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      Treatment of chronic low back pain in patients with spinal deformities using a sagittal re-alignment brace

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      Scoliosis
      BioMed Central

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          Abstract

          Background

          For adult scoliosis patients with chronic low back pain bracing is initially indicated before spinal surgery is considered. Until recently there has been a lack of research into the effect upon pain reductions in the mid and long-term. Promising results have been documented in short-term studies for the application of a sagittal re-alignment brace in patients with spinal deformities and along with pain; however mid-term and long-term results are not yet available. The purpose of this study is to investigate the mid-term effects of this brace with respect to pain control.

          Materials and methods

          67 patients (58 females and 9 males) with chronic low back pain (> 24 months) and the diagnosis of scoliosis or hyperkyphosis were treated with a sagittal re-alignment brace (physio-logic brace™) between January 2006 and July 2007. The indication for this kind of brace treatment was derived from a positive sagittal re-alignment test (SRT) and the exclusion of successful conservative treatment during the last 24 months. The aim of this type of conservative intervention was to avoid surgery for chronic low back pain.

          Results

          The average pain intensity was measured on the Roland and Morris VRS (5 steps) before treatment. This was 3.3 (t1), at the time of brace adjustment it was 2.7 (t2) and after at an average observation time of 18 months it was 2.0 (t3). The differences were highly significant in the Wilcoxon test.

          Discussion

          Short-term measurements showed that a significant pain reduction is possible in chronic postural low back pain using a sagittal re-alignment brace inducing lumbar re-lordosation. In a preliminary report at adjustment (t2), highly significant improvements of pain intensity have also been demonstrated. At 6 months of treatment however, no improvement was measured. The improvement of the mid-term effects (18 months) found in this study compared to the preliminary report may be due to the changed approach to compliance: whilst the bracing standard was not changed; the patients in this study were obligated to wear the brace for a minimum of 20 hrs per day for the first 6 months of treatment.

          Conclusion

          The effect of the sagittal re-alignment brace leads to promising short-term improvements in patients with chronic low back pain and spinal deformities. Contrary to unspecific orthoses, which after a short period without persistent pain reduction are omitted by the patients, the sagittal re-alignment brace (physio-logic™ brace) leads to an effective reduction of pain intensity in mid-term even in patients who have stopped brace treatment after the initial 6 months of treatment. In conservative treatment of chronic low back pain specific approaches such as the sagittal re-alignment brace are indicated prior to considering the surgical options.

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          Most cited references12

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          Forced lordosis on the thoracolumbar junction can correct coronal plane deformity in adolescents with double major curve pattern idiopathic scoliosis.

          A prospective radiographic study was conducted. To support our hypothesis that correction of the scoliosis may benefit from a lordotic fulcrum force in the sagittal plane on the thoracolumbar spine. Adolescent idiopathic scoliosis is an important spinal deformity. Correction can be achieved with limited options by current bracing techniques. Lateral bending radiographs are used to assess flexibility and predict treatment outcome. The corrective potential of a lordotic fulcrum force in the sagittal plane has not been addressed. Anterioposterior spine radiographs of patients with a double major curve pattern scoliosis were obtained in 2 groups of patients. In group A radiographs in 3 positions: standing, and supine with and without fulcrum (n = 12), and group B radiographs in 2 positions (n = 28): standing, and supine with lordotic fulcrum. Cobb angles were determined and evaluated statistically. The sagittal contour of the thoracolumbar junction in standing position was measured. In group A with the patients lying supine a correction of the Cobb angle was obtained at the thoracic level of 15.4% and the lumbar level of 27.5% (P < 0.001). Adding in supine position a lordotic fulcrum on the thoracolumbar junction resulted in a coupled further correction at the thoracic level of 15.7% and lumbar 18.1% (P < 0.001). Comparing in group A the thoracic and lumbar curvatures in standing position with that on a lordotic fulcrum in supine position revealed a total reduction of 31% and 45.6%, respectively. For the independent group B this reduction in 1 step is 38% and 44.4%, respectively. Scoliotic deformities are significantly reduced in supine position by a lordotic fulcrum force on the thoracolumbar junction. These findings may have consequences on bracing techniques.
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            Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group.

            A systematic review of randomized and nonrandomized controlled trials. Lumbar supports are used in the treatment of low back pain, but also to prevent the onset (primary prevention) or recurrences of a low back pain episode (secondary prevention). To assess the effects of lumbar sup-ports for prevention and treatment of nonspecific low back pain. The Medline, Cinahl, and Current Contents databases; the Cochrane Controlled Trials Register up to September 1999; and the Embase database up to September 1998 were all searched. References of identified trials and systematic reviews were reviewed and the Science Citation Index used to identify additional trials. Methodologic quality assessment and data extraction were performed by two reviewers independently. A quantitative analysis was performed in which the strength of evidence was classified as strong, moderate, limited or conflicting, and no evidence. Five randomized and two nonrandomized preventive trials and six randomized therapeutic trials were included in the review. Only 4 of the 13 studies were of high quality. There was moderate evidence that lumbar supports are not effective for primary prevention. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, whereas it is still unclear whether lumbar supports are more effective than other interventions for treatment of low back pain. There continues to be a need for high quality randomized trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance.
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              Feasibility of lumbar supports for home care workers with low back pain.

              The aims of this study were to assess the compliance of home care workers with low back pain (LBP) in using a lumbar support, to establish the benefit experienced from the support, and to determine the predictive factors for that compliance and benefit. Only home care workers who had LBP at the start of the study or who had experienced at least two episodes of LBP in the 12 months prior to the study could apply for participation. The study consisted of two phases. In phase I (the first week of the study), workers used the lumbar support each working day. In phase II (the following 6 months), subjects were instructed to use the lumbar support only on those working days when they experienced LBP. Weekly questionnaires were used to measure compliance; monthly questionnaires were used to measure the benefit experienced. Fifty-nine workers participated in the study. Overall, they scored their perceived benefit from the lumbar support as 7 on a scale of 0-10, and 61-81% of the workers were compliant. Multiple linear regression analysis showed that the best predictor for experienced benefit is the degree of confidence in expected pain reduction due to the lumbar support, measured after phase I (R(2) = 0.70). Multiple logistic analysis showed that the best predictor for compliance is the extent to which subjects consider they can influence their own health status (R(2) = 0.49). Because both the benefit experienced and the compliance rate were substantial, the use of lumbar supports by home care workers with LBP seems feasible. However, we cannot recommend extensive use of lumbar supports in home care workers with LBP based solely on the results of the present study. First, there is a clear need for a randomized clinical trial on this topic.
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                Author and article information

                Journal
                Scoliosis
                Scoliosis
                BioMed Central
                1748-7161
                2009
                9 March 2009
                : 4
                : 7
                Affiliations
                [1 ]Koob-Scolitech, Orthopedic Rehabilitation Services, Huehnerhof 100, D-55568 Abtweiler, Germany
                [2 ]Orthomed Orthopedic Technical Services, Bad Sobernheim, Germany
                Article
                1748-7161-4-7
                10.1186/1748-7161-4-7
                2655283
                19272146
                22811b58-6be4-4cbf-8f0f-0db4328c8333
                Copyright © 2009 Weiss and Werkmann; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research

                Orthopedics
                Orthopedics

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