The Shiraniwa Study, a longitudinal observational study, has evaluated the physical symptoms, physical function, and radiological findings in 409 elderly people (aged 65 years or older) living in a suburban area since August 2016.

Cross-sectional analysis of the study data identified spinal sagittal imbalance, obesity, prevalent vertebral fractures, and anxiety as independent factors associated with low back pain. Interventions against these factors appeared to be effective in preventing low back pain. Longitudinal analysis revealed stage 2 locomotive syndrome (LS) as an independent predictor of deteriorating spinal sagittal imbalance. In addition, elderly in whom the locomotion level improved over time also showed weight loss, which suggests that weight loss may contribute to preventing the progression of spinal imbalance. Weight loss affects two factors associated with low back pain in the elderly (obesity and spinal imbalance) and might therefore be an effective countermeasure against low back pain in this population.

Number of osteoporosis patients is increasing continuously in Japan, which has a super-aged society. Pain is not considered a typical symptom of osteoporosis patients, if they have no fractures. However, low back pain is one of the most frequent complaints in elderly people, osteoporosis is common in elderly persons, and osteoporosis might cause such low back pain. In this review, I will discuss my presentation at the symposium of The 29^th Annual Meeting of the Japanese Society for the Study of Low Back Pain.

Exercise is the most common and important intervention for chronic low back pain (CLBP) and locomotive syndrome (LS). We have developed an innovative exercise device (RECORE^®) for the abdominal trunk muscles that also measures muscle strength in a sitting position without the need for trunk movement. The device, which is easy for elderly patients with CLBP and/or LS to use, allows for lumbar stabilization exercise under pressure. Our studies have demonstrated that the strengthening exercises using the device both activate and increase the strength of the diaphragm, abdominals, and pelvic-floor muscles. The abdominal core can be described as a muscular box with the abdominals in the front and sides, the diaphragm as the roof, and the pelvic floor as the base. The strength of the abdominal trunk muscles, as measured using the device, is created by the contraction of all deep and superficial abdominal core muscles to increase intra-abdominal pressure, thus creating a semirigid cylinder surrounding the spinal column, which is capable of stabilizing the trunk and relieving some of the imposed stress on the vertebral column. This mechanism improves patients' CLBP and mobility function. Our studies have demonstrated that muscle weakness in the elderly was associated with the presence of CLBP and with a history and risk of falling and osteoporotic vertebral fracture. Our prospective intervention study showed that the strengthening exercise using the device was effective in improving the strength of the abdominal trunk muscles, the pain intensity of CLBP, and mobility.

The primary goal in treatment of chronic pain is to improve the patient's activities of daily living and quality of life, and analgesia is a secondary objective. Among treatments, pharmacotherapy is very effective for acute pain but less so for chronic pain. Physiotherapy and psychosocial interventions are the mainstay of treatment for chronic pain, and pharmacotherapy is considered an adjunct therapy. Compared with healthy non-elderly patients, the treatment of chronic pain in elderly patients requires consideration of 1) decline in physical functions, including renal, liver, gastrointestinal, and brain dysfunctions; 2) various comorbidities and medication for their treatment; and 3) social factors including economic problems, loneliness, and elderly care.

When taking care of elderly patients with chronic pain, it is important to set appropriate and realistic treatment goals, regardless of the diagnosis of chronic pain, while ensuring that organic diseases have not been overlooked.

The organization of medications is an important process in pharmacotherapy. Many elderly patients are prescribed numerous medications by multiple medical institutions. Some patients may even be treated for the side effects of medications prescribed by another medical institution. The condition of many patients can be improved simply by reassessment of their medications, after which, drugs with fewer side effects can be titrated up from small doses. It is important to remember that pharmacotherapy is regarded only as an adjunct in the treatment of chronic pain.

Background: Musculoskeletal disorders are the key cause of morbidity in elderly people. However, the exact reasons for musculoskeletal disorders related to healthy life expectancy remain elusive. Hence, we aimed to estimate gains in healthy life expectancy from the elimination of musculoskeletal disorders by using recent national health statistics data in Japan.

Methods: The present data were used from the population, life tables, and the number of deaths in Japan in 2016. Data regarding the activity and disease status of persons living at home were obtained from the 2016 Comprehensive Survey of Living Conditions. Data for persons admitted to hospitals and clinics were obtained from the Patient Surveys in 2014 and 2017. Data of elderly individuals admitted to healthcare and welfare facilities for long-term care were obtained from the 2016 Survey of Institutions and Establishments for Long-term Care. We selected eight disorders: rheumatoid arthritis, arthrosis, low back pain, osteoporosis, fracture, malignant neoplasms, ischemic heart disease, and cerebrovascular disease.

Results: There were small gains in life expectancy from elimination of rheumatoid arthritis, arthrosis, low back pain, osteoporosis, fracture, arthrosis, and low back pain and large gains from eliminating cerebrovascular diseases, ischemic heart disease, and malignant neoplasms. Elimination of rheumatoid arthritis, osteoporosis, and fracture slightly increased the expected years without activity limitation and slightly decreased years with activity limitation. Elimination of arthrosis, low back pain, and arthrosis and low back pain moderately increased expected years without activity limitation and decreased years with activity limitation. The elimination of malignant neoplasms greatly increased the expected years, both without and with activity limitation. Elimination of ischemic heart disease and cerebrovascular diseases increased the expected years without activity limitation; however, there were only minimal changes in years with activity limitation after eliminating these diseases.

Conclusions: These findings provide clear evidence that low back pain and arthrosis are the key conditions that can be addressed to prolong healthy life expectancy.

The prevalence of osteoporotic fractures continues to increase due to an aging society. In particular, osteoporotic vertebral fracture (OVF) affects activities of daily living and quality of life in elderly persons. Therefore, early diagnosis and treatment of OVF are important. Magnetic resonance (MR) image is useful in diagnosis, but it is sometimes difficult to diagnose whether fractures are fresh. In this review, we introduce our previous report and summarize previous papers on the diagnosis of OVF and artificial intelligence related to OVF. Our study included 814 patients with fresh OVF. A total of 1,624 slices of T1-weighted MR images were obtained and used for CNN training and validation. Furthermore, two spine surgeons independently evaluated 100 vertebrae, which were randomly extracted from the test data. To evaluate the performance of the CNN, we plotted a receiver operating characteristic (ROC) curve and calculated the area under the curve (AUC). We then compared the sensitivity, specificity, and accuracy of the diagnosis by CNN and that of the two spine surgeons. The AUC was 0.95. The evaluation metrics of the diagnosis (CNN/surgeon 1/surgeon 2) for 100 vertebrae were as follows: sensitivity 0.88 / 0.88 / 1.00; specificity 0.88 / 0.86 / 0.66; and accuracy 0.88 / 0.87 / 0.80. The performance of the CNN was comparable to that of the two spine surgeons in diagnosing fresh OVF on MR images. The performance of some diagnostic support tools using CNN has become comparable to that of specialists in various medical fields. Thus,such tools are expected to contribute to the highly accurate diagnosis of OVF in the near future.

Introduction: Peripheral nerves are deeply involved in low back pain. Ultrasound-guided injection enables accurate injection of solution into peripheral nerves, and more accurate interpretation of pathological conditions from the pain-relieving effect than blind injection. We will explain the basics of the clinical practice of ultrasound-guided injection targeting peripheral nerves for low back pain.

Technical Note: For ultrasound-guided injection, positioning, proper probe selection and scan technique, proper needle selection and needle insertion method, drug selection, accurate injection technique, and evaluation before and after injection are important. Ultrasound-guided hydrorelease, which injects saline into the paraneurium, is free of concerns about side effects caused by drugs. The main target nerves for ultrasound-guided injection are the posterior rami of the spinal nerves, the meningeal branch of the spinal nerve, the superior cluneal nerve, the middle cluneal nerve, the posterior femoral cutaneous nerve, and the superior gluteal nerve. The target nerve for injection is determined based on the site of pain and tenderness.

Conclusions: It is important to consider the pathophysiology of low back pain with neuropathy rather than rely on imaging.

Low back pain (LBP), a common symptom experienced by all age groups, has been reported to be the primary cause of disability worldwide. The aim of this study was to investigate changes in relative circulation over time in the lumbar multifidus in different standing positions between subjects with and without LBP.

Ten subjects (mean age, 21.0 years) with LBP (LBP group) for the past three months and ten healthy subjects (mean age, 21.1 years) without LBP (non-LBP group) were recruited. They received a full explanation of the study, and all agreed to participate. Near-infrared spectroscopy (NIRS) was used to non-invasively measure oxygenated hemoglobin (Oxy-Hb), deoxygenated hemoglobin (Deoxy-Hb), and total hemoglobin (Total-Hb) of the lumbar multifidus at the L5-S1 segment. All measurements were obtained in the neutral position, at trunk flexion of 30 degrees, and at trunk extension of 20 degrees while standing. The subjects were asked to move into either the flexed or the extended position from the starting (neutral) position in 3 seconds, timed by a metronome, and to maintain the positions for 30 seconds. The angles of the flexed and extended positions were measured with a goniometer, and self-made devices were used to properly maintain these positions. All participants received education and practice time to be able to perform the proper body movements and positions prior to assessment. The measurements were obtained at -3 seconds (neutral position), 0, and 30 seconds in each flexed and extended position while standing and compared between the LBP and non-LBP groups.

In flexion, there were no significant interactions in both LBP and non-LBP groups. In both groups, significant decreases were noted in Oxy-Hb, Deoxy-Hb, and Total-Hb once the trunk started moving into the flexed position (-3 to 0 seconds) on standing. There were also significant increases in Deoxy-Hb and Total-Hb from 0 to 30 seconds in the flexed position. In extension, there were no significant interactions in both the LBP and non-LBP groups. In both groups, significant increases were noted in Oxy-Hb, Deoxy-Hb, and Total-Hb.

The results of this study showed that the intramuscular circulation of lumbar multifidus decreased in both the LBP and non-LBP groups once the trunk started moving into the flexed position on standing. On the other hand, the intramuscular circulation of lumbar multifidus increased once the trunk started moving into the extended position in both the LBP and non-LBP groups.

Introduction: Preoperative psychological factors are widely recognized to negatively affect patient outcomes and satisfaction after lumbar spine surgery. Few published studies have looked at the potential of preoperative psychosocial interventions to improve outcomes. In our spine center, patients with lumbar spinal stenosis (LSS) participated in our rehabilitation program. The program consisted of preoperative information about the postoperative recovery courses and the standardized postoperative active rehabilitation interventions, including therapist-led exercise training and self-training. Information and rehabilitation interventions were given by the physiotherapists using the illustrated leaflet edited based on the data of our previous studies. The objective of this study was to evaluate the effects of our physiotherapist-led psychosocial interventions on patient-related outcomes and satisfaction after LSS surgery.

Methods: Patients with LSS who underwent decompression surgery with/without fusion from February 2018 to December 2018 were screened for anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). The patients were then divided into two groups: patients with anxiety and depression [HADS(+) group] and those without anxiety and depression [HADS(−) group]. The groups were compared using the following variables: demographic data; patient-related outcomes [Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ)] at preoperative and 3-month follow-up; and patients' satisfaction and relief of distress at 3-month follow-up.

Results: Twenty patients were in the HADS(+) group, with 54 patients in the HADS(−) group. Preoperative JOABPEQ category scores showed a significantly lower score in the HADS(+) group than in the HADS(−) group for four categories, with the exception of lumbar function.

Both groups achieved good functional outcomes with similar scores at 3-month follow-up in the categories of low back pain, walking ability and social function. However, the HADS(+) group had a significantly lower score in the categories of lumbar function and mental health. There were significant differences between groups in patients' satisfaction and relief of distress.

Conclusions: Although psychological distress is related to clinical and functional impairment in the preoperative period, postoperative improvements in patient-related outcomes were achieved even in patients with anxiety and depression. Our findings support the need for further research into the use of physiotherapist-led psychosocial interventions using illustrated information leaflet with standardized postoperative active rehabilitation among patients with psychological issues.

Introduction: The Denver SI-Joint Questionnaire (DSIJQ) is a questionnaire that asks about pain in the sacroiliac joint (SIJ) region and evaluates 10 disabilities that can result from sacroiliac joint disorders (SIJD), such as sitting time and instability of the SIJ region. In a previous study estimated the minimal clinically important difference (MCID) of the DSIJQ using the criteria of the Roland-Morris-Disability Questionnaire (RDQ) for patients with SIJD who underwent SIJ arthrodesis, and we found that the cutoff value was a total decrease of 12 points (> 24% improvement). This study aimed to examine the MCID of the DSIJQ in the SIJD conservative treatment group.

Methods: There were 17 patients (nine men and eight women; mean age 55.1±15.9 years) with SIJD diagnosed by SIJ injections between April and December 2020 and treated conservatively with hospitalization who were included in this study. The reliability and internal consistency of the DSIJQ, the mean of the total score of the DSIJQ and RDQ, respectively, at admission and discharge, the correlation between the two questionnaires, and the MCID of the DSIJQ were evaluated. A P-value less than 0.05 was considered significant.

Results: The DSIJQ had good reliability [Intraclass correlation coefficients (ICC) = 0.92] and internal consistency (α = 0.97). The mean DSIJQ score was 27.1 on admission and 16.1 at discharge (Δ -11.0), and RDQ was 13.1 on admission and 9.3 at the point of discharge (Δ -3.8) (p< 0.05). ΔDSIJQ and ΔRDQ were positively correlated (r = 0.54, p = 0.025). The MCID of the DSIJQ was reduced by 11 points (more than a 22% improvement).

Conclusions: In the surgical and conservative treatment of SIJD, the treatment outcome target may be to achieve an approximate improvement of 22-24% or more on the DSIJQ.

Introduction: The effects of physical therapy on elderly patients with adult spinal deformity with chronic low back pain have been observed sporadically, and the characteristics of patients who can be expected to show improvement are unknown. In this study, the patients characteristics associated with the improvement effect of physical therapy focusing on exercise therapy were verified, while the effect of physical therapy was verified.

Methods: Visual analogue scale (VAS), Six-minute work test (6 MWT), Timed Up and go test (TUG), and Japanese Orthopaedic Association back pain evaluation questionnaire (JOABPEQ) were evaluated before and after the intervention in 53 patients who had received 3 months of physical therapy. On statistical analysis, (1) verification of the intervention effect, (2) verification of the difference of various evaluation items before the intervention, and (3) the cutoff values of the items for which significance was found in (2) were performed.

Results: The VAS was improved in 22 patients (41%), and more than 1 domain of JOABPEQ was improved in 44 patients (83%). In the comparison before and after the intervention, significant improvements were seen in all items except for TUG. Of the various evaluations before the intervention, the VAS and 6 MWT were identified as being associated with improvement, with cutoff values of 53.5 and 243, respectively.

Conclusions: The results suggest that 3 months of physical therapy for elderly patients with adult spinal deformity with chronic low back pain can reduce low back pain, improve walking ability, and improve health-related quality of life. In addition, a VAS of over 52 mm and a 6 MWT of over 242 m were associated with improvement by physical therapy.

Introduction: Recent histological studies on musculoskeletal tissues with chronic pain demonstrated that the presence of abnormal growth of microvasculature often accompanied innervation of peripheral nerves. Subsequently, transcatheter arterial microembolization (TAME) was also applied to other intractable joint diseases, but its efficacy for low back pain has not been evaluated. The therapeutic effect of TAME in 6 patients with lumbar facet joint disease was evaluated.

Methods: The subjects included 6 patients (3 males and 3 females; average age 68.5 years; average duration of morbidity of 16.5 months) with lumbar facet joint disease. The relationship between the pain area and abnormal blood vessels was evaluated by angiography. The numeric rating scale (NRS) scores at rest, during movement, and during back bending and JOA scores before, 1 week, 1 month and 3 months after TAME were determined.

Results: Angiography showed the presence of abnormal blood vessels around the area of facet joints with pain and tenderness, and they disappeared after TAME in all cases. The pain improvement after TAME was observed at as early as 1 week, when judged by the NRS at rest, during movement and during back bending, and it continued for up to 3 months after surgery. The improvement rate of the JOA score was 31.4% at 3 months after TAME.

Conclusions: Abnormal blood vessels were observed in all cases of chronic lumbar facet joint disease, and improvement of pain related to lumbar facet joint disease continued for up to 3 months after TAME. TAME appears to be an effective intervention for lumbar facet joint disease, but further clinical studies were warranted.