摘要:

Study Design.A systematic review of prospective cohort studies in low back pain.Objectives.To evaluate the evidence implicating psychological factors in the development of chronicity in low back pain.Summary of Background Data.The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions; however, to date, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed.Methods.A systematic literature search was followed by the application of three sets of criteria to each study: methodologic quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care settings, pain clinics, and workplace.Results.Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement, and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from psychological distress/depressive mood and, to a lesser extent, somatization emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophizing as a coping strategy.Conclusion.Psychological factors (notably distress, depressive mood, and somatization) are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors (particularly coping strategies and fear avoidance) there is a need to clarify their role in back-related disability through rigorous prospective studies.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.Description of a workshop entitled “Implementation and Dissemination: Getting Research into Practice,” that was held at the Fourth International Forum on Low Back Pain Research in Primary Care, in Israel in March 2000.Summary of Background Data.A gap exists between research endeavors and the dissemination and implementation of new research findings.Objectives.To describe the outcomes of a workshop on implementation and dissemination of research findings.Methods.The Fourth International Forum on Low Back Pain Research in Primary Care aimed to encourage open discussion and consensus building among leading experts in the field, and to develop a research agenda. The workshop on implementation and dissemination focused on issues surrounding the gap between research results and actual practice. These issues were introduced by several presentations. The broad conclusions of the subsequent debate are summarized in this paper as a series of responses to key questions: 1) who should do the implementation?, 2) what should researchers do to help implementation?, 3) what are the key outcomes?, and 4) what are important ingredients for successful implementation?Results.There was consensus about the importance of implementation of research findings, about the ineffectiveness of merely publishing or disseminating research findings, and about the need for prospective randomized trials evaluating the cost-effectiveness of different implementation strategies. The majority view is that the health provider professions and the professional bodies are the central organizations to implement guidelines, rather than the researchers themselves. Success in getting guidelines or research results into practice is dependent on involving local health service groups, experts, and opinion leaders (both local and national). Patient-centered outcomes and cost-effectiveness of guideline implementation were considered important. It was acknowledged that there are many potentially effective ingredients for successful implementation, but a clear indication of the contents of an effective implementation strategy is still lacking.Conclusions.The plenary and workshops focused on closing the gap between research results and actual practice. As long as we do not fully understand how best to influence and change physician behavior, the choice of implementation strategies should be based on the present knowledge of potentially effective interventions and should include considerations of available resources for, and potential barriers to, implementation.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.Review of advances in the primary care research on low back pain (LBP) from a unique international forum, and analysis of open-ended questionnaires from participants.Summary of Background Data.LBP continues to be one of the most common and challenging problems in primary care. It is associated with enormous costs in terms of direct health care expenditures, and indirect work and disability-related losses.Objective.To ascertain the current status and state of the art regarding LBP in primary care.Methods.Four reviewers independently assessed the content and implications of presentations at the Fourth International Forum for Primary Care Research on LBP, pooled the data, and then augmented it with open-ended questionnaires completed by 35 participants.Results.The Fourth Forum documented the field’s emergent new paradigm–a transition from thinking about back pain as a biomedical “injury” to viewing LBP as a multifactorial biopsychosocial pain syndrome. The paradigm shift has occurred in the context of increased interest in evidence-based medicine regarding LBP in primary care. The Forum demonstrated the strides taken in moving from research and evidence gathering, through guidelines and policy formulations and finally to the dissemination and implementation imperative. There was an increasing confidence among the Forum researchers that LBP can be managed successfully in primary care settings through a combination of encouraging activity, reassurance, short-term symptom control, and alteration of inappropriate beliefs about the correlations of back pain with impairment and disability. There is also recognition that a wide range of international, evidence-based guidelines now exists that have very similar messages.Conclusions.The Fourth Forum reflected a major shift in the conceptualization of LBP in primary care and an increased emphasis on implementation and dissemination of LBP research findings and clinical guidelines. Although there is a wide array of challenges ahead, the Fourth Forum provided a clear message regarding the need to focus research energies on changing practitioner behavior.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.An amalgamated review of the current state of knowledge about psychosocial factors in low back pain (LBP), as presented at the plenary session at the Fourth International Forum on LBP Research in Primary Care (March 16–18, 2000, Israel).Objectives.To outline evidence-based theories that have lead to the identification of yellow flags (psychosocial risk factors for developing long-term disability) for nonspecific LBP. To discuss the role of clinicians in primary care in detecting and addressing these psychosocial factors and to outline future directions for research to clarify this role.Summary of Background Data.It is widely accepted that psychological and social factors play an important role in LBP; however, it is currently unclear which specific factors merit intervention to reduce the burden of disease.Method.The review is an integration based on the plenary session presented at the Fourth International Forum on LBP Research in Primary Care. The presentations included original research studies, a systematic review, and theoretical descriptions of models of risk and treatment.Results.There is good evidence to support the role of psychological risk factors at early stages of LBP in the development of long-term disability. There are evidence-based theories and models that provide directions for future interventions.Conclusion.In the treatment of psychological factors, the role of clinicians in primary care remains unclear. Further evidence is needed to identify specific psychological risk factors, primary care tools for their identification need developing, and interventions at different stages of LBP by different professionals need to be tested.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.For a single L5 radicular lesion produced by constant, localized compression, sequential changes of epidurally recorded potentials after sciatic nerve stimulation or direct L5 root stimulation were compared with those after indirect L5 root stimulation with a collision technique in rats.Objective.To determine whether the use of the collision technique improves the diagnostic yield of the lumbosacral-evoked potential study for a single radicular lesion.Summary of Background Data.Clinical recording of the evoked potentials at serial intervertebral spaces after stimulation of the peroneal or the tibial nerve was less sensitive than what might be expected for a single radicular lesion, presumably because peripheral nerve stimulation activates more than a nerve root, thereby normal responses arising from the unaffected roots tending to mask mild conduction abnormalities of the diseased root. Furthermore, direct stimulation of the nerve root with a monopolar electrode, despite potential advantages, produces an overloading stimulus artifact. This precludes accurate recording because of the short distance between the stimulus and recording sites. A collision technique should circumvent these problems.Methods.A vascular clip was applied to the L5 root and evoked potentials were recorded epidurally at T10–11 after sciatic nerve stimulation (Group 1, 11 rats), L5 root stimulation (Group 2, 14 rats), or a combination of L6 root and sciatic nerve stimulation (Group 3, 11 rats), at 3-minute intervals during a 15-minute period of compression and additionally 15 minutes after release of the compression.Results.The N1 potential significantly decreased in amplitude immediately after L5 root compression and then decreased slightly but progressively in all three groups. Throughout the recording, the N1 peak amplitude, shown as a percentage relative to the baseline value, was significantly smaller in Groups 2 and 3 than in Group 1, whereas there was no significant difference between Groups 2 and 3. The removal of the compression caused a significant recovery of the N1 peak amplitude in Groups 2 and 3, but not in Group 1.Conclusion.The present animal experiment demonstrated that the collision technique improved the sensitivity of the lumbosacral-evoked potential for a single radicular lesion. With this technique, the evoked potential study in the clinical domain will identify conduction abnormalities more consistently than peripheral nerve stimulation alone.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.A prospective, randomized, double-blinded clinical trial was conducted.Objective.To study the efficacy of piroxicam fast-dissolving dosage form in reducing postoperative pain after simple lumbar spine surgery.Summary of Background Data.Many reports mention the use of nonsteroidal antiinflammatory drug for relieving postoperative pain, but study still is lacking on their use in spine surgery.Methods.For this study, 50 patients who underwent discectomy or one-level laminectomy were randomly sampled into two groups: 21 patients in the placebo control group and 29 patients in the study group. In addition to a normal postoperative analgesic regimen, each patient received placebo or piroxicam fast-dissolving dosage form (2 tablets administered sublingually 1 to 3 hours before surgery). This regimen was repeated with 2 tablets after 24 hours, then 1 tablet after 48 hours. Postoperative pain was evaluated every 6 hours by a visual analog scale for 3 days. The amount of morphine usage was measured on postoperative days 1, 2, and 3. Postoperative variables such as blood loss, length of wound, and time of operation also were recorded.Results.There was no difference between the groups with respect to age, weight, height, gender, and type of operation. The postoperative pain of the study group, as measured by visual analog scale, showed significant improvement (P< 0.05) during the postoperative period 12 to 42 hours after surgery. The study group used less morphine, but their usage showed no significant difference on postoperative days 1, 2, and 3. When the visual analog scale between the types of operation was compared, the scale for the discectomy group was better than that for the laminectomy group. The results of the postoperative variables showed no difference between the groups in terms of postoperative blood loss, length of wound, and time of operation.Conclusions.Sublingual administration of piroxicam fast-dissolving dosage form after simple spine surgery is effective and efficient in relief of postoperative pain. Because of its low side effects and high toleration, piroxicam fast-dissolving dosage form may be considered as an alternative for postoperative pain control during the early postoperative period.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.A morphometric study of lumbar vertebral pedicular parameters in cadavers and comparison with previous studies in the literature was conducted.Objectives.To suggest dimensions for pedicular implants in the Indian population, and to improve the pedicular screw placement technique.Summary of Background Data.Detailed knowledge of pedicle morphometry is critical for proper placement of a transpedicular screw. The size and shape of the vertebral pedicle vary between different races. Morphometric studies have been conducted in white and nonwhite populations (e.g., Chinese, Koreans).Methods.The vertebral pedicles at L1–L5 were studied in 20 cadavers by direct roentgenographic and computerized tomographic scan methods. The following parameters were studied: transverse diameter, transverse angle, sagittal diameter, sagittal angle, chord length, interpedicular distance, medial and lateral cortical thickness.Results.Transverse diameter was largest at L5 (16.19 mm) and smallest at L1 (7.05 mm). The transverse angle was largest at L5 (29°) and smallest at L1 (9°). The pedicles were directed cranially in the sagittal plane at all lumber levels except L5. The sagittal angle was largest at L5 (29°) and smallest at L1 (9°). Chord length was largest at L2 (47.5 mm) and smallest at L1 (46.01 mm). The values of linear measurements were smaller in females at all levels.Conclusions.On the basis of this limited study in a subset of the Indian population, it appears that the transverse diameter and pedicle entrance point differ from those in the white population. The results suggest that a 5-mm screw would be safer in the upper lumbar levels (L1, L2), and 6-mm screw in the lower lumbar levels (L3–L5). The pedicle entrance point migrates laterally for lower lumbar levels, especially at L5. The medial pedicle cortex can be safely sounded while the pedicle is probed.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.An experimental study of cardiovascular complications that arise during vertebroplasty was conducted.Objective.To investigate the sequential occurrence of fat embolism and hypotension during vertebroplasty.Summary of Background Data.Vertebroplasty, the augmentation of vertebrae with polymethylmethacrylate, is a technique for treating osteoporotic compression fractures and achieving prophylactic stabilization of osteoporotic vertebral bodies at risk of fracture. However, there is concern that fat embolism and acute hypotension could occur as in a variety of other orthopedic procedures.Methods.In six sheep, 6 mL of polymethylmethacrylate was injected unilaterally into L1. Transesophageal echocardiography monitored the pulmonary artery for echodense particles. Heart rate, arterial and venous pressures, and blood gas values were recorded before and for 25 minutes after injection. The lungs were subjected to postmortem histologic evaluation and compared with lung specimens from two sheep that had not undergone vertebroplasty.Results.Injection of cement elicited a very rapid decrease in heart rate (within 2 ± 1 seconds) and a rapid increase in venous pressure (within 3 ± 1 seconds), which was followed by a fall in arterial pressure (within 5 ± 2 seconds) (phase 1). Thereafter, showers of echogenic material appeared (within 6 ± 1 seconds) and lasted for 138 ± 36 seconds. A second more severe fall in arterial pressure was observed beginning at 18 ± 2 seconds (phase 2). The injection resulted in an increase in partial pressure of carbon dioxide and a decrease in pH. The histology showed intravascular fat globules and bone marrow cells in lung tissue.Conclusions.The results suggest that immediately after cement injection, there was a reflex fall in heart rate and arterial pressure. The second fall in arterial pressure was a consequence of fat emboli passing through the heart and getting trapped in the lungs.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

Study Design.A rabbit posterolateral intertransverse process fusion model was used to evaluate the effect that different doses of recombinant human bone morphogenetic protein-4 delivered in a porous hydroxyapatite–tricalcium phosphate ceramic had on osteogenesis and spinal fusion.Objective.To study the biologic effect and threshold dose of recombinant human bone morphogenetic protein-4 in enhancing spinal fusion.Summary of Background Data.Biologic manipulation for spinal fusion is an area undergoing active research. The enhancing effects of recombinant human bone morphogenetic proteins 2 and 7 on spinal fusion have been proved, and clinical trials of their application are in progress. Recombinant human bone morphogenetic protein-4 is another osteoinductive protein that has the ability to induce heterotopic bone formation, and its potential for enhancing spinal fusion has not yet been studied.Methods.For this study, 24 adult New Zealand white rabbits underwent single-level unilateral posterior intertransverse process spinal fusion at L5–L6. The animals were divided into four groups using different graft materials: allograft as well as hydroxyapatite–tricalcium phosphate augmented with 0, 1.25, and 5 &mgr;g of recombinant human bone morphogenetic protein-4, respectively. The local changes were evaluated by sequential radiograph, manual palpation, histomorphology, and microradiography.Results.At week 7, ossification in the intertransverse process area ceased in groups without recombinant human bone morphogenetic protein-4, whereas active multicentric endochondral bone formation was demonstrated in groups with this growth factor. The success rate of contiguous bony bridging was found to correlate positively with the dose of recombinant human bone morphogenetic protein-4.Conclusions.Recombinant human bone morphogenetic protein-4 effectively enhances new bone formation and accelerates fusion in the rabbit posterolateral posterior spinal fusion model. The effective dose of recombinant human bone morphogenetic protein-4 is 10 times lower than the reported dosage of recombinant human bone morphogenetic proteins 2 and 7.

ISSN:0362-2436    

出版商:OVID    

年代:2002

数据来源: OVID