showed no relaxation of the back muscles at L5 when in the fully flexed position; no changes were observed in any group post-therapy. Endurance time during the Biering-Sørensen test increased significantly post-therapy in all groups (P = 0.0001), but there were no significant changes in EMG-determined fatigability. Fatigability of the lumbar muscles at L5 (EMG median frequency changes) during the dynamic test increased post-therapy (P = 0.0001) without group differences. CONCLUSION: Significant changes in muscle performance were observed in all three active therapy groups post-therapy, which appeared to be mainly due to changes in neural activation of the lumbar muscles and psychological changes concerning, for example, motivation or pain tolerance.

Mannion AF, Müntener M, Taimela S, Dvorak J. · Schulthess Clinic, Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #10626305 No free full text.

Abstract: STUDY DESIGN: A randomized clinical trial. OBJECTIVES: To examine the relative efficacy of three active therapies for chronic low back pain. SUMMARY OF BACKGROUND DATA: There is much evidence documenting the efficacy of exercise in the conservative management of chronic low back pain, but many questions remain regarding its exact prescription and method of application. The most successful method must be identified to enable refinement of future rehabilitation programs to target the specific needs of the patient with chronic low back pain and the budget of the healthcare provider. METHODS: One hundred forty-eight patients with chronic low back pain were randomized to one of the following treatments, which they attended twice a week for 3 months: 1) modern active physiotherapy, 2) muscle reconditioning on training devices, or 3) low-impact aerobics. Pretherapy and posttherapy, objective measurements of lumbar mobility were performed, and questionnaires were administered inquiring about self-rated pain and disability, and psychosocial factors. Similar questionnaires were administered 6 months after therapy. The data were analyzed using the intention-to-treat principle. RESULTS: Of the 148 patients, 16 (10.8%) dropped out of the therapy. One hundred thirty-seven questionnaires (93%) were available for analysis at all three time points. After therapy, significant reductions were observed in pain intensity, frequency, and disability; Fear-Avoidance Beliefs about physical activity (FABQactivity); and "praying/hoping," "catastrophizing," and "pain behavior" coping strategies--each with no group differences in the extent of the response. These effects were maintained over the subsequent 6 months, with the exception of disability and FABQactivity for the physiotherapy group. There were small but significant posttherapy increases in lumbar mobility, with aerobics and devices showing a greater response than physiotherapy. CONCLUSION: The general lack of treatment specificity suggests that the main effects of the therapies were educed not through the reversal of physical weaknesses targeted by the corresponding exercise modality, but rather through some "central" effect, perhaps involving an adjustment of perception in relation to pain and disability. The direct costs associated with administering physiotherapy were three times as great, and devices four times as great, as those for aerobics. Administration of aerobics as an efficacious therapy for chronic low back pain has the potential to relieve some of the huge financial burden associated with the condition.

Meyer K, Tschopp A, Sprott H, Mannion AF. · Department of Rheumatology and Institute of Physical Medicine, University Hospital Zurich, Zurich, Switzerland. · J Rehabil Med. · Pubmed #19565155 No free full text.

Abstract: BACKGROUND: Catastrophizing plays an important role in models of pain chronicity, showing a consistent correlation with both pain intensity and disability. It is conceivable that these associations are mediated or confounded by other psychological attributes. OBJECTIVE: To examine the relative influence of catastrophizing and other psychological variables on pain and disability in patients with chronic low back pain. METHODS: Seventy-eight patients completed the Pain Catastrophizing Scale, Roland Morris Disability Questionnaire, Fear-Avoidance Beliefs Questionnaire (work/activity), Modified Somatic Perception Questionnaire, Modified Zung Depression Scale, and Pain Intensity scale. RESULTS: Catastrophizing was significantly correlated with both Pain intensity and Roland and Morris Disability, and with all other psychological variables (all p < 0.001). However, multiple regression analyses showed that Catastrophizing explained no significant variance in Pain intensity beyond that explained by the unique contributions of Modified Somatic Perception and Fear-Avoidance Beliefs (work) and explained no further variance in Disability beyond that explained by the unique contributions of Fear-Avoidance Beliefs (work) and Depression. CONCLUSION: These findings are consistent with previous models proposing that negative psychological attributes are associated with greater perceptions of pain and disability. Nonetheless, our study indicates that measures of catastrophizing show notable measurement overlap in multivariate models.

Mannion AF, Junge A, Elfering A, Dvorak J, Porchet F, Grob D. · Spine Center, Schulthess Klinik, Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #19521272 No free full text.

Abstract: STUDY DESIGN: Prospective study. OBJECTIVE: The present study compared different theories on the role of expectations in a group of patients undergoing lumbar decompression surgery. SUMMARY OF BACKGROUND DATA: Patients' expectations of treatment are a potentially important predictor of self-rated outcome after surgery. Some studies suggest that high baseline expectations per se yield better outcomes, others maintain that the fulfillment of prior expectations is paramount, and still others assert that it is the actual improvement in symptom status that governs outcome, regardless of prior expectations. METHODS: Hundred patients took part (33 F, 67 M; mean [SD] age, 65 [11] yrs). Before surgery, they completed a booklet containing the Roland-Morris (RM) disability questionnaire, 0-10 pain graphic rating scales (back and leg separately), and Likert-scales about the degree of improvement expected in various domains. Two and 12 months after surgery, questions were answered regarding the perceived improvement for each of these domains, the RM and pain scales were completed again, and the patients rated the global outcome on a 5-point Likert-scale. RESULTS: Compared with the actual improvement recorded at 12 months, prior expectations had been overly optimistic in about 40% patients for the domains leg pain, back pain, walking capacity, social life, mental well-being, and independence, and in 50% patients for everyday activities and sport. There was no significant relationship between baseline expectations and follow-up scores for back pain, leg pain, RM-disability (corrected for baseline values), or global outcome. Hierarchical multiple regression analysis revealed that "expectations being fulfilled" was the most significant predictor of global outcome. CONCLUSION: In this patient group, expectations of surgery were overly optimistic. Having one's expectations fulfilled was most important for a good outcome. The results emphasize the importance of assessing patient-orientated outcome in routine practice, and the factors that might influence it, such that realistic expectations can be established for patients before surgery.

Kleinstück FS, Grob D, Lattig F, Bartanusz V, Porchet F, Jeszenszky D, O'Riordan D, Mannion AF. · Spine Center, Schulthess Klinik, Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #19407677 No free full text.

Abstract: STUDY DESIGN: Prospective study with 12-month follow-up. OBJECTIVE: To examine how the relative severity of low back pain (LBP) to leg/buttock pain (LP) influences the outcome of decompression surgery for spinal stenosis. SUMMARY OF BACKGROUND DATA: Decompression surgery is a common treatment for lumbar spinal canal stenosis, with generally good outcome. However, concomitant LBP at presentation can make it difficult to decide whether decompression alone will result in a good overall outcome. METHODS: The Spine Society of Europe Spine Tango system was used to acquire the data from 221 patients. Inclusion criteria were lumbar degenerative spinal stenosis, first-time surgery, maximum 3 affected levels, and decompression as the only procedure. Before and 12 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; includes 0-10 LP and LBP scales); at 12 months, global outcome was rated on a Likert-scale and dichotomized into "good" and "poor" groups. RESULTS: There was a low but significant positive correlation between baseline LP-minus-LBP scores and both improvement in the multidimensional COMI score after 12 months (r = 0.21, P = 0.003) and the score on the 12-month global outcome scale (r = 0.19, P = 0.007). In the good outcome group, mean baseline LP was 2.3 (+/-3.7) points higher than LBP; in the poor group, the corresponding value was 0.8 (+/-3.4) (P = 0.01 between groups). In multivariate regression analyses (controlling for age, gender, comorbidity), baseline LBP intensity was the most significant predictor of the 12-month COMI score, and preoperative LP-minus-LBP score of the global outcome (each P < 0.05). CONCLUSION: Overall, greater back pain relative to LP at baseline was associated with a significantly worse outcome after decompression. This finding seems intuitive, but has rarely been quantified in the many predictor studies conducted to date. Consideration of relative LBP and LP scores may assist in clinical decision-making and in establishing realistic patient expectations.

Mannion AF, Pulkovski N, Toma V, Sprott H. · Spine Center Division, Department of Research and Development, Schulthess Klinik, Zurich, Switzerland. · J Anat. · Pubmed #19172732 No free full text.

Abstract: The symmetry of, and physical characteristics influencing, the thickness of the lateral abdominal muscles at rest and during abdominal exercises were examined in 57 healthy subjects (20 men, 37 women; aged 22-62 years). M-mode ultrasound images were recorded from the abdominal muscles at rest and during abdominal hollowing exercises in hook-lying. The fascial lines bordering the transvs. abdominis, obliquus internus and obliquus externus were digitized and the absolute thickness, relative thickness (% of total lateral thickness) and contraction ratio (thickness during hollowing/thickness at rest), as well as the asymmetry (difference between sides expressed as a percent of the smallest value for the two sides) for each of these parameters were determined for each muscle. Both at rest and during hollowing, obliquus internus was the thickest and transvs. abdominis the thinnest muscle. There were no significant differences between left and right sides for group mean thicknesses of any muscle; however, individual asymmetries were evident, with mean values for the different muscles ranging from 11% to 26%; asymmetry was much less for the contraction ratios (mean % side differences, 5-14% depending on muscle). Body mass was the most significant positive predictor of absolute muscle thickness, for all muscles at rest and during hollowing, accounting for 30-44% variance. Body mass index explained 20-30% variance in transvs. abdominis contraction ratio (negative relationship). The influence of these confounders must be considered in comparative studies of healthy controls and back pain patients, unless groups are very carefully matched. Asymmetries observed in patients should be interpreted with caution, as they are also common in healthy subjects.

Meyer K, Sprott H, Mannion AF. · Department of Rheumatology and Institute of Physical Medicine, Gloriastr. 25, University Hospital, Zürich, Switzerland. · J Psychosom Res. · Pubmed #18440399 No free full text.

Abstract: OBJECTIVE: In patients with chronic pain, catastrophizing is a significant determinant of self-rated pain intensity and disability. The Pain Catastrophizing Scale (PCS) was developed to assist with both treatment planning and outcome assessment; to date, no German version has been validated. METHODS: A cross-cultural adaptation of the PCS into German was carried out, strictly according to recommended methods. A questionnaire booklet containing the PCS, visual analogue scales (numeric rating scale) for pain intensity and general health, the ZUNG self-rating depression scale, the Modified Somatic Perception Questionnaire (MSPQ), the Fear Avoidance Beliefs Questionnaire (FABQ), and the Roland-Morris (RM) disability questionnaire was completed by 111 patients with chronic low back pain (mean age, 49 years), 100 of which also completed it again 7 days later. RESULTS: Cronbach's alpha (internal reliability) for the three subsections of the PCS--helplessness, magnification, rumination--and for the whole questionnaire (PCSwhole) were .89, .67, .88, and .92, respectively. The intraclass correlation coefficients of agreement for the reproducibility were .81, .67, .78, and .80, respectively. The PCSwhole scores correlated with the other scores as follows: pain intensity r=.26, general health r=-.29, ZUNG r=.52, MSPQ r=.53, FABQactivity r=.51, FABQwork r=.61 and RM r=.57. Factor analysis revealed three factors, with an almost identical factor structure to that reported in previous studies. CONCLUSION: The psychometric properties of our German version of the PCS were comparable to those reported in previous studies for the original English version. It represents a valuable tool in the assessment of German-speaking chronic low back pain patients.

Bremerich FH, Grob D, Dvorak J, Mannion AF. · Spine Center, Schulthess Klinik, Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #18427324 No free full text.

Abstract: STUDY DESIGN: Cross-cultural adaptation of an outcome questionnaire. OBJECTIVE: The aim of the study was to cross-culturally adapt the Neck Pain and Disability Scale (NPAD) for the German language, and to assess its psychometric qualities. SUMMARY OF BACKGROUND DATA: Neck pain and its associated disability represent an extremely common musculoskeletal problem. Reliable and valid questionnaires for its assessment are available in English, but no German versions of these exist. METHODS: The English version of the NPAD was translated into German (NPAD-D) and back-translated according to established guidelines. Twenty-three patients with chronic neck pain completed the NPAD-D twice over 1 to 2 weeks, to assess its test-retest reliability. A further 80 patients [40% male, mean (SD) 54 (18) years] completed the questionnaire and underwent a clinical follow-up examination, 1 to 14 years after C1-C2 fusion. These patients also documented their satisfaction with the surgery. RESULTS: Cronbach's alpha values (internal consistency) for the NPAD-D whole scale and for the NPAD-D subscales pain, disability, and neck-specific function were 0.97, 0.95, 0.97, and 0.87, respectively. The ICC for the test-retest reliability of the NPAD-D was excellent (0.97) and the SEM was relatively low (3.8), giving a "minimal detectable difference" for the scale of 10.5 (scale range is 0-100). The range of motion in rotation, assessed during the clinical examination, correlated significantly with the scores on NPAD-D item 16 (stiffness of neck) (Rho = -0.52, P < 0.0001) and item 17 (trouble turning neck) (Rho = -0.59, P < 0.0001). Range of motion in flexion-extension correlated significantly with the scores on item 18 (trouble looking up and down) (Rho = -0.60, P < 0.0001) and item 19 (trouble working overhead) (Rho = -0.45, P < 0.0001). The NPAD-D scores differed significantly between patients who were satisfied with the result of their operation and those who were not [mean values 36.4 (SD 24.3) and 58.1 (SD 27.4), respectively; P = 0.008]. CONCLUSION: The NPAD-D is a reliable and valid patient-orientated instrument for use in future studies of neck pain and disability in German speaking patients.

Mannion AF, Pulkovski N, Gubler D, Gorelick M, O'Riordan D, Loupas T, Schenk P, Gerber H, Sprott H. · Spine Center Division, Department of Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland. · Eur Spine J. · Pubmed #18196294 links to  free full text

Abstract: Spine stabilization exercises, in which patients are taught to perform isolated contractions of the transverses abdominus (TrA) during "abdominal hollowing", are a popular physiotherapeutic treatment for low back pain (LBP). Successful performance is typically judged by the relative increase in TrA thickness compared with that of the internal (OI) and external (OE) oblique muscles, measured using ultrasound. The day-to-day measurement error (imprecision) associated with these indices of preferential activation has not been assessed but is important to know since it influences the interpretation of changes after treatment. On 2 separate days, 14 controls and 14 patients with chronic LBP (cLBP) performed abdominal hollowing exercises in hook-lying, while M-mode ultrasound images superimposed with tissue Doppler imaging (TDI) data were recorded from the abdominal muscles (N = 5 on each side). The fascial lines bordering the TrA, OI and OE were digitized, and muscle thicknesses were calculated. The between-day error (intra-observer) was expressed as the standard error of measurement, SEM; SEM as a percentage of the mean gave the coefficient of variation (CV). There were no significant between-day differences for the mean values of resting or maximal thickness for any muscle, in either group (P > 0.05). The median SEM and CV of all thickness variables was 0.71 mm and 10.9%, respectively for the controls and 0.80 mm or 11.3%, respectively for the cLBP patients. For the contraction ratios (muscle thickness contracted/thickness at rest), the CVs were 3-11% (controls) and 5-12% (patients). The CVs were unacceptably high (30-50%, both groups) for the TrA preferential activation ratio (TrA proportion of the total lateral abdominal muscle thickness when contracted minus at rest). In both the controls and patients, the precision of measurement of absolute muscle thickness and relative change in thickness during abdominal hollowing was acceptable, and commensurate with that typical of biological measurements. The TrA preferential activation ratio is too imprecise to be of clinical use. Knowledge of the SEM for these indices is essential for interpreting the clinical relevance of any changes observed following physiotherapy.

Mannion AF, Pulkovski N, Schenk P, Hodges PW, Gerber H, Loupas T, Gorelick M, Sprott H. · Spine Center Division, Department of Research and Development, Schulthess Klinik, Zürich, Switzerland. · J Appl Physiol. · Pubmed #18187614 links to  free full text

Abstract: Rapid arm movements elicit anticipatory activation of the deep-lying abdominal muscles; this appears modified in back pain, but the invasive technique used for its assessment [fine-wire electromyography (EMG)] has precluded its widespread investigation. We examined whether tissue-velocity changes recorded with ultrasound (M-mode) tissue Doppler imaging (TDI) provided a viable noninvasive alternative. Fourteen healthy subjects rapidly flexed, extended, and abducted the shoulder; recordings were made of medial deltoid (MD) surface EMG and of fine-wire EMG and TDI tissue-velocity changes of the contralateral transversus abdominis, obliquus internus, and obliquus externus. Muscle onsets were determined by blinded visual analysis of EMG and TDI data. TDI could not distinguish between the relative activation of the three muscles, so in subsequent analyses only the onset of the earliest abdominal muscle activity was used. The latter occurred <50 ms after the onset of medial deltoid EMG (i.e., was feedforward) and correlated with the corresponding EMG onsets (r = 0.47, P < 0.0001). The mean difference between methods was 20 ms and was likely explained by electromechanical delay; limits of agreement were wide (-40 to +80 ms) but no greater than those typical of repeated measurements using either technique. The between-day standard error of measurement of the TDI onsets (examined in 16 further subjects) was 16 ms. TDI yielded reliable and valid measures of the earliest onset of feedforward activity within the anterolateral abdominal muscle group. The method can be used to assess muscle dysfunction in large groups of back-pain patients and may also be suitable for the noninvasive analysis of other deep-lying or small/thin muscles.

Mannion AF, Denzler R, Dvorak J, Müntener M, Grob D. · Schulthess Klinik, Lengghalde 2, 8008 Zürich, Switzerland. · Eur Spine J. · Pubmed #17593405 links to  free full text

Abstract: Spinal decompression is the most common type of spinal surgery carried out in the older patient, and is being performed with increasing frequency. Physiotherapy (rehabilitation) is often prescribed after surgery, although its benefits compared with no formal rehabilitation have yet to be demonstrated in randomised control trials. The aim of this randomised controlled trial was to examine the effects on outcome up to 2 years after spinal decompression surgery of two types of postoperative physiotherapy compared with no postoperative therapy (self-management). Hundred and fifty-nine patients (100 men, 59 women; 65 +/- 11 years) undergoing decompression surgery for spinal stenosis/herniated disc were randomised to one of the following programmes beginning 2 months post-op: recommended to "keep active" (CONTROL; n = 54); physiotherapy, spine stabilisation exercises (PT-StabEx; n = 56); physiotherapy, mixed techniques (PT-Mixed; n = 49). Both PT programmes involved 2 x 30 min sessions/week for up to 12 weeks, with home exercises. Pain intensity (0-10 graphic rating scale, for back and leg pain separately) and self-rated disability (Roland Morris) were assessed before surgery, before and after the rehabilitation phase (approx. 2 and 5 months post-op), and at 12 and 24 months after the operation. 'Intention to treat' analyses were used. At 24 months, 151 patients returned questionnaires (effective return rate, excluding 4 deaths, 97%). Significant reductions in leg and back pain and self-rated disability were recorded after surgery (P < 0.05). Pain showed no further changes in any group up to 24 months later, whereas disability declined further during the "rehabilitation" phase (P < 0.05) then stabilised, but with no significant group differences. 12 weeks of post-operative physiotherapy did not influence the course of change in pain or disability up to 24 months after decompression surgery. Advising patients to keep active by carrying out the type of physical activities that they most enjoy appears to be just as good as administering a supervised rehabilitation program, and at no cost to the health-care provider.

Balagué F, Mannion AF, Pellisé F, Cedraschi C. · Department of Rheumatology, Physical Medicine and Rehabilitation, Cantonal Hospital, 1708 Fribourg, Switzerland. · Lancet. · Pubmed #17336636 No free full text.

This publication has no abstract.

Kleinstück F, Dvorak J, Mannion AF. · Spine Unit, Schulthess Klinik, Zürich, Switzerland. · Spine (Phila Pa 1976). · Pubmed #16946663 No free full text.

Abstract: STUDY DESIGN: Prospective study. OBJECTIVE: To examine the association between structural abnormalities recorded on magnetic resonance imaging (MRI) and outcome after evidence-based conservative treatment in patients with chronic nonspecific low back pain (LBP). SUMMARY OF BACKGROUND DATA: In most guidelines for the management of LBP, MRI is not recommended unless the diagnostic triage suggests serious spinal pathology or nerve root involvement for which surgical treatment is foreseen. This is because many structural changes seen on MRI appear to be as common in asymptomatic individuals as in people with LBP and are, therefore, considered of little value in either explaining the cause of pain or deciding the subsequent course of management. However, to our knowledge, no studies have assessed whether the presence of such MRI abnormalities influences the outcome of the conservative treatment that patients with chronic nonspecific LBP typically receive. METHODS: T2-weighted, 4-mm spin-echo MRI sequences of the lumbar spine were obtained from 53 patients with chronic nonspecific LBP before a 3-month program of exercise therapy. Disc degeneration, disc bulging, high intensity zones, and endplate/bone marrow changes were assessed for each lumbar segment. Back pain (average and worst) and disability (Roland Morris score) were assessed before and after therapy, and 12 months later, and the improvements were examined in relation to the presence or absence of baseline MRI "abnormalities." RESULTS: Eighty-nine percent of patients had severe disc degeneration (grade 4 or 5), 74% had disc bulging, 60% had high intensity zones, and 62% had endplate/bone marrow changes in at least 1 lumbar segment. Only 11% patients had none of these changes at any level. The MRI abnormalities showed only minimal association with baseline symptoms. In multivariate regression analyses, in which age, gender, and baseline symptoms were controlled for, only 1 significant association between the MRI variables and outcome was observed: the presence of a high intensity zone in any vertebral segment was associated with lower average pain at the 12-month follow-up (standardized beta -0.376, P = 0.006, 16.5% variance accounted for). CONCLUSION: In the patient group examined, the presence of common "structural abnormalities" on MRI had no significant negative influence on the outcome after therapy.

Mannion AF, Elfering A, Staerkle R, Junge A, Grob D, Semmer NK, Jacobshagen N, Dvorak J, Boos N. · Spine Unit, Schulthess Klinik, Lengghalde 2, 8008, Zürich, Switzerland. · Eur Spine J. · Pubmed #15937673 No free full text.

Abstract: The present study examined the psychometric characteristics of a "core-set" of six individual questions (on pain, function, symptom-specific well-being, work disability, social disability and satisfaction) for use in low back pain (LBP) outcome assessment. A questionnaire booklet was administered to 277 German-speaking LBP patients with a range of common diagnoses, before and 6 months after surgical (N=187) or conservative (N=90) treatment. The core-set items were embedded in the booklet alongside validated 'reference' questionnaires: Likert scales for back/leg pain; Roland and Morris disability scale; WHO Quality of Life scale; Psychological General Well-Being Index. A further 45 patients with chronic LBP completed the booklet twice in 1-2 weeks. The minimal reliability (similar to Cronbach's alpha) for each core item was 0.42-0.78, increasing to 0.84 for a composite index score comprising all items plus an additional question on general well-being ('quality of life'). Floor or ceiling effects of 20-50% were observed for some items before surgery (function, symptom-specific well-being) and some items after it (disability, function). The intraclass correlation coefficient (ICC) ("test-retest reliability") was moderate to excellent (ICC, 0.67-0.95) for the individual core items and excellent (ICC, 0.91) for the composite index score. With the exception of "symptom-specific well-being", the correlations between each core item and its corresponding reference questionnaire ("validity") were between 0.61 and 0.79. Both the composite index and the individual items differentiated (P<0.001) between the severity of the back problem in surgical and conservative patients (validity). The composite index score had an effect size (sensitivity to change) of 0.95, which was larger than most of the reference questionnaires (0.47-1.01); for individual core items, the effect sizes were 0.52-0.87. The core items provide a simple, practical, reliable, valid and sensitive assessment of outcome in LBP patients. We recommend the widespread and consistent use of the core-set items and their composite score index to promote standardisation of outcome measurements in clinical trials, multicentre studies, routine quality management and surgical registry systems.

Mannion AF, Junge A, Fairbank JC, Dvorak J, Grob D. · Schulthess Klinik, Lengghalde 2, 8008, Zürich, Switzerland. · Eur Spine J. · Pubmed #15856341 No free full text.

Abstract: Patient-orientated assessment methods are of paramount importance in the evaluation of treatment outcome. The Oswestry Disability Index (ODI) is one of the condition-specific questionnaires recommended for use with back pain patients. To date, no German version has been published in the peer-reviewed literature. A cross-cultural adaptation of the ODI for the German language was carried out, according to established guidelines. One hundred patients with chronic low-back pain (35 conservative, 65 surgical) completed a questionnaire booklet containing the newly translated ODI, along with a 0-10 pain visual analogue scale (VAS), the Roland Morris Disability Questionnaire, and Likert scales for disability, medication intake and pain frequency [to assess ODI's construct (convergent) validity]. Thirty-nine of these patients completed a second questionnaire within 2 weeks (to assess test-retest reliability). The intraclass correlation coefficient for the test-retest reliability of the questionnaire was 0.96. In test-retest, 74% of the individual questions were answered identically, and 21% just one grade higher or lower. The standard error of measurement (SEM) was 3.4, giving a "minimum detectable change" (MDC(95%)) for the ODI of approximately 9 points, i.e. the minimum change in an individual's score required to be considered "real change" (with 95% confidence) over and above measurement error. The ODI scores correlated with VAS pain intensity (r = 0.78, P < 0.001) and Roland Morris scores (r = 0.80, P < 0.001). The mean baseline ODI scores differed significantly between the surgical and conservative patients (P < 0.001), and between the different categories of the Likert scales for disability, medication use and pain frequency (in each case P < 0.001). Our German version of the Oswestry questionnaire is reliable and valid, and shows psychometric characteristics as good as, if not better than, the original English version. It should represent a valuable tool for use in future patient-orientated outcome studies in German-speaking lands.