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PubMed1995

Factors associated with choosing a chiropractor for episodes of back pain care.

Back pain is a common illness and chiropractors provide a large proportion of back pain care in the United States. This is the first study to systematically compare chiropractic patients with those who saw other providers for back pain. The authors analyzed data from the RAND Health Insurance Experiment, a community-based study of the use of health services. Insurance claims forms were examined for all visits specified by the patient as occurring for back pain. Visits were grouped into episodes using decision rules and clinical judgment. The primary provider of back pain care was defined as the provider who delivered most of the services. Sociodemographic and health status and attitudes variables of patients were examined for association with the choice of chiropractor. Multivariate logistic regression models were constructed to calculate adjusted odds ratios for independent predictors. There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits. Results indicated that chiropractors were the primary provider for 40% of episodes, and retained as primary provider a greater percentage of their patients (92%) who had a second episode of back pain care than did medical doctors. Health insurance experiment site, white race, male sex, and high school education were independent predictors of choosing a chiropractor. Conclusions suggested that chiropractors were the choice of one third of all patients who sought back pain care, and provided care for 40% of all episodes of care. Geographic site, education, gender, and income were independent patient factors predicting chiropractic use.

Adult↗

PubMed2005

Evidence-based medicine and the challenge of low back pain: where are we now?

Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.

Journal Article↗

PubMedDate not supplied

The impact of treatment confidence on pain and related disability among patients with low-back pain: results from the University of California, Los Angeles, low-back pain study.

BACKGROUND CONTEXT: Although many researchers and practitioners believe that patients' positive expectations of their treatment favorably influence clinical outcomes, there is little scientific evidence to support this belief. PURPOSE: To describe the level of patients' initial confidence in the success of their assigned treatment, by treatment group and other factors; and to estimate the effects of treatment confidence on subsequent changes in low-back pain and related disability. STUDY DESIGN AND PATIENT SAMPLE: Randomized clinical trial involving 681 patients treated for low-back pain in a managed-care facility in Southern California. OUTCOME MEASURES: Treatment confidence; and changes in three clinical measures of low-back pain: average pain, most severe pain and back-pain-related disability. METHODS: Patients were randomly assigned to one of four treatment groups: medical care with and without physical therapy, and chiropractic care with and without physical modalities. Information was collected by questionnaires at baseline, 2 weeks, 6 weeks and 6 months. Treatment confidence was measured just after randomization on a scale of 0 to 10. RESULTS: Treatment confidence was lowest, on average, for patients assigned to medical care only and highest for patients assigned to medical care plus physical therapy. Other predictors of high treatment confidence were having acute pain and being older, female and nonwhite. Although treatment confidence was only weakly associated with subsequent changes in low-back pain or disability in the total sample, high treatment confidence was associated with greater improvement among patients assigned to medical care plus physical therapy. CONCLUSIONS: Initial confidence in treatment for low-back pain varies by type of care and other factors. Higher confidence may have some beneficial effect on the course of low-back pain in certain patients, but this effect may depend on the type of interaction between client and provider.

Adult↗

PubMed1996

Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study.

BACKGROUND: A pathological cause cannot be identified for most new episodes of low back pain (LBP) presenting to the general practitioner. One important potential influence on susceptibility is previous pain experience. To accurately investigate the contribution of this phenomenon to the onset of new episodes of LBP a prospective population study is required. AIMS: To determine the relationship of prior pain in the back and other musculoskeletal sites to risk of subsequent new episodes of LBP. METHODS: The population studied included all 2715 adults from the South Manchester Back Pain Study who were free of LBP during the month prior to the baseline survey. At baseline a detailed musculoskeletal pain history was obtained. New episodes of LBP over the subsequent 12 months were ascertained by: (i) prospectively monitoring all primary care consultations in the study cohort (consulting episodes) and (ii) a follow-up survey after 1 year to determine new episodes during that 12-month period not leading to consultation (non-consulting episodes). RESULTS: The 12-month cumulative incidence of new consulting episodes was 3% in males and 5% in females, and for new non-consulting episodes 31% in males and 32% in females. Those with a history of previous LBP had twice the rate of new episodes, both consulting and non-consulting, compared to those with no LBP in the past. Neck pain or pain in other musculoskeletal sites at baseline also doubled the risk of a subsequent new episode of LBP. Adjusting for psychological distress and the other pain variables had little influence on the findings. CONCLUSION: In those currently free of LBP a previous history of the symptom substantially increases the risk of a further episode, with pain in other sites an equally strong independent predictor of subsequent LBP.

Adolescent↗

PubMed1996

[Guidelines for treating low back pain in primary care. The Israeli Low Back Pain Guideline Group].

Low back pain (LBP) is a common problem in primary care, the successful management of which poses special challenges for patients and practitioners alike. It has been estimated that all adults will suffer LBP sometime during their lifetimes. It is one of the most frequent reasons for visiting a primary care physician, yet practitioners often find it difficult and frustrating to treat. This medical protocol is concerned with the diagnosis, treatment, and follow-up of low back pain in adults. It was developed for community-based, primary care physicians (general practitioners, family physicians, and internists) to serve as a general outline, to be adjusted in accord with the individual's circumstances. The protocol provides a "Ten Commandments" for the care of LBP, outlines the background of the problem, presents an overall algorithm and deals with issues of diagnosis, imaging, and treatment. In general, LBP in primary care is conceived of as a benign ailment, and emphasis is placed on reducing pain, resuming functioning and returning to work. The main task of the physician is to distinguish the less than 10% of cases with serious, specific causes of LBP from the more than 90% with nonspecific etiologies. In the great majority of patients, imaging studies such as X-ray, CT, MRI, and bone scan, and also EEG are unnecessary.

Family Practice↗

PubMed2002

Comparison of spine motion in elite golfers with and without low back pain.

Low back pain is a common musculoskeletal disorder affecting golfers, yet little is known of the specific mechanisms responsible for this injury. The aim of this study was to compare golf swing spinal motion in three movement planes between six male professional golfers with low back pain (age 29.2+/-6.4 years; height 1.79+/-0.04 m; body mass 78.2+/-12.2 kg; mean +/- s) and six without low back pain (age 32.7+/-4.8 years; height 1.75+/-0.03 m; body mass 85.8+/-10.9 kg) using a lightweight triaxial electrogoniometer. We found that golfers with low back pain tended to flex their spines more when addressing the ball and used significantly greater left side bending on the backswing. Golfers with low back pain also had less trunk rotation(obtained from a neutral posture), which resulted in a relative 'supramaximal' rotation of their spines when swinging. Pain-free golfers demonstrated over twice as much trunk flexion velocity on the downswing, which could relate to increased abdominal muscle activity in this group. This study is the first to show distinct differences in the swing mechanics between golfers with and without low back pain and provides valuable guidance for clinicians and teachers to improve technique to facilitate recovery from golf-related low back pain.

Adult↗

PubMed2001

Surfing for back pain patients: the nature and quality of back pain information on the Internet.

STUDY DESIGN: A prospective, systematic review of web sites related to back pain. OBJECTIVE: To assess the nature and quality of back pain-related information on the World Wide Web during a 2-year period. SUMMARY OF BACKGROUND DATA: The Internet has become a rich source of medical information. Limited knowledge is available, however, about the quality of online resources. Although previous systematic reviews on medical-related web sites found problems in varying degrees with the credibility of information, no such review was conducted to assess the back pain-related sites. METHODS: A search of web sites was conducted in November 1996 using five search engines (AltaVista, Infoseek, Lycos, Yahoo, and Magellan) and two key terms ("back pain" and "back problems"). A sample of sites was evaluated by two independent reviewers. Each site was described by the type and nature of the sponsor, target audience, and content. Overall quality was assessed in terms of evidence-based information available. RESULTS: Seventy-four web sites were reviewed in 1996, and nine of them (12.2%) were identified as high-quality sites. Advertising was the focus of 80.8% of the sites. Eleven sites (14.9%) were found to be discontinued 1 year later, and 20 (27.0%) were not accessible by the reviewers at the 2-year follow-up evaluation. Of the remaining 54 sites, 44.4% were produced by for-profit companies, and most sites targeted people with back pain (63.0%). Only seven out of the nine high-quality sites held their ratings at the 2-year follow-up evaluation. CONCLUSION: Most back pain-related web sites can be classified as advertising. The quality varied considerably, resulting in difficulties for patients to find useful information in this field. The increasing number of people seeking medical information on the Web creates a need for more high quality sites. Further, systematic review of web sites should be encouraged to monitor the accuracy of Internet publication.

Bias↗

PubMed2000

Influence of occupational factors on the relation between socioeconomic status and self-reported back pain in a population-based sample of German adults with back pain.

STUDY DESIGN: Population-based cross-sectional postal survey and interview substudy. OBJECTIVES: To examine the association between socioeconomic status and severe back pain and to determine whether this association can be explained by occupational factors. SUMMARY OF BACKGROUND DATA: Like other disorders, back pain and its consequences are inversely related to indicators of high socioeconomic status. METHODS: The associations between indicators of socioeconomic status and presence or severity of current back pain (no back pain or back pain of low intensity and low disability versus back pain with high intensity and/or high disability) were investigated in a survey among German adults 25 to 74 years of age (n = 2731) and an interview substudy of 770 participants with a recent history of back pain.- RESULTS: In the survey, educational level was inversely associated with back pain and severe current back pain. Similarly, in the interview substudy, educational level, vocational training, occupational class, household income, and health insurance status were inversely related to severe current back pain. Age-adjusted and gender-adjusted odds ratios were 0.36 (95% confidence interval [CI] 0.25-0.52) for immediate educational level and 0.37 (95% CI 0.18-0.73) for high educational level. Recalled work tasks at the onset of back pain were significant risk factors of severe current back pain (heavy physical work: odds ratio [OR] 1.77, 95% CI 1.06-2.93; work in bent position among males: OR 1.89, 95% CI 1.03-3.46). After adjusting for occupational class or work tasks, the association between educational level and severe current back pain remained unchanged.- CONCLUSIONS: The findings support the hypothesis that severe back pain is less prevalent among adults of higher socioeconomic status. The underlying mechanism could not be explained by differences in self-reported occupational factors.

Adult↗

PubMed2006

[Low back pain in 2006: back to the root].

Low back pain is a major burden for health care. According to the International Classification of Function, it is a disability of complex origin. Risk factors for chronification are of psychosocial and not physical nature. Primary targets of treatment should be physical fitness and the self-management of problem by the patient. Awareness of the psychosocial factors (yellow, blue and black flags) which can disturb occupational reintegration should be developed. Rehabilitation is based on measures to modify patient's beliefs and fitness. The prescribed treatment should aim to relieve pain, correct disability, prevent relapses, inform and educate the patient. Every low back pain sufferer which does not improve in 1 month should be sent to a team skilled in handling this kind of problem.

Humans↗

PubMedDate not supplied

[Satisfaction of patients with cervical pain and low back pain in a rehabilitation service].

BACKGROUND: The aims of the present paper are: to reduce waiting time for treatment of patients with low back pain/cervical pain; to determine the degree of satisfaction of patients being treated by groups; and to determine whether there is correlation amongst satisfaction, improvement of pain and impact on the activities of everyday life. METHODS: Prospective observational study. STUDY POPULATION: users of the surgeries of a tertiary hospital and the specialties center attached to it, who attended surgery because of cervical/low back pain, and practiced a serie of exercises. PERIOD OF STUDY: 1 october 2001 to 1 April 2002. The instrument of measurement used for evaluating pain and disability was the Von Korff questionnaire for low back pain, with an adaptation of this questionnaire for cervical pain. STATISTICAL ANALYSIS: Wilcoxon's non-parametric test. RESULTS: Total number of patients 273 (176 with cervical pain and 97 with low back pain): 198 women and 75 men. Average age: 48.5 (20-81). The self perceived evaluation of the patients treated in a group improved in 72 subjects (p<0.0001) with cervical pain and in 33 (p<0.001) with low back pain. Post-treatment pain was significantly better (p<0.001) than pre-treatment pain in both groups. Its influence on the activities of everyday life did not achieve statistical significance. Perception of the information received was positive in the cervical group (p<0.05). CONCLUSIONS: Following the application of different techniques: reduction in number of patients and waiting time - decisive factors in the satisfaction of these patients; a good acceptance of group treatment was obtained, ameliorating pain. The degree of knowledge of their pathology only improved in the cervical group.

Adult↗

PubMed2005

Trunk muscle co-ordination during gait: relationship between muscle function and acute low back pain.

Low back pain costs billions of Euros annually in all industrialized countries. Often radiological diagnosis fails to give evidence of the pathogenesis of low back pain. Although psychophysiological characteristics have an influence, it seems that insufficient muscular spinal stabilization may play the major role in the development of low back pain. Assessment of trunk muscle stabilization activity during everyday activities is rare. Therefore, in this study healthy persons were investigated during walking on a treadmill at a speed of 4 km/h. Women (n = 16) with no history of back pain were investigated before and after a static loading situation of the spine, i.e. while wearing a waistcoat. After this loading situation four women developed pain (pain subjects). Surface EMG (SEMG) was taken from five trunk muscles of both sides. Grand averaged amplitude curves over stride, amplitude normalized curves and variation between all included strides were calculated for all muscles and subjects, respectively. The normal range of all calculated parameters was defined within the span between the 5th and the 95th percentiles of all pain free subjects. Data were evaluated according to deviations from the normal range. Already before the load situation, pain subjects showed considerable deviations from the normal range, mainly of their abdominal muscles. There was no relationship between magnitude of deviation and pain intensity, but perceived exertion was highest in those subjects who showed the most symptoms in terms of number of muscles being identified as considerably deviating from the normal range. No specific "dysfunction pattern" could be identified, which argues for highly individual mechanisms instead of a single target muscle. The results suggest cumulative effects of different disturbance levels resulting in acute back pain. Since deviations could be identified already before the pain occurred, disturbed muscle function seems to be a risk factor for developing back pain. Further investigations aimed at clear identification of and, as a second step, correction of muscle function are necessary.

Journal Article↗

PubMed2001

Imaging the pain of low back pain: functional magnetic resonance imaging in combination with monitoring subjective pain perception allows the study of clinical pain states.

Most brain imaging studies of pain are done using a two-state subtraction design (state-related design). More recently event-related functional magnetic reasonance imaging (fMRI) has also been used for studying pain. Both designs severely limit the application of the technology to clinical pain states. Recently we demonstrated that monitoring time fluctuations of perceived pain could be used with fMRI to identify brain regions involved in conscious, subjective perception of pain. Here we extend the methodology to demonstrate that the same approach can be used to study clinical pain states. Subjects are equipped with a finger-spanning device to continuously rate and log their perceived pain during fMRI data collection. These ratings are convolved with a canonical hemodynamic response function to generate predictor waveforms with which related brain activity can be identified. Chronic low back pain patients and a normal volunteer were used. In one series of fMRI scans the patient simply lies in the scanner and indicates spontaneous fluctuations of the subjective pain. In other fMRI scans, a straight-leg raising procedure is performed to exacerbate the back pain. In the normal volunteer, fMRI scans were done during painful and non-painful straight-leg raisings. The results indicate the feasibility of differentiating between different pain states. We argue that the approach can be generalized to identify brain circuitry underlying diverse clinical pain conditions.

Brain Mapping↗

PubMed2001

The efficacy of an aerobic exercise and health education program for treatment of chronic low back pain.

Low back pain is one of the most common and important musculoskeletal disorders. In addition, chronic low back pain can deteriorate the patient's physical, psychosocial and socioeconomic status. The objective of this quasi-experimental research was to assess the efficacy of an aerobic exercise and health education program in the treatment of chronic low back pain. Seventy-two patients whose ages ranged from 30 to 50 years who had chronic low back pain were enrolled and randomly assigned into two groups. Eight men and 28 women in the experimental group participated in a series of 3 health education sessions and an aerobic exercise training program. Nine men and 27 women in the control group received regular health education and a lumbar flexion exercise program. After a 3-month period of treatment, the results revealed the experimental group had statistically significant improvement of pain score and resting pulse rates when compared to the values of the control group (p-value < 0.001 and < 0.01, respectively). The average serum High Density Lipoprotein-Cholesterol (HDL-C) in the experimental group was also significantly higher (p-value < 0.05) than that of the control group. This health education program is useful and may be applicable to patients with chronic low back pain as an alternative treatment.

Adult↗

PubMed2000

Work-related low back pain.

Low back pain is a common problem among working adults in the United States. Occupational risk factors for low back pain include forceful lifting, bending and twisting of the trunk, whole body vibration and heavy manual labor. The initial assessment of the patient with low back pain requires obtaining an occupational history to identify risk factors in the workplace in addition to the usual inquiries and physical assessment. For those with uncomplicated low back pain, minimal use of medical tests and rapid return to limited activity are indicated. Long-term prevention of low back pain requires modification of occupational or other risk factors.

Adult↗

PubMed1991

Personality traits in patients with acute low-back pain. A comparison with chronic low-back pain patients.

This study investigates the possibilities to identify, within a group of acute low-back pain patients, individuals with psychogenic etiology to pain. 26 acute back pain patients and 25 healthy control subjects were tested with the Minnesota Multiphasic Personality Inventory Hysteria: (Hs), Hypochondria (Hy), Depression (D); Cesarek-Marke Personality Scale: Aggression (Agg), Defence of status (Dst), Guilt (Gui); Mood Adjective Check List: (Hedonism, Activity, Calmness = Hed, Act, Clm) and a 'pain questionnaire' including 'pain drawing'. Differences between groups and correlation patterns between test variables indicate that a combination of Hs, Hy, D, Dst, Gui, Hed, Act, Clm as well as predisposition to somatization, Som (a quantification of pain drawing) provides a useful predictive screening instrument.

Acute Disease↗

PubMed1992

Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low-back pain patients and subjects without low-back pain.

The interexaminer reliability of an inclinometer procedure to measure lumbar rotation was evaluated by two chiropractic clinicians who examined 25 chronic (greater than 6 months) low-back pain patients and 25 subjects without low-back pain. These groups were compared for differences in mean left, right, and total rotation. Patients who had lumbar spinal surgery were excluded. Twenty-eight men and 22 women, ranging in age from 28-38 years, were evaluated. Reliability between examiners was evaluated by Pearson's correlation coefficient and the intraclass correlation coefficient. All coefficients were significant (P less than 0.01). Errors in prediction and examiner disagreement were evaluated by the standard error of estimate and the interexaminer measurement error. The standard errors of estimate (range: 1.4-4.4) and the interexaminer measurement errors (range: 3.8-10.4) were large compared to the scale of measurement. An analysis of variance of differences between the chronic low-back pain patients and asymptomatics revealed significantly more left rotation in the asymptomatic subjects (F = 8.4; df = 1; P less than 0.006). Also, there was significantly more total rotation in the asymptomatic subjects (F = 4.143; df = 1; P less than 0.048). However, because of the large error attributed to this procedure, it is not possible to say whether the difference between the two groups is a result of the large error or some "real" difference. Therefore, the procedure described in this study should not be used as a clinical outcome measure.

Adult↗

PubMed1995

Low back pain.

Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral.

Ambulatory Care↗

PubMed2005

Effect of Iyengar yoga therapy for chronic low back pain.

Low back pain is a significant public health problem and one of the most commonly reported reasons for the use of Complementary Alternative Medicine. A randomized control trial was conducted in subjects with non-specific chronic low back pain comparing Iyengar yoga therapy to an educational control group. Both programs were 16 weeks long. Subjects were primarily self-referred and screened by primary care physicians for study of inclusion/exclusion criteria. The primary outcome for the study was functional disability. Secondary outcomes including present pain intensity, pain medication usage, pain-related attitudes and behaviors, and spinal range of motion were measured before and after the interventions. Subjects had low back pain for 11.2+/-1.54 years and 48% used pain medication. Overall, subjects presented with less pain and lower functional disability than subjects in other published intervention studies for chronic low back pain. Of the 60 subjects enrolled, 42 (70%) completed the study. Multivariate analyses of outcomes in the categories of medical, functional, psychological and behavioral factors indicated that significant differences between groups existed in functional and medical outcomes but not for the psychological or behavioral outcomes. Univariate analyses of medical and functional outcomes revealed significant reductions in pain intensity (64%), functional disability (77%) and pain medication usage (88%) in the yoga group at the post and 3-month follow-up assessments. These preliminary data indicate that the majority of self-referred persons with mild chronic low back pain will comply to and report improvement on medical and functional pain-related outcomes from Iyengar yoga therapy.

Adult↗