Der Schmerz
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The central and lateral lumbar canals constitute complex osteofibrous neurovascular tunnels, allowing movement and deformation of the spine without loss of their main configuration. Intervertebral discs play an important role in determining their configuration. Disc degeneration may alter or even threat the functional anatomical relationships between successive adjacent "juncturae" of the vertebral column. ⋯ The sympathetic nerve plexus inside the anterior longitudinal ligament and the SNVs provide a network of nerve fibers around the vertebral bodies and intervertebral discs. These pathways explain the sympathetic component of the innervation of a number of spinal structures. The dorsal ramus innervates the facet joints at the corresponding level and one below, before it gives off muscular and cutaneous branches.
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During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain. The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence. Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical, social and occupational factors. ⋯ 20 years of research, several qualitative reviews and a recently published systematic review of 37 good-quality prospective studies regarding the role of psychological, biomedical, social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain. Furthermore, the psychological factors displayed more predictive power than biomedical or biomechanical variables. As a consequence for clinical practice, these psychological risk factors have to be considered as "yellow flags" if a back pain problem won't respond to medical treatment for more than four weeks. As a further consequence, special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain. The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group.
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Back pain causes high costs to society. In Germany, these amount to an estimated total of 5 billion euro of direct costs per year and 13 billion euro of indirect costs, the latter being caused by incapacity to work. The purpose of this study is to develop a concept for economic rehabilitation management. This concept is based on the managed care approach and aims at improving efficiency of care. ⋯ Economic rehabilitation management might help to save money and to improve health outcomes, thus increasing the efficiency of care. The results of our empirical studies show the feasibility of tools for the economic management of rehabilitation. Risk adjustment of the management components is of paramount importance.
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The present article concentrates on mechanisms that lead to the excitation of nociceptors in soft tissues and nociceptive neurones in the spinal dorsal horn. These mechanisms may contribute to the so-called unspecific low back pain. Properties of nociceptors in soft tissues: A nociceptive ending in soft tissue contains a multitude of receptor molecules in its membrane. ⋯ These data show that structural changes appear quite early in the development of a painful disorder. A novel hypothesis for the development of chronic pain states that a strong nociceptive input to the spinal cord leads to cell death predominantly in inhibitory interneurones. Most of these interneurones are assumed to be tonically active; when their number decreases, the nociceptive neurones are chronically disinhibited and elicit continuous pain also in the absence of a noxious stimulus.
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In the last 50 years conventional treatments have not been able to slow down the expanding chronic low back pain problem. However, nowadays health care has changed according to a broad biopsychosocial model of health, the positive effect of activity on health and healing, emphasis on function rather than pain or impairment, and reliance upon clinical evidence. In search for new solutions "functional restoration" (FR) programs have been developed. ⋯ The patients' efficacy expectations are the most potent determinants of change in the training process. Exacerbation of pain is not taken as a failure of the therapeutic concept, but as a challenge to self-management. However, the important principle in managing chronic low back pain is "treating patients rather than spines."