BACKGROUND AND AIMS: Globally, chronic low back pain (CLBP) affects 70-80% of adults at some point in their lives and current treatments are widely unsuccessful in relieving pain. Understanding the underlying neurophysiological (e.g., descending pain inhibition) and biobehavioral (e.g., stress) processes contributing to chronic pain in patients with CLBP is needed for the development of novel treatments. Previous studies have shown that acute stress can impact pain sensitivity and that childhood trauma may predispose a person to CLBP, but the mechanisms underlying this impact are unknown. Conditioned Pain Modulation (CPM) is a psychophysical paradigm used in research to assess descending pain modulatory pathways, which are thought to be impaired in patients with CLBP as well as in those with childhood trauma. The overlap of conditions has not been explored. The current study explored the impact of childhood trauma on the CPM response within a sample of patients with CLBP being treated at a tertiary pain clinic. CLBP patients exposed to an acute stress paradigm were expected to shower higher pain sensitivity, with acute stress significantly interacting with a history of childhood trauma as a factor leading to the higher pain sensitivity. METHODS: 46 Participants with CLBP (n=46, mean age=49 years, 55.3% female) recruited from a pain treatment service completed a Quantitative Sensory Testing (QST) and CPM before and after an acute psychological stressor. Participants were randomized to a control (n=25) or an acute-stress (n=21) condition. The acute-stress condition included the Stroop Color Word Task (SCWT) and a mental arithmetic task prior to completing the QST protocol a second time. The control participants did not undergo any additional stressors and completed the QST protocol a second time after a 20-minute break. Participants’ CPM response was measured by the average change in pressure pain threshold (PPT) from baseline to the conditioning stimulus (non-dominant hand in ice-water bath). A “Good CPM response” was defined as a CPM effect above 100, indicating that the pain threshold increased when exposed to the conditioning stimulus. To examine the impact of childhood trauma on pain sensitivity, participants completed a Childhood Traumatic Events Scale (CTES) to assess the presence and severity of six types of trauma (death, parental upheaval, sexual, violence, illness or injury, other upheaval) during childhood. The CTES was scored as a continuous variable by calculating the sum the trauma severity for all six trauma types. RESULTS: A large majority of the sample (94% of participants) showed an increase in pain threshold during hand immersion in ice water, which was contrary to our hypothesis based on prior research done on other chronic pain conditions and CLBP. Participants exposed to an acute stressor had an impaired CPM effect compared to those that were not exposed to an acute stressor, however there was no difference between groups (p=0.277). A history of childhood traumatic events did not correlate significantly with an impaired baseline CPM or a change in CPM effect when exposed to an acute stressor. CONCLUSION: The current study used novel QST modalities, including CPM, to analyze the interaction between acute and chronic stress on pain sensitivity. Ultimately, this study found that exposure to an acute stressor had a negative effect on CPM, indicating that when under experimental stress participants were more sensitive to pain compared to when they were not under stress, although the findings were not statistically significant. These findings should be further investigated to expand the understanding of the neurophysiological mechanisms underlying CLBP and to potentially provide novel treatment modalities for patients with CLBP.

Syfte: Syftet med den här studien var att undersöka om 4 veckors övervakad slyngträning påverkar smärta och funktionsförmåga hos enskilda individer med långvarig ländryggssmärta. Metod: Studiens design är en Single-System Experimental Design med AB-design. Tre deltagare med långvarig ländryggssmärta inkluderades i studien genom ett ändamålsenligt urval. Interventionen bestod av övervakad slyngträning tre gånger i veckan under fyra veckor. Smärta mättes med Visual Analogue Scale (VAS 0–100 mm) och funktionsförmåga mättesmed Oswestry Disability Index (ODI). Mätningar utfördes tre gånger i veckan under baslinjefasen och tre gånger i veckan under interventionsfasen. Resultat: Hos två av deltagarna sågs effekt på smärta efter introduktion av interventionen medan ingen effekt kunde säkerställas för en. Hos två av deltagarna sågs effekt på funktionsförmåga efter introduktion av interventionen medan ingen signifikant effekt kunde indikeras för en. Följsamheten till interventionen var god och deltagarnas upplevelser visade att de kände sig starkare och upplevde minskad rörelserädsla. Slutsats: Interventionen uppvisade potential att förbättra smärta och funktionsförmåga hos enskilda individer med ländryggssmärta. Resultaten kan inte generaliseras till andra patienter och miljöer utan replikering. / Objective: The purpose of the current study was to assess the influence of 4 weeks supervised sling exercise on pain and dysfunction in subjects with chronic low back pain. Methods: A Single-System Experimental Design with AB-design was applied. Three participants with chronic lower back pain were recruited by purposive sample. The intervention consisted of 4 weeks of supervised sling exercises thrice a week. Pain was rated with Visual Analogue Scale (VAS 0-100 mm) and disability was rated with Oswestry disability Index (ODI). Measurements was performed trice a week during baseline phase and trice a week during the intervention phase. Results: The results showed a decrease in pain for two participants after introduction of the intervention while it showed no effect for one participant. Improvement in dysfunction was shown for two participants after introduction of the intervention while no effect was shown for one participant. Compliance was good and the participants experienced feeling stronger and reduced fear of movement. Conclusions: A 4 weeks supervised sling exercise programme indicates potential in improving pain and dysfunction in individuals with lower back pain. The results cannot be generalized to other patients or contexts without replication.

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Acute and chronic pain conditions cause significant patient distress, interference with daily activities, and increased health care costs. It is important to evaluate analgesic interventions to improve pain relief, function, quality of life, and also to prevent persisting pain after surgery. This thesis is a combination of studies evaluating analgesic interventions in the setting of acute surgical pain; prevention of persistent post-surgical pain; and chronic low back pain. In part 1, we report our comparison of morphine and hydromorphone in 402 ambulatory surgery patients, for their ability to achieve satisfactory analgesia with minimal emesis using a design of multicentre randomized controlled trial. We observed no differences in their analgesic potential and common side effects and note that appearance of side effects is likely to be idiosyncratic. In part 2, we report our 2×2 factorial feasibility trial to prevent persistent post-surgical pain in patients having elective video-assisted thoracic surgery lobectomies, comparing N-methyl-D-aspartate antagonists versus placebo, and intravenous steroids versus placebo. As our feasibility outcomes were not met, we suggest appropriate considerations for protocol changes before embarking on a definitive larger trial. In part 3, we report on our systematic review and meta-analysis assessing the effectiveness and safety of gabapentinoids (gabapentin and pregabalin) in adult patients with chronic low back pain. We observed that the existing evidence is small and there is minimal improvement in pain and other outcomes with potential for adverse events. We suggest that the use of gabapentinoids for chronic low back pain merits caution and there is need for large high-quality trials. / Thesis / Doctor of Philosophy (PhD) / It is important to evaluate analgesic interventions to decrease pain, improve function, and lessen health care costs. In a randomized controlled trial of day surgery patients, we demonstrate that there are no differences between morphine and hydromorphone in achieving pain relief and common side effects. To prevent persistent post-surgical pain in patients having elective video-assisted thoracic surgery lobectomies, we performed a 2×2 factorial, feasibility randomized controlled trial, to compare N-methyl-D-aspartate antagonists versus placebo, and intravenous steroids versus placebo. We observe that appropriate protocol changes must be made before embarking on a larger trial. Finally, we report our systematic review and meta-analysis on the use of gabapentinoids in adult patients with chronic low back pain and observe that the existing evidence is small and not supportive, and the use of gabapentinoids for chronic low back pain merits caution.

Lower back pain is a widespread problem affecting millions worldwide, because understanding its development and effective treatment remains challenging. Current treatment success is often evaluated using patient-reported outcomes, which tend to be qualitative and subjective in nature, making objective success measurement difficult. Wearable sensors can provide quantitative measurements, thereby helping physicians improve care for countless individuals around the world. These sensors also have the potential to provide longitudinal data on daily motion patterns, aiding in monitoring the progress of treatment plans for lower back pain. In this work it was hypothesized that a new wearable sensor garment that makes use of high-deflection strain gauge technology--called the Z-SPINE System--will be capable of collecting biomechanical information capable of detecting characteristics of motion associated with chronic lower back pain from subjects as compared to skin-adhered wearable sensor systems. The initial prototyping development of the Z-SPINE System focused on optimizing the device's conformity to the skin, as well as the ease of use and comfortability of the design. Preliminary motion capture tests concluded that a waist belt made of an elastic four way stretch material with silicone patches and no ribbing had the highest skin conformity of the garment types tested, and further design decisions were made utilizing this knowledge. A human subject study was conducted with 30 subjects who performed 14 functional movements with both the Z-SPINE System, and the SPINE Sense System--a pre-existing wearable sensor system that utilizes the same high-deflection strain gauge technology and is adhered directly to the back. Multiple features were extracted from the strain sensor datasets for use in machine learning modeling, where the model was trained to distinguish the different movements from each other. The accuracy of the model was assessed using 4 different category number variations--two 4 category, one 7 category, and one 13 category variation. Four different machine learning models were used, with the random forest classifier generally performing the best, yielding prediction accuracies of 85.95% for the SPINE Sense System data, and 71.23% for the Z-SPINE System data in the 4 category tests. As an additional part of the human subject study, the usability of the Z-SPINE System was also assessed. Each participant filled out a system usability scale questionnaire in regards to their opinion and experience with the system after having used it; the average score given by participants was 83.4, with general feedback consisting of positive remarks about the comfort and ease of use of the current design and suggestions for improving the battery placement and fit of the Z-SPINE system. It is concluded that a machine learning model of the data from the Z-SPINE System can identify biomechanical motion with reasonable accuracy as compared to a skin-adhered wearable sensor system when the number of categories is limited. It is also concluded that the system is simple and intuitive to use.

In this study, the use of hypnosis in the treatment of chronic low back pain is described in terms of Ecosystemic thinking, as opposed to traditional conceptualisations of hypnosis. Six case studies were used. Each is described in detail, as well as the therapeutic rationale behind each case, in order to present the reader with an understanding of the thinking behind using Ecosystemic hypnotherapy. / Psychology / M.A. (Psychology)

Thesis (MScPhysio)--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: Aim: The aim of the study was to improve understanding of the hip joint kinematics in cricket fast bowlers and to ascertain whether a relationship exists between hip joint biomechanical parameters, including kinematics, ROM characteristics and lumbar symptoms. Study design: A descriptive cross-sectional study was conducted. Participants: Sixteen adult male fast bowlers between the ages of 18 and 40 years old, playing first-club league, were featured in the study. Main outcome measures: To obtain data with regards to the training history, as well as the nature of lumbar-spine symptoms experienced by the cricket fast bowlers, a newly designed questionnaire was compiled. For analysis of the front foot hip joint ROM and kinematics, the biomechanical equipment used included: a two-dimensional Canon MV950 Digital Video Camcorder, a Kodak EasyShare C310 camera and XSENS Motion Tracking equipment (Xsens Technologies B. V., Enschede, Netherlands). Results: Eight of the sixteen bowlers in our study experienced LBP in the season with seven of these bowlers presenting with recent symptoms most of which are experienced after bowling a spell and described as “tightness” or a “stabbing pain” in the lower back. Intensity of LBP ranged between 1/10 to 8/10. Front foot hip joint kinematics of fast bowlers showed highly individualised patterns of movement between different subjects. Medium amplitude movements in the flexion/extension as well as the rotation plane of movement showed a significant difference in bowlers with- and without LBP. No significant differences between groups with LBP and without LBP were found in the three passive hip ROM measurements. Conclusions: It has proved to be very difficult to improve the understanding of the front foot hip biomechanics in cricket fast bowlers due to the high inter-subject variability. Variability in movement patterns remains under-researched by sports biomechanics. Although decreased hip mobility could alter mechanical forces transmitted to the lumbar spine and therefore predispose or be a causative factor in LBP development, this study found no significant relation between these parameters. The sample size was very small in this study which will influence the validity of results. Our study confirmed the high incidence of LBP and preventative efforts for bowlers should therefore be strongly supported. / AFRIKAANSE OPSOMMING: Doelwit: Die doelwit van die studie was om die heupgewrig kinematika van krieket snelboulers beter te verstaan en om vas te stel of daar ‘n verwantskap bestaan tussen heupgewrig biomeganiese parameters, insluitende kinematika, omvang van beweging karakter en lumbale simptome. Studie ontwerp: ‘n Deursneë beskrywende studie is onderneem. Deelnemers: Sestien volwasse manlike snelboulers tussen die ouderdomme van 18 en 40 jaar oud wat eerste liga speel maak deel uit van die studie. Hoof uitkoms maatreëls: ‘n Nuut ontwerpte vraelys is opgestel om data aangaande oefen geskiedenis sowel as aard van lumbale simptome wat deur krieket snelboulers ervaar word in te samel. Die biomeganiese apparaat wat gebruik is vir die analiese van die voorvoet heup omvang van beweging, sowel as die kinematika, sluit in: ‘n twee dimensionele Canon MV950 Digitale Video Camcorder, ‘n Kodak EasyShare C310 kamera en XSENS beweging volgende apparaat (Xsens Technologies B. V., Enschede, Netherlands). Resultate: Agt van die sestien boulers in ons studie het lae rug pyn in die seisoen ervaar. Sewe van die boulers het gepresenteer met onlangse simptome waarvan die meeste na ‘n bouler se boulbeurt ervaar is en beskryf was as ‘n “styfheid” of “steekpyn” in die lae rug. Die intensiteit van die lae rug pyn het gewissel tussen 1/10 en 8/10. Voorvoet heup kinematika van snelboulers het hoogs individualistiese patrone van beweging getoon tussen verskillende deelnemers. Medium amplitude bewegings in die fleksie/ekstensie sowel as die rotasie plein van beweging het ‘n beduidende verskil tussen boulers met- en sonder lae rug pyn getoon. Geen beduidende verskille tussen die groep met- en sonder rugpyn is gevind met die drie passiewe heup omvang van beweging meetings nie. Gevolgtrekkings: Dit blyk baie moelik te wees om die voorvoet heup biomeganika in krieket snelboulers beter te verstaan a.g.v. die hoë inter-deelnemer veranderlikheid. Veranderlikheid in bewegings patrone is nog nie genoeg nagevors deur sport biomeganici nie. Alhoewel ingekorte heup mobiliteit meganiese kragte wat deur die lumbale werwelkolom gaan kan wysig, en sodoende die ontwikkeling van lae rug pyn kan predisponeer of ‘n oorsakende faktor kan wees, het hierdie studie nie ‘n beduidende verwantskap tussen die parameters gevind nie. Die steekproef groote was baie klein en dit sal die geldigheid van die resultate beïnvloed. Ons studie het die hoë insidensie van lae rug pyn bevestig en pogings tot voorkomende maatreëls moet daarom ten sterkste ondersteun word.

The Diploma thesis titled "Using biofeedback for patients with non-specific low back pain" in theoretic part gives basic information about motor learning, biofeedback, low back pain and postural stability. In the research part, it deals with influence of postural stability- focused therapy (performed on Nintendo Wii Fit Plus device) on low back pain and postural stability. The work also deals with influence of added feedback on reduction low back pain, postural stability and realizing intrinsic feedback. We demonstrate that this therapy reduced low back pain but has no significant influence on postural stability. We also demonstrate that added feedback has positive effect on persistence of pain and affective part of the Short Form of McGill Pain Questionary, but it does not influence postural stability. On the contrary, absence of added feedback significantly influenced the postural stability. The added feedback does not influence awareness intrinsic feedback.

Title: Physiotherapy with golf players having vertebrogenic disorders Objectives: The goal of the work is to find out and analyze, from selected foreign studies, the causes of the development of the most common pathologies in the lumbar area of the spine in adults, professionals and amateurs and based on the evaluation of the studies suggest appropriate physiotherapeutic procedures to be used as a prevention against low back pain (further LBP). Methods: The work is structured as a research, which has been created on the basis of an analysis of relevant sources. The literature, printed and electronic monographs, textbooks and specialized periodical were obtained from bibliographical databases, library catalogues and the Internet. The work contains foreign studies from USA, Canada, England and Australia. The studies were obtained from specialized medical databases: PubMed, PEDro, EBSCO. Results: The main cause of the development of LBP in golf players is the full golf swing, especially the modern type of swing. The following pathologies mainly develop in the lumbar area of the spine within the golf players: hypertonus paravertebral muscles, prolapses of intervertebral disc, fatigue vertebrae fracture and artrophaty of facet joints. In the prevention of LBP we use physiotherapeutic processes based on...

Title: Therapeutic intervention of low back pain - comparing of two therapeutic approaches Objectives: The main objective of this experimental study was to compare two therapeutic approaches: Sensorimotor stimulation by Janda Vávrová and Proprioceptive neuromuscular facilitation in patients with low back pain. Methods: Experimental comparative study aimed at comparing the effect of Proprioceptive neuromuscular facilitation method of Kabat and Sensorimotor stimulation by Jandy and Vávrová in patients with chronic low back pain. The probands were selected from among patients of private healthcare facilities Medi-centre Skalka s.r.o. The assessment of pain, we used a standardized questionnaire Oswestry. The data will be processed using statistical method Mann-Whitney U test. Results: The study showed no significant difference in treatment effect low back pain between Sensorimotor stimulation method by Janda and Vávrová and Proprioceptive neuromuscular facilitation. Keywords: Proprioceptive neuromuscular facilitation, Sensorimotor stimulation by Janda Vávrová, low back pain.