Israel Medical Association Journal

A 90-year-old female with a medical history of untreated gout presented to the emergency department with acute low back pain. On physical examination, the area over the 4th lumbar spinous process was extremely tender. Serum C-reactive protein was 184 mg/L, and uric acid was 8.3 mg/dl.

Conventional [Figure 1A] and dual-energy computed tomography (DECT) [Figure 1B] studies of the lumbar spine showed multiple tophi-engulfing posterior vertebral structures of the involved vertebral unit, including the spinous and transverse processes and facet joints. This condition is schematically shown in Figure 1C with asterixis indicating tophi-induced erosion and osteolysis of the spinous process.

The patient was treated for a suspected acute gouty attack with prednisone and colchicine followed by allopurinol treatment with rapid and uneventful recovery.

Axial gout is an underdiagnosed and potentially curable cause of recurrent low back pain [1,2]. Referral to DECT should be considered in patients with uncontrolled gout and concurrent back pain.

Background: Low back pain has been the leading cause for disability worldwide for several decades, and clinical guidelines for its management clearly emphasize a multifactorial approach. Yet, current guidelines are still not well implemented by clinicians.

Objectives: To explore the attitudes of family medicine residents regarding low back pain and to determine whether they positively correlate with their treatment approaches. To test if these attitudes can be affected by the Enhanced Transtheoretical Model Intervention (ETMI), a guideline-based workshop.

Methods: Participants completed an online questionnaire regarding their attitudes toward low back pain and clinical habits, after which they attended an online ETMI educational workshop. One month later all participants were asked to complete the questionnaire a second time. Statistical analysis was conducted to explore the attitudes of the residents and clinical approaches, as well as any associations between them, as well as possible differences pre- and post-intervention.

Results: The participants exhibited highly psychologically oriented attitudes. Correlations between the attitudes and treatment did not show consistent coherency. Results regarding the participants clinical approaches were revealed to have two distinct and opposed inclinations: biomedically and biopsychosocially. Last, results for the re-activation subscale were significantly higher post-intervention.

Conclusions: Family medicine residents seem to be highly psychologically oriented regarding low back pain; however, they do not necessarily treat their patients accordingly. Their clinical choices seem to follow two different approaches: guideline-consistent and non-guideline-consistent. An ETMI guideline-based workshop may sway their attitudes toward re-activation of patients. Further research is needed to determine whether similar results would arise in larger physician populations.

Background: Self-management, an active life routine, and adherence to physical activity are effective in the management of low back pain (LBP). However, delivering effective education and reassurance to patients can be a difficult for practitioners. The enhanced transtheoretical model intervention (ETMI) has shown to be successful and cost effective. The intervention focuses on educating practitioners to reassure patients, empower them to increase physical activity, and improve their self-efficacy.

Objectives: To assess whether ETMI can be implemented among primary care practitioners and to examine whether it reduces pain, disability, and fear avoidance as well as decreasing healthcare utilization. This protocol outlines the methodology for the implementation of ETMI through a hybrid implementation–effectiveness design.

Methods: Two qualitative and mixed-method studies provided a basis for an implementation prospective cohort study. Discussions are followed by a prospective cohort study with pre-and post-intervention measures as well as descriptions retrieving economic and therapeutic outcome data from the Maccabi Healthcare Services (MHS) databases. In addition, a fourth qualitative study was conducted at the midpoint of the implementation to evaluate the process by measuring the perceptions and practice of practitioners. The intervention group was 220 primary care practitioners and their patients (~n=10,000) from the central district of MHS. The control data was provided by other care districts with similar socioeconomic makeup (~n=40,000).

Conclusions: We evaluated the process and outcomes of the implementation of ETMI. We investigated the relationship between the care received (ETMI against treatment as usual) and healthcare utilization, costs, and patient-clinical outcomes.

Background: Lumbar spinal stenosis (LSS) is a narrowing of the lumbar canal causing lower back pain, gluteal pain, and neurogenic claudication. LSS has been associated with cardiovascular co-morbidities. Metabolic syndrome (MetS), a pro-inflammatory condition involving a cluster of risk factors for cardiovascular disease and diabetes, is increasingly prevalent worldwide.

Objectives: To evaluate the prevalence of MetS in patients with LSS, compared to age- and sex-matched healthy controls, and to explore potential associations between MetS and LSS-related clinical parameters and cardiovascular risk factors.

Methods: We conducted a cross-sectional study including 64 patients diagnosed as symptomatic LSS (NASS criteria) and 32 controls. MetS was diagnosed using the 2009 Harmonizing criteria adjusted for South Americans. Multivariate logistic regression was used to identify independent risk factors for MetS. The level of statistical significance was set at 5%.

Results: The prevalence of MetS was significantly higher in the LSS group than in the control group (76.6% vs. 31.3%; P < 0.001). LSS patients displayed greater waist circumference (P = 0.003), blood glucose levels (P = 0.009) and arterial pressure (P < 0.001) than controls. The variables with independent influence on MetS in the logistic regression model were: diabetes (P = 0.008), blood glucose (P = 0.004), and body mass index (P = 0.005).

Conclusions: MetS was significantly more prevalent among LSS patients, and diabetes and elevated body mass index were found to be risk factors for MetS in these LSS patients

Background: Magnetic resonance imaging (MRI) is the most sensitive imaging modality for the detection of sacroiliitis. Diagnosing sacroiliitis on MRI is not always straightforward and can be challenging in some cases.

Objectives: To evaluate the prevalence of alternative diagnoses suggested by MRI and characterize the MR appearance of the most common ones.

Methods: Consecutive MRI examinations of the sacroiliac joints (SIJ) performed between 2005 and 2012 were retrospectively evaluated for the presence of structural and active sacroiliitis findings according to the Assessment of SpondyloArthritis International Society guidelines. Alternative diagnoses, including degenerative changes, diffuse idiopathic skeletal hyperostosis (DISH), Osteitis condensans ilii (OCI), septic sacroiliitis/discitis, stress reaction as well as anatomic variants, were registered

Results: We evaluated 281 MRI examinations, 116 males, 165 females, average age 44 ± 15 years. Sacroiliitis was found in 71 examinations (25%) and alternative diagnoses were suggested in 87 (31%) (OCI 8.9%, anatomic variants 5.3%, septic sacroiliitis 5.3%, degenerative findings 4.3%, diffuse idiopathic skeletal hyperostosis [DISH] 1.5%, stress reaction 0.7%, tumor 0.3%). A normal examination was found in the remaining 123 examinations. Patients with alternative diagnoses were older than those with sacroiliitis (62 vs. 47 years of age, respectively, P > 0.05). Alternative pathologies in the SIJ were significantly more common in females (66) than males (21), P < 0.05.

Conclusions: A substantial proportion of patients with suspected sacroiliitis had normal SIJ while the rest were more commonly diagnosed with other pathologies. A referral by an experienced rheumatologist may improve the sensitivity and specificity of this important examination.

Background: Low back pain (LBP) is chronic disease without a curative therapy. Alternative and complementary therapies are widely used in the management of this condition.  

Objectives: To evaluate the efficacy of home application of Dead Sea mud compresses to the back of patients with chronic low back pain (LBP).

Methods: Forty-six consecutive Patients suffering from chronic LBP were recruited. All patients were followed at the Soroka University Rheumatic Diseases Unit.  The patients were randomized into two groups: group 1 was treated with mineral-rich mud compresses, and group 2 with mineral-depleted compresses. Mud compresses were applied five times a week for 3 consecutive weeks. The primary outcome was the patient’s assessment of the overall back pain severity. The score of the Ronald & Morris questionnaire served as a secondary outcome.

Results: Forty-four patients completed the therapy and the follow-up assessments: 32 were treated with real mudpacks and 12 used the mineral-depleted packs. A significant decrease in intensity of pain, as described by the patients, was observed only in the treatment group. In this group, clinical improvement was clearly seen at completion of therapy and was sustained a month later. Significant improvement in the scores of the Roland & Morris questionnaire was observed in both groups.

Conclusions: The data suggest that pain severity was reduced in patients treated with mineral-rich mud compresses compared with those treated with mineral-depleted compresses. Whether this modest effect is the result of a “true” mud effect or other causes cannot be determined in this study. 

Background: Professional drivers have been found to be at high risk for developing low back pain. However, the exact reasons are poorly understood.

Objectives: To assess the prevalence of LBP[1] among Israeli professional urban bus drivers, and evaluate the association between LBP in drivers and work-related psychosocial and ergonomic risk factors.

Methods: A total of 384 male full-time urban bus drivers were consecutively enrolled to this cross-sectional study. Information on regular physical activity and work-related ergonomic and psychosocial stressing factors was collected during face-to-face interviews. The prevalence of LBP was assessed using the Standardized Nordic Questionnaire.

Results: From the total cohort, 164 bus drivers (45.4%) reported experiencing LBP in the previous 12 months. Ergonomic factors associated with LBP were uncomfortable seat (odds ratio 2.6, 95% confidence interval 1.4–5.0) and an uncomfortable back support (OR[2] 2.5, 95% CI[3] 1.4–4.5). In the group of drivers with LBP, 48.5% reported participation in regular physical activities vs. 67.3% in the group without LBP (P < 0.01). The following psychosocial stressing factors showed significant association with LBP: “limited rest period during a working day” (1.6, 1.0–2.6), “traffic congestion on the bus route” (1.8, 1.2–2.7), “lack of accessibility to the bus stop for the descending and ascending of passengers” (1.5, 1.0–1.5), and “passengers' hostility” (1.8, 1.1–2.9).

Conclusions: Work-related ergonomic and psychosocial factors showed a significant association with LBP in Israeli professional urban bus drivers. Prevention of work-related stress, organizational changes targeted to reduce stressful situations, improvement in seat comfort, and encouraging regular sports activity need to be evaluated as prevention strategies for LBP in professional bus drivers.

Background: Low back pain is a common problem managed by primary care physicians and orthopedic specialists.

Objectives: To evaluate the outcome of new LBP[1] episodes in patients who chose to visit either an orthopedist or a general practitioner.

Methods: All patients visiting the orthopedist or physician during the study period were screened for a new complaint of LBP. After the initial visit the patients were interviewed by phone by means of a structured questionnaire, with a follow-up interview one month later. The study was performed at Clalit Health Services primary care and consultation clinics. A random sample of 125 GPs[2] and 17 orthopedists were chosen. Consecutively recruited were 166 patients who visited the GP and 75 the orthopedist. The main outcome measures evaluated were perceived complaint severity and degree of disturbance to everyday functioning, problem resolution, and health services utilization.

Results: Patients who decided to first visit the orthopedist indicated a higher disturbance to everyday functioning (75% vs. 70%, P < 0.01), were invited for further follow-up visits (6% vs. 51%, P < 0.05) and had more computed tomography and bone scans (20 vs. 3%, P < 0.001 and 9 vs. 2%, P < 0.05, respectively). Health status after one month showed that patients who chose the GP were more likely to have their problem solved (36 vs. 17%, P < 0.05).

Conclusions: Symptom resolution for a new LBP complaint was significantly higher in patients who decided on the GP, even when controlling for severity of illness and degree of disturbance to everyday functioning.

Background: Balneotherapy is an established treatment modality for musculoskeletal disease. However, few studies have examined the efficacy of spa therapy in elderly patients with degenerative spine and joint diseases.

Objectives: To assess the effects of balneotherapy on chronic musculoskeletal pain, functional capacity, and quality of life in elderly patients with osteoarthritis of the knee or chronic low back pain.

Methods: A total of 81 patients enrolled and the results of 76 were analyzed. Subjects underwent a 1 day course of 30 minute daily baths in mineral water. Changes were evaluated in the following parameters:  pain intensity, functional capacity, quality of life, use of non-steroidal anti-inflammatory or analgesic drugs, subjective disease severity perceived by the patients, investigator-rated disease severity, and severity of pain perceived by the patients.

Results: Compared to baseline, all monitored parameters were significantly improved by balneotherapy in both investigated groups. Moreover, the favorable effect was prolonged for 3 months after treatment.

Conclusions: This study showed that balneotherapy is an effective treatment modality for elderly patients with osteoarthritis of the knee or with chronic low back pain, and its benefits last for at least 3 months after treatment.