요추부 불안정성을 가진 요통환자에게 요부안정화운동과 신경가동술의 치료적 효과

Degenerative spondylolisthesis (DS) is a disorder that causes the slip of one vertebral body over the one below due to degenerative changes in the spine. Lumbar DS is a major cause of spinal canal stenosis and is often related to low back and leg pain. We reviewed the symptoms, prognosis and conservative treatments for symptoms associated with DS. PubMed and MEDLINE databases (1950-2007) were searched for the key words "spondylolisthesis", "pseudospondylolisthesis", "degenerative spondylolisthesis", "spinal stenosis", "lumbar spine", "antherolisthesis", "posterolisthesis", "low back pain", and "lumbar instability". All relevant articles in English were reviewed. Pertinent secondary references were also retrieved. The prognosis of patients with DS is favorable, however, those who suffer from neurological symptoms such as intermittent claudication or vesicorectal disorder, will most probably experience neurological deterioration if they are not operated upon. Nonoperative treatment should be the initial course of action in most cases of DS, with or without neurologic symptoms. Treatment options include use of analgesics and NSAIDs to control pain; epidural steroid injections, and physical methods such as bracing and flexion strengthening exercises. An up-to-date knowledge on diagnosis and prevention of lumbar DS can assist in determination of future research goals. Additional studies are required to establish treatment protocols for the conservative treatment of DS.

본 연구는 만성요통환자에서 PNF 기법을 이용한 요부안정화 운동이 요부 심부근의 두께 변화와 기능적 활동에 미치는 효과를 알아보고자 하였다. 연구대상은 만성 요통환자 30명을 대상으로 하였으며, 실험군을 세군으로 10명씩 무작위 할당하였다; 실험군I은 일반물리치료군(n=10), 실험군II는 일반 요부안정화운동군(n=10), 실험군III은 PNF 기법을 이용한 요부안정화운동군(n=10)으로 나누었다. VAS를 사용하여 통증 변화를 측정하였고, 초음파 장비를 사용하여 4주간의 각 운동에 따른 요부 심부근들(복횡근, 외복사근, 다열근)의 근 두께 변화를 알아보았고, ODQ, RMDQ를 사용하여 기능적 활동 수준 변화를 알아보았다. 그 결과, 실험 전 후에 실험군II와 실험군III의 비교에서 VAS와 근 두께의 변화에 유의한 차이를 보였으며, 각 실험군 간의 유의성 검정 결과, 실험군III에서 다른 군들에 비해 유의한 차이를 나타냈다. ODQ, RMDQ 검사 결과에서는 실험 전 후에 실험군II와 실험군III의 비교에서 유의한 차이를 보였으며, 각 실험군 간의 유의성 검정 결과, 실험군III에서 다른 군들에 비해 유의한 차이를 나타냈다. 이상의 결과로 보아, PNF 기법을 이용한 요부 안정화운동은 일반 요부안정화운동에 비해 통증경감 및 요부에 위치한 심부근들의 두께 향상에 더 효과적임을 알 수 있었으며, 이러한 결과는 기능적 활동수준에도 긍정적인 영향을 미치는 것을 확인할 수 있었다. The purpose of this study was to examine the effects of lumbar stabilization exercise using the PNF techniques on the lumbar deep muscles thickness and functional activity in chronic low back pain patient. Group I(n=10): general physical therapy group; Group II(n=10): general lumbar stabilization exercise group; Group III(n=10): lumbar stabilization exercise using PNF techniques(stabilizing reversal, rhythmic stabilization, combination of isotonic) group. Change of pain was measured with visual analog scale(VAS). To observe muscle thickness changes, we measured transverse abdominis(TrA), external oblique(EO), multifidus with real time ultrasound scanning. The functional activity were measured with Oswestry Disability Questionnaire(ODQ) and Roland & Morris Disability Questionnaire(RMDQ). In VAS test, group III had more significantly decreased than before exercise. In muscle thickness test, group III had more significantly increased than before exercise in right/left TrA, EO, multifidus. In ODQ & RMDQ test, group III had more significantly decreased than before exercise. This study show that the PNF techniques is effective in improving the lumbar stability and functional activity in chronic low back pain patients.

Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache.

Surface electromyography and kinetics during step descent in individuals with low-level chronic or recurrent low back pain and lumbar instability

Lumbar functional instability: a critical appraisal of the literature

Objectives This study was to investigate the effects of lumbar stabilization exercise in using the simulation on pelvic movements and pain in the elderly patients with chronic low back pain. Methods In order to achieve the purpose of this study, 36 elderly patients with chronic low back pain at K located in C city, were selected at random and allocated 12 elderly women each for the Non Exercise Group (NEG/ n=12)and Deficient Exercise Group (DEG/n=12) and Over Exercise Group (OEG/n=12) the measured kinematic pelvic movements and pain before and after the experiment. The data obtained from this study were analyzed using the SPSS 24.0 statistical program the two-way repeated measures ANOVA and Bonferroni post-hoc test was performed. Results The lumbar stabilization exercise in using the simulation for 16 weeks. The results of this study were as follows: First, there were significantly increased in pelvic movements in OEG compared with DEG and NEG after 16 weeks. Second, there were significantly decreased in pain in OEG compared with DEG and NEG after 16 weeks. Conclusions As conclusions, this study confirmed that the lumbar stabilization exercise in using the simulation could improve the pelvic movements of elderly patients with chronic low back pain.

The evidence gap in low back pain management strategies – Authors' reply

Back and neck pain and poor sleep quality in adolescents are associated even after controlling for confounding factors: An epidemiological study.

HISTORY: A 17 y/o male high-school athlete originally experienced low back pain while pitching during a varsity baseball game. He has chronic low back and left leg pain since his injury almost two years ago. Previously treated conservatively with combination of physical therapy, trigger point injections, medications and interlaminar & transforaminal epidural steroid injections. A surgical consultation recommended discectomy. Returns to our practice for continued conservative management. Reports Axial back pain with radiation into the posterior aspect of the left lower leg. Pain ranged from 5/10 to 10/10. Worse at night. Denies any numbness, weakness or parasthesias. No Bowel or bladder incontinence.He continues to compete with pain. PHYSICAL EXAM: Height: 6.0 Weight: 170 BMI: 23.1 Neuro: Neural Tension-Mild positive left slump and SLR. Negative femoral stretch. Sensation-Grossly intact & symmetric to light touch. Muscle Tone-Normal, without clonus. No significant atrophy. Strength- Normal & symmetric in both lower extremities Reflexes- Normal & symmetric Patellar, Achilles and Medial Hamstrings MSK: Palpation-Segmental tenderness lower lumbosacral spine. Mild paraspinal spasm & tenderness. Nontender bilateral PSIS, greater trochanters, iliotibial band & Piriformis. Spine ROM: Grossly intact, end range pain. Stork test negative. Bilateral hamstring tightness. DIFFERENTIAL DIAGNOSIS Left Lumbar radiculopathy Chronic mechanical low back pain Sacroiliac Dysfunction Piriformis Syndrome TEST AND RESULTS Lumbar MRI 7/8/2007: L5-S1 left paracentral herniation, with mass effect, left S1 nerve. No central canal stenosis. Severe left neural foramen stenosis Minimal change from 2005 study. FINAL WORKING DIAGNOSIS Herniated disc at L5-S1 causing a chronic left S1 radiculopathy. TREATMENT and OUTCOME Left L5 and S1 transforaminal epidural steroid injection. Initiate Physical Therapy Consider discography prior to percutaneous disc procedure or surgical considerations. Consider Electrodiagnostic testing to evaluate for radiculopathy Treatment is on-going. Our interest, is to explore the effectiveness of minimally invasive and non-operative options for the adolescent athlete with chronic pain secondary to a herniated lumbar disc.

To investigate the effects of lumbar stabilization exercises on pain severity, functional disability, and physical performance after two weeks following radiofrequency denervation in patients with lumbar facet joint syndrome (LFJS). Thirty-nine patients diagnosed with LFJS and had radiofrequency denervation were assigned to study and control groups. The study group (n=20) received a six-week stabilization exercise program and was informed about spine biomechanics, while the control group (n=19) received only informations about spine biomechanics. Pain severity with visual analogue scale, perceived disability with Oswestry disability index, physical performance with physical performance tests and gait speed test were applied before and after radiofrequency denervation, and after six weeks of intervention program. Despite the similar improvements were shown in terms of all outcomes in both groups following radiofrequency denervation (p > 0.05), the improvements were more in favor of study group after six week intervention program (p < 0.05). These results indicate that radiofrequency denervation is effective in improving the pain, disability, and physical performance in patients with LFJS and this effect is further enhanced by the stabilization exercises following this procedure. Adding stabilization exercises to radiofrequency denervation yielded positive outcomes and these exercise are strongly advised in physiotherapy and rehabilitation program.

BackgroundAlthough results of case series support the use of spinal cord stimulation in failed back surgery syndrome patients with predominant low back pain, no confirmatory randomized controlled trial has been undertaken in this patient group to date. PROMISE is a multicenter, prospective, randomized, open-label, parallel-group study designed to compare the clinical effectiveness of spinal cord stimulation plus optimal medical management with optimal medical management alone in patients with failed back surgery syndrome and predominant low back pain.Method/DesignPatients will be recruited in approximately 30 centers across Canada, Europe, and the United States. Eligible patients with low back pain exceeding leg pain and an average Numeric Pain Rating Scale score ≥5 for low back pain will be randomized 1:1 to spinal cord stimulation plus optimal medical management or to optimal medical management alone. The investigators will tailor individual optimal medical management treatment plans to their patients. Excluded from study treatments are intrathecal drug delivery, peripheral nerve stimulation, back surgery related to the original back pain complaint, and experimental therapies. Patients randomized to the spinal cord stimulation group will undergo trial stimulation, and if they achieve adequate low back pain relief a neurostimulation system using the Specify® 5-6-5 multi-column lead (Medtronic Inc., Minneapolis, MN, USA) will be implanted to capture low back pain preferentially in these patients. Outcome assessment will occur at baseline (pre-randomization) and at 1, 3, 6, 9, 12, 18, and 24 months post randomization. After the 6-month visit, patients can change treatment to that received by the other randomized group. The primary outcome is the proportion of patients with ≥50% reduction in low back pain at the 6-month visit. Additional outcomes include changes in low back and leg pain, functional disability, health-related quality of life, return to work, healthcare utilization including medication usage, and patient satisfaction. Data on adverse events will be collected. The primary analysis will follow the intention-to-treat principle. Healthcare use data will be used to assess costs and long-term cost-effectiveness.DiscussionRecruitment began in January 2013 and will continue until 2016.Trial registrationClinicaltrials.gov: NCT01697358 (http://www.clinicaltrials.gov)

요부안정화운동에 따른 산업체 만성요통환자의 운동능력의 변화

Background: Low back pain after either post lumbar surgery syndrome or spinal stenosis in the absence of surgery is a vexing problem. Post lumbar surgery syndrome can occur in any age group, while low back and radicular pain from spinal stenosis is a disease of aging. As the population ages, the incidence of symptomatic spinal stenosis will increase. There are currently limited treatment options for either group. Further surgery is not uniformly effective in relieving pain after previous surgery. While therapies are being developed to treat pain due to spinal stenosis, no therapy other than adhesiolysis will treat pain due to scarring. Adhesiolysis was developed as a means of removing epidural scarring leading directly or indirectly to compression, inflammation, swelling, or a decreased nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the effort to break up epidural scarring, including the use of a wirebound catheter for mechanical adhesiolysis, placement of the catheter in the ventro-lateral aspect of the epidural space at the site of the exiting nerve root, and the use of high volumes of injectate, including local anesthetics and saline, either hypertonic or isotonic, along with steroids. Study Design: A systematic review of percutaneous adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. Objective: To evaluate the effectiveness of percutaneous adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. The severity of risks and adverse events associated with percutaneous adhesiolysis were also evaluated. Methods: The available literature on percutaneous adhesiolysis for the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief of at least 6 months. Secondary outcome measures were improvement in functional status, change in psychological status, return to work, and reduction in opioid use or interventions. Results: For this systematic review, 15 studies were identified and selected for review. Of these, 5 randomized controlled trials and 2 observational studies met the inclusion criteria. Applying the USPSTF criteria, these studies indicate that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain caused by post lumbar surgery syndrome and that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/ or leg pain caused by spinal stenosis The incidence of complications from percutaneous adhesiolysis is low and the complications are generally minimal and self-limited. The procedure should be considered to be low risk for serious adverse events when performed by well-trained physicians. Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: In summary, there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain due to post lumbar surgery syndrome or spinal stenosis. Key words: Spinal pain, chronic low back pain, leg pain, adhesiolysis, Racz procedure, post lumbar surgery syndrome, spinal stenosis

The effect of exercise in prevention of low back and pelvic girdle pain during pregnancy is uncertain. This study aimed to assess the effect of exercise on low back pain, pelvic girdle pain and associated sick leave. Literature searches were conducted in PubMed, EMBASE, Cochrane Library, Google Scholar, ResearchGate and ClinicalTrials.gov databases from their inception through May 2017. Randomized controlled trials (RCTs) were eligible for inclusion in the review if they compared an exercise intervention with usual daily activities and at least some of the participants were free from low back pain and/or pelvic girdle pain at baseline. Methodological quality of included studies was evaluated using the Cochrane Collaboration's tool. A random-effects meta-analysis was performed, and heterogeneity and publication bias were assessed. Eleven randomized controlled trials (2347 pregnant women) qualified for meta-analyses. Exercise reduced the risk of low back pain in pregnancy by 9% (pooled risk ratio (RR)=0.91, 95% CI 0.83-0.99, I2 =0%, seven trials, N=1175), whereas it had no protective effect on pelvic girdle pain (RR=0.99, CI 0.81-1.21, I2 =0%, four RCTs, N=565) or lumbopelvic pain (RR=0.96, CI 0.90-1.02, I2 =0%, eight RCTs, N=1737). Furthermore, exercise prevented new episodes of sick leave due to lumbopelvic pain (RR=0.79, CI 0.64-0.99, I2 =0%, three RCTs, N=1168). There was no evidence of publication bias. Exercise appears to reduce the risk of low back pain in pregnant women, and sick leave because of lumbopelvic pain, but there is no clear evidence for an effect on pelvic girdle pain. Exercise has a small protective effect against low back pain during pregnancy.

Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis