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408 PHYSICAL, COGNITIVE-BEHAVIOURAL OR COMBINATION TREATMENT FOR CHRONIC LOW BACK PAIN?RESULTS OF A RANDOMIZED CONTROLLED TRIAL
Topic C: DISEASE ENTITIES (HUMAN) psychosocial distress measured with the Symptom Checklist-90-Revised (SCL-90-R) and self reported disability measured with the Roland Morris Disability Questionnaire (RMDQ) has not been investigated. Aim of this study is to analyze the relationship between psychosocial distress measured with the SCL-90-R and disability measured with the RMDQ in patients with CLBP. Methods: The study was performed in an outpatient pain rehabilitation setting. The study sample consisted of 152 patients with CLBP admitted for multidisciplinary treatment. All patients completed the SCL-90-R and RMDQ. Results: Pearson’s correlation coefficients between SCL-90-R (Global Severity Index and subscales) and RMDQ ranged from 0.18 to 0.31 (p < 0.05). Conclusion: The relationship between psychosocial distress measured with the SCL-90-R and self reported disability measured with the RMDQ in CLBP patients is weak.
408 PHYSICAL, COGNITIVE-BEHAVIOURAL OR COMBINATION TREATMENT FOR CHRONIC LOW BACK PAIN? RESULTS OF A RANDOMIZED CONTROLLED TRIAL R.J. Smeets1,2 ° , J.W. Vlaeyen3 , A. Hidding4 , A.D. Kester5 , G.J. van der Heijden6 , J.A. Knottnerus2 . 1 Rehabilitation Centre Blixembosch, Eindhoven; 2 Netherlands School of Primary Care Research, University of Maastricht; 3 Department of Medical, Clinical and Experimental Psychology, University of Maastricht; 4 Department of Innovation & Research, Atrium Medical Centre, Heerlen; 5 Department of Methodology and Statistics, University of Maastricht; 5 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands Background and Aims: Several models for the maintenance of chronic low back pain have been postulated but explicitly model-based treatments has never been directly compared. The specific aim of this study is to compare the effectiveness of explicitly model-based treatments and especially whether a combination treatment is more effective than a physical or a cognitive-behavioural treatment. Methods: In three Dutch outpatient rehabilitation centres, 172 patients, 18 to 65 years of age, with chronic disabling nonspecific low back pain were randomized to either 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant behavioural principles and problem solving training (cognitive-behavioural treatment; CBT) or APT combined with CBT (combination treatment; CT). The main outcome was the level of disability (Roland Disability Questionnaire). Secondary outcomes were patients’ main complaints, pain intensity, self-perceived improvement, depression and six physical performance tasks. Results: For disability, pain and self-perceived improvement, follow-up measurements at 6 and 12 months post-treatment showed an increasing small to moderate difference in favour of the single treatments compared to CT, and self-perceived improvement reached statistical significance at 12 months for CBT (0.65 [CI, 0.10 to 1.21]) and APT (0.61 [CI, 0.05 to 1.16]). The improvement of main complaints favoured CBT. No differences were found regarding depression and performance tasks. Conclusions: Combination treatment is not more effective than the single treatments. Self-perceived improvement at 12 months showed a significant difference in favour of the single treatments.
409 AN UNCOMMON CAUSE OF LOW-BACK PAIN: SUPERIOR CLUNEAL NERVE ENTRAPMENT G.K. Talu ° , A. Cimen, N.S. Ozyalcin, S. Erdine. Department of Algology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey Background and Aims: Superior cluneal nerve entrapment is an uncommon cause of low-back pain. The nerve is compressed while it passes
S109 through the superior iliac crest. It presents with unilateral low-back pain radiating to the posterior thigh. We present 3 cases diagnosed and treated with superior cluneal nerve block. Methods: The first case was a 55 year-old woman who had pain for 5 months, the second case was a 52 year-old man who suffered from lowback pain for 8 months and the third case was a 33 year-old man having the symptoms for 3 months. The main findings in the physical examination of these patients were pain with palpation over the superior border of the iliac crest and exacerbation of pain with simultaneous full flexion of the ipsilateral hip and knee joints. All three patients had undergone local anesthetic blockade of the superior cluneal nerve during the diagnosis phase. The first case had complete symptom relief after this diagnostic blockade while a second block with the addition of 40 mg triamcinolone acetate was performed to the second and third cases. Results: The follow-up times for all the three cases were 3 months, and they were pain free at the end of this period. Conclusions: Superior cluneal nerve entrapment should be kept in mind, especially when more common causes of low-back pain are excluded. The blockade of the nerve as it crosses the iliac crest, will confirm the diagnose while it may provide long-term symptom relief.
410 RELIABILITY OF MEASURES OF ABDOMINAL MUSCLE THICKNESS DURING ABDOMINAL HOLLOWING, AS ASSESSED WITH M-MODE ULTRASOUND V. Toma1 ° , N. Pulkovski1 , H. Sprott1 , D. Gubler1 , M. Gorelick2 , D. O’Riordan2 , T. Loupas3 , P. Schenk4 , H. Gerber4 , A.F. Mannion2 . 1 Dept Rheumatology and Institute of Physical Medicine, University Hospital Z¨urich; 2 Spine Unit, Schulthess Klinik, Z¨urich, Switzerland, 3 Philips Medical Systems, The Netherlands, 4 Swiss Federal Institute of Technology, Z¨urich, Switzerland Background: Spine stabilisation exercises are a popular treatment for low back pain (LBP). Patients are initially taught how to perform sustained, isolated contractions of the transversus abdominis muscle (TA), using “abdominal hollowing” (AH) exercises. Successful performance is typically judged by the relative increase in TA thickness (measured with ultrasound) compared with that of internal (IO) and external (EO) obliques. However, no studies have examined the day-to-day measurement error associated with these measures. Methods: On each of two days, 16 subjects (8M, 8F; 33 (SD11) yrs) performed 10 AH exercises in lying. M-mode ultrasound images of the left and right abdominal muscles (N = 5 each) were recorded using a Philips HDI-5000 with linear-array transducer (5–12 MHz). Grey-scale images superimposed with tissue Doppler signals were recorded (at 300 Hz) at rest and throughout a 10-second contraction. The fascial lines bordering the TA, IO and EO were digitised, and the muscle thicknesses at rest (average over 1 s) and at maximal TA thickness (highest over any 3 s period) were calculated using custom-written software. Results: There were no significant between-day differences for the mean values of resting and maximal thickness for any muscle (p 0.12). Intraclass correlation coefficients were reasonably high (0.70–0.94) and standard errors of measurement (SEM) were relatively low (0.44–0.74 mm; 8–15% mean thickness). An index describing the selective activation of TA was somewhat less reliable (left, ICC 0.44; right, 0.70). Conclusion: Overall, the muscle thickness measures during AH were acceptably reliable. The SEMs are useful in interpreting the clinical relevance of changes following treatment. Support: NFP53–405340–104787/1.
408 PHYSICAL, COGNITIVE-BEHAVIOURAL OR COMBINATION TREATMENT FOR CHRONIC LOW BACK PAIN? RESULTS OF A RANDOMIZED CONTROLLED TRIAL R.J. Smeets1,2 ° , J.W. Vlaeyen3 , A. Hidding4 , A.D. Kester5 , G.J. van der Heijden6 , J.A. Knottnerus2 . 1 Rehabilitation Centre Blixembosch, Eindhoven; 2 Netherlands School of Primary Care Research, University of Maastricht; 3 Department of Medical, Clinical and Experimental Psychology, University of Maastricht; 4 Department of Innovation & Research, Atrium Medical Centre, Heerlen; 5 Department of Methodology and Statistics, University of Maastricht; 5 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands Background and Aims: Several models for the maintenance of chronic low back pain have been postulated but explicitly model-based treatments has never been directly compared. The specific aim of this study is to compare the effectiveness of explicitly model-based treatments and especially whether a combination treatment is more effective than a physical or a cognitive-behavioural treatment. Methods: In three Dutch outpatient rehabilitation centres, 172 patients, 18 to 65 years of age, with chronic disabling nonspecific low back pain were randomized to either 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant behavioural principles and problem solving training (cognitive-behavioural treatment; CBT) or APT combined with CBT (combination treatment; CT). The main outcome was the level of disability (Roland Disability Questionnaire). Secondary outcomes were patients’ main complaints, pain intensity, self-perceived improvement, depression and six physical performance tasks. Results: For disability, pain and self-perceived improvement, follow-up measurements at 6 and 12 months post-treatment showed an increasing small to moderate difference in favour of the single treatments compared to CT, and self-perceived improvement reached statistical significance at 12 months for CBT (0.65 [CI, 0.10 to 1.21]) and APT (0.61 [CI, 0.05 to 1.16]). The improvement of main complaints favoured CBT. No differences were found regarding depression and performance tasks. Conclusions: Combination treatment is not more effective than the single treatments. Self-perceived improvement at 12 months showed a significant difference in favour of the single treatments.
409 AN UNCOMMON CAUSE OF LOW-BACK PAIN: SUPERIOR CLUNEAL NERVE ENTRAPMENT G.K. Talu ° , A. Cimen, N.S. Ozyalcin, S. Erdine. Department of Algology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey Background and Aims: Superior cluneal nerve entrapment is an uncommon cause of low-back pain. The nerve is compressed while it passes
S109 through the superior iliac crest. It presents with unilateral low-back pain radiating to the posterior thigh. We present 3 cases diagnosed and treated with superior cluneal nerve block. Methods: The first case was a 55 year-old woman who had pain for 5 months, the second case was a 52 year-old man who suffered from lowback pain for 8 months and the third case was a 33 year-old man having the symptoms for 3 months. The main findings in the physical examination of these patients were pain with palpation over the superior border of the iliac crest and exacerbation of pain with simultaneous full flexion of the ipsilateral hip and knee joints. All three patients had undergone local anesthetic blockade of the superior cluneal nerve during the diagnosis phase. The first case had complete symptom relief after this diagnostic blockade while a second block with the addition of 40 mg triamcinolone acetate was performed to the second and third cases. Results: The follow-up times for all the three cases were 3 months, and they were pain free at the end of this period. Conclusions: Superior cluneal nerve entrapment should be kept in mind, especially when more common causes of low-back pain are excluded. The blockade of the nerve as it crosses the iliac crest, will confirm the diagnose while it may provide long-term symptom relief.
410 RELIABILITY OF MEASURES OF ABDOMINAL MUSCLE THICKNESS DURING ABDOMINAL HOLLOWING, AS ASSESSED WITH M-MODE ULTRASOUND V. Toma1 ° , N. Pulkovski1 , H. Sprott1 , D. Gubler1 , M. Gorelick2 , D. O’Riordan2 , T. Loupas3 , P. Schenk4 , H. Gerber4 , A.F. Mannion2 . 1 Dept Rheumatology and Institute of Physical Medicine, University Hospital Z¨urich; 2 Spine Unit, Schulthess Klinik, Z¨urich, Switzerland, 3 Philips Medical Systems, The Netherlands, 4 Swiss Federal Institute of Technology, Z¨urich, Switzerland Background: Spine stabilisation exercises are a popular treatment for low back pain (LBP). Patients are initially taught how to perform sustained, isolated contractions of the transversus abdominis muscle (TA), using “abdominal hollowing” (AH) exercises. Successful performance is typically judged by the relative increase in TA thickness (measured with ultrasound) compared with that of internal (IO) and external (EO) obliques. However, no studies have examined the day-to-day measurement error associated with these measures. Methods: On each of two days, 16 subjects (8M, 8F; 33 (SD11) yrs) performed 10 AH exercises in lying. M-mode ultrasound images of the left and right abdominal muscles (N = 5 each) were recorded using a Philips HDI-5000 with linear-array transducer (5–12 MHz). Grey-scale images superimposed with tissue Doppler signals were recorded (at 300 Hz) at rest and throughout a 10-second contraction. The fascial lines bordering the TA, IO and EO were digitised, and the muscle thicknesses at rest (average over 1 s) and at maximal TA thickness (highest over any 3 s period) were calculated using custom-written software. Results: There were no significant between-day differences for the mean values of resting and maximal thickness for any muscle (p 0.12). Intraclass correlation coefficients were reasonably high (0.70–0.94) and standard errors of measurement (SEM) were relatively low (0.44–0.74 mm; 8–15% mean thickness). An index describing the selective activation of TA was somewhat less reliable (left, ICC 0.44; right, 0.70). Conclusion: Overall, the muscle thickness measures during AH were acceptably reliable. The SEMs are useful in interpreting the clinical relevance of changes following treatment. Support: NFP53–405340–104787/1.