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PubMed2001

Low Back Pain.

Low back problems are extremely common. In the United States, it is estimated that 15% to 20% of the population, and approximately half of working-age adults, admit to back pain each year. Low back pain (LBP) is a symptom and not a specific disease, and there are a large number of potential causes. The vast majority of patients with LBP have a musculoskeletal cause. Ninety percent of patients with acute low back problems recover within a month with very conservative treatment. Because of the multiple possible causes in the musculoskeletal category, and because of the self-limited nature of most patients' pain, only about 15% of patients can be given a specific diagnosis to explain their LBP. Although 90% of patients with LBP have self-limited disease, recurrent attacks of pain are common, and approximately 10% of patients develop chronic LBP. In general, LBP is over-evaluated and over-treated, which results in wasted money and medical resources, and often yields inferior clinical outcomes. The physician's job, when evaluating a patient with acute LBP, is to look for "red flags"--symptoms and signs that should prompt additional evaluation and treatment. Without "red flag" conditions, LBP should be treated with "comfort control" measures only. These measures include activity modification and the use of simple analgesics. Manipulation therapy may be helpful in the short term (within the first month of onset), although other physical therapies are more helpful beyond 1 month from onset. Surgical intervention on the spine for patients without tumors, infection, and fracture should be reserved for patients with progressive or unrelenting compression of one or more lumbosacral nerve roots by a herniated intervertebral disk. Neurologists should be involved in the evaluation and treatment of patients with LBP, because many of the worrisome underlying conditions affect the nerve roots, and most of the surgical interventions are based on documentation of the presence of nerve root impingement. Neurologists can determine if these indications are present, and do not have a vested interest in recommending costly procedures.

Journal Article↗

PubMed2005

Myths and perceptions of back pain in the Norwegian population, before and after the introduction of guidelines for acute back pain.

AIM: Deyo's seven "myths" about back pain are based on common misconceptions of causality and therapy of back pain. These myths were alive in the Norwegian population in 2001; this report investigates whether this is true two years later. METHODS: A representative sample of the Norwegian population in 2003 (n = 1,014) were asked to rate their agreement with the seven myths. RESULTS: There is significantly less acceptance of all myths except "Most back pain is caused by injuries or heavy lifting" in 2003. Myths concerning the use and importance of X-ray were still common: 43% agreed that "X-ray and newer imaging tests can always identify the cause of pain" and 50% that "Everyone with back pain should have a spine X-ray". Low level of education is still associated with high acceptance of the myths, but the changes from 2001 are most pronounced for these groups. CONCLUSION: Perceptions in the general population in Norway are slowly changing to be more in accordance with existing knowledge on accurate behaviour and treatment of back pain. This may be related to introduction of new evidence-based guidelines. The difference between educational groups is reduced, but is still a challenge to health professionals and health authorities.

Acute Disease↗

PubMed1995

The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project.

BACKGROUND: Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. METHODS: Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. RESULTS: The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors. CONCLUSIONS: Among patients with acute low back pain, the outcomes are similar whether they receive care from primary care practitioners, chiropractors, or orthopedic surgeons. Primary care practitioners provide the least expensive care for acute low back pain.

Acute Disease↗

PubMed2003

UK Back pain Exercise And Manipulation (UK BEAM) trial--national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578].

BACKGROUND: Low back pain has major health and social implications. Although there have been many randomised controlled trials of manipulation and exercise for the management of low back pain, the role of these two treatments in its routine management remains unclear. A previous trial comparing private chiropractic treatment with National Health Service (NHS) outpatient treatment, which found a benefit from chiropractic treatment, has been criticised because it did not take treatment location into account. There are data to suggest that general exercise programmes may have beneficial effects on low back pain. The UK Medical Research Council (MRC) has funded this major trial of physical treatments for back pain, based in primary care. It aims to establish if, when added to best care in general practice, a defined package of spinal manipulation and a defined programme of exercise classes (Back to Fitness) improve participant-assessed outcomes. Additionally the trial compares outcomes between participants receiving the spinal manipulation in NHS premises and in private premises. DESIGN: Randomised controlled trial using a 3 x 2 factorial design. METHODS: We sought to randomise 1350 participants with simple low back pain of at least one month's duration. These came from 14 locations across the UK, each with a cluster of 10-15 general practices that were members of the MRC General Practice Research Framework (GPRF). All practices were trained in the active management of low back pain. Participants were randomised to this form of general practice care only, or this general practice care plus manipulation, or this general practice care plus exercise, or this general practice care plus manipulation followed by exercise. Those randomised to manipulation were further randomised to receive treatment in either NHS or private premises. Follow up was by postal questionnaire one, three and 12 months after randomisation. The primary analysis will consider the main treatment effects before interactions between the two treatment packages. Economic analysis will estimate the cost per unit of health utility gained by adding either or both of the treatment packages to general practice care.

Adult↗

PubMedDate not supplied

Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice.

BACKGROUND: Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain. METHODS: For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat. FINDINGS: Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded. INTERPRETATION: Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

Acute Disease↗

PubMed1977

Back pain: osteoarthritis.

Back pain is one of the chief complaints of the elderly. It may be either a chronic deep skeletal muscular pain or an acute circumscribed pain arising from nerve-root irritation. The main causes of back pain in older people are: 1) degenerative changes (spondylosis, osteoarthritis, ankylosing hyperostosis); 2) malignancy (multiple myeloma, metastases from carcinoma or lymphoma); and 3) metabolic disorders (osteoporosis, osteomalacia, chondrocalcinosis, Paget's disease). Mechanisms and variations are discussed in detail.

Adolescent↗

PubMed2006

[The role of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain. A randomized controlled trial in a rehabilitation unit].

OBJECTIVES: To compare the efficacy of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain referred to a rehabilitation department. METHODS: An alternate-month design was used for 142 patients with subacute or chronic low back pain who were hospitalized for treatment. Seventy-two patients received written standardized information about back pain (the "back book") and usual physical therapy (intervention group), and 70 received usual physical therapy only along with nonstandardized oral information (control group). The main outcome measure was disability (measured on the Quebec back-pain disability scale), and secondary outcome measures were pain intensity (measured on a visual analog scale), fear-avoidance beliefs (measured on the Fear-Avoidance Beliefs Questionnaire [FABQ] Physical component), and knowledge of the relation of back pain to physical activity assessed at baseline, just before discharge from the hospital and 3 months after discharge. Satisfaction related to the information received was assessed on the day of discharge. RESULTS: Receiving the "back book" had a significant impact on disability at 3 months, from 48.40+/-14.55 to 34.57+/-18.42 in the intervention group and from 52.17+/-16.88 to 42.40+/-14.95 in the control group (p=0.03). Receipt of the book also had a significant impact on patients' knowledge and satisfaction about information but a nonsignificant effect on fear-avoidance beliefs. CONCLUSIONS: Providing an information booklet about back pain to patients with subacute and chronic low back pain referred to a rehabilitation unit contributes to reduced disability in these patients.

Adult↗

PubMed1988

Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients.

Mobility of hips and lumbar spine were measured in 301 men and 175 women who were in employment but suffered from chronic or recurrent low-back pain. The degree of low-back pain (LBP) was assessed with a questionnaire. Hip flexion, extension, internal rotation, and hamstring flexibility in the men, and hip flexion and extension in the women had statistically significant negative correlations with LBP. Among the correlations between hip and lumbar spinal mobility, hip flexion and extension with lumbar rotation were strongest.

Adult↗

PubMed1996

Bone SPECT imaging of the painful back.

Bone SPECT imaging offers advantages over planar techniques based on improved contrast enhancement plus tomographic effect, with the latter allowing for precise anatomic localization of an abnormality. This is important when evaluating patients with back pain because placement of a lesion in the vertebral body, component of the vertebral arch, or disc space region significantly affects diagnostic possibilities and, in some circumstances, can effectively exclude malignancy in favor of benign disease. Such an approach to SPECT interpretation requires high-quality images capable of precise anatomic placement of a lesion and a systematic method of analysis based on recognition of normal anatomic relationships plus knowledge of the common presentations of bony abnormalities shown on SPECT scanning.

Back Pain↗

PubMedDate not supplied

Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain.

BACKGROUND CONTEXT: A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain (LBP) illness. Although the relative contributions of structural and psychosocial variables are intensely debated, the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects. These factors dictate the requirement for large sample sizes, extensive structural imaging and extended longitudinal study. Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline. PURPOSE: To establish, using a strict patient sample design, the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness. STUDY DESIGN/SETTING: A prospective, longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics. PATIENT SAMPLE: One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic (non-lumbar) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease, to undergo baseline examination, testing and 5-year follow-up. OUTCOME MEASURES: Observations were made at 6-month intervals over 4 to 6 years (mean, 5.3) for the after primary outcomes measures: episodes of serious back pain (visual analogue scale [VAS] > or =6), episodes of occupational disability less than 1 week, episodes of occupational disability for 1 week, remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment. METHODS: Lumbar magnetic resonance imaging (MRI), lumbar provocative discography (in psychometrically normal subjects), physical examinations, medical and work histories and psychometric testing were performed at baseline. Imaging and psychometric testing were graded by blinded examiners. A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data. The interview covered interval medical, occupational and accident or injury histories. RESULTS: Psychosocial variables strongly predicted both long- and short-term disability events, duration and health-care visits for LBP problems (p<0.0001-0.004). The likelihood of a sustained remission from the baseline persistent (subclinical) LBP appeared to be linked to occupation factors (leaving a heavy labor occupation; p=0.0001), neurophysiologic variables (chronic nonlumbar pain; p=0.0002) and psychometric profiles at baseline (DRAM and FABQ-PA; p=0.003-0.002). Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome. A positive provocative discogram at baseline did not predict any future adverse event. CONCLUSION: The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables. Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care.

Adult↗

PubMed1999

Recurrence and care seeking after acute back pain: results of a long-term follow-up study. North Carolina Back Pain Project.

OBJECTIVE: To explore the relationship between type of initial care as well as the likelihood of recurrence and consequent care seeking behavior. RESEARCH DESIGN: Prospective observational cohort recruited from 208 randomly selected North Carolina practices. Cohort study examined the recurrence of low back pain among patients free of back pain 3 months after their index visit to a practitioner for that problem. The following four practitioner strata were examined: primary care providers, chiropractors, orthopedic surgeons, and practitioners in a group model HMO. Patients were interviewed by telephone at 6 and 22 months after the initial visit. MAIN OUTCOME MEASURES: Rates of disabling and non-disabling low back pain; functional status using the Roland back disability scale; and care seeking. RESULTS: Rates of recurrence were substantial; functionally disabling recurrence rates varied between 8% and 14% between 3 to 6 months, and 20% to 35% between 6 to 22 months. Differences in rates among practitioner strata were statistically significant only between 6 to 22 months with higher recurrence rates for HMO patients. Functional status, number of bed days, and time off work were very similar among the practitioner strata. Care seeking, however, was greater among those patients who had initially seen a chiropractor for their back pain. Patients with recurrence saw the same practitioner type they had seen for the index episode 88% of the time. Satisfaction was slightly greater for patients who saw chiropractors when compared with patients seeing allopathic physicians. CONCLUSIONS: The recurrence of low back pain is common. Severe disability is rare. Patients who had sought care from chiropractors are more likely to return for recurrences than patients who had initially sought care from MDs.

Acute Disease↗

PubMed2003

Back pain online: a cross-sectional survey of the quality of web-based information on low back pain.

STUDY DESIGN: A cross section of Web sites accessible to the general public was surveyed. OBJECTIVE: To evaluate the quality of information on low back pain and its treatment that a "typical" patient user might access on the Internet. SUMMARY OF BACKGROUND DATA: Individuals with back pain have a desire to learn about their condition, what to expect, and what they can do about it. Web sites play a potentially useful role in providing information to help people learn about their low back pain and select the most appropriate methods of management. METHODS: A general search using popular search engines located 60 Web sites about back pain for review. A list of criteria for evaluating and scoring back pain Web sites was established using available literature and current clinical guidelines for the management of acute low back pain. The total quality score (maximum score, 38) was composed of two separate scores: one for general quality of the site (maximum score, 14) and one for site content specific to low back pain (maximum score, 24). Statistical tests, as appropriate, were used to investigate the relation between general indicators of Web site quality and total scores obtained. RESULTS: The quality of the Web sites surveyed was poor, most of them (n = 58, 97%) scoring less than half the maximum available score. The mean total score was 7.4 (range, 2-25). The mean score was 4.9 (range, 1-12) for general Web site quality and 2.4 (range, 1-13) for content specific to low back pain. Web sites providing references, sites created more recently, and sites not created for advertising purposes tended to be of better quality. CONCLUSIONS: This study highlighted the poor quality of information, particularly information about low back pain, available to "typical" patient users on the Internet. Health care professionals must have a role in evaluating existing information and in developing good-quality evidence-based Web sites. Patients with back pain should be discouraged from using the Internet as a source of information unless the Web sites they access have been evaluated and found to provide evidence-based messages.

Back Pain↗

PubMed1997

Treatment of occupationally acquired low back pain.

Lumbosacral back pain is one of the most common reasons for patients with a work-related injury to present to a primary care physician. In most cases, low back pain has a good prognosis, but the condition is often the source of much frustration for clinicians, patients and employers. The family physician should be able to treat the patient's symptoms and address the psychosocial issues that frequently complicate recovery. Three decision points, based on the history and physical examination, allow the physician to determine the severity of illness and implement an appropriate treatment plan. These three points are as follows: Is it likely that systemic disease or bone pathology is the cause of pain? Has neurologic compromise occurred? Are social or psychologic stressors present that may prolong the clinical course?

Algorithms↗

PubMed1985

Low back pain.

Low back pain is one of the most common and costly afflictions of our Society. The majority of adults will have at least one episode of acute low back pain that will likely resolve regardless of treatment. Lumbar spine radiographs are overused and there is little scientific support for many of the therapeutic interventions advocated. Even for those patients with symptomatic herniated disc, only a small fraction will ultimately require surgical intervention.

Arthritis↗

PubMed1989

Radiologic investigation of low back pain.

Low back pain is one of the commonest disorders, yet is the most confusing. The cost in work-time lost and in the search for and treatment of its many causes amounts to billions of dollars annually. The traditional techniques for anatomic visualization have been plain-film radiography and myelography, but they have limitations. The development of computed tomography and magnetic resonance imaging have substantially improved anatomic imaging. However, invasive procedures, such as discography, percutaneous nerve-root blocking and percutaneous facet injection, may be helpful in patients with disabling pain in whom noninvasive methods give negative findings, show abnormalities that do not correlate with the symptoms or identify multiple sites of disease. The invasive procedures are believed by some to be associated with too many complications. We have attempted to clarify the strengths and weaknesses of the currently available methods of investigating low back pain and the indications for their use.

Adult↗

PubMed2001

A nonsurgical approach to low back pain.

Low back pain, a leading cause of disability in the United States, has a significant economic impact not only on lost productivity but also on healthcare expenditures. Approximately a fifth of patients will see multiple physicians in their quest for relief of low back pain. Primary care physicians therefore play a crucial role in the initial approach to these patients. A thorough history and physical examination directed toward the neurologic, orthopedic, and osteopathic evaluation are essential. This article reviews the diagnosis and assessment of pain levels and a triad system of therapy involving cortical, spinal, and peripheral levels. Options include antidepressants, neuroleptics, neurostimulants, and osteopathic manipulative treatment (OMT) (cortical level); opiates, tramadol hydrochloride, and transcutaneous electrical nerve stimulators (spinal level); and nonsteroidal anti-inflammatory drugs, epidural injections, spinal blocks, antispasmodics, physical therapy, muscle relaxants, exercise, and OMT (peripheral level), By choosing a modality directed at each level, the clinician may provide the patient with a pain management program that will maximize the chosen mode of therapy and restore function and mobility.

Analgesics↗

PubMed2002

[Contribution of psychosocial factors in chronic low-back pain].

Low back pain (LBP) is a highly prevalent and costly cause of disability. In spite of a large amount of research in this field, there is still controversy about which factors are more important to determine chronicity in low back pain. Recent results have shown that LBP becomes a chronic condition mainly because of the relationship between psychosocial factors and pain. This relationship would explain the resistance of chronic LBP to classical medical treatment, which results in absenteeism and high economical costs. In this study we review recent results, including our own, that elucidate the contribution of psychosocial factors to chronic LBP. A biopsychosocial approach to these patients is highly recommended.

Chronic Disease↗

PubMed2006

Chronic low back pain.

Low back pain (LBP) is one of the most prevalent medical problems in society today. In addition to the profound effect LBP can have on patients, it has an exceedingly high societal cost. Although most acute episodes of back pain will ultimately resolve, this condition will become chronic for many. Those with chronic LBP are a challenge to treat. Nonetheless, with a better understanding of the underlying pathophysiology and treatment options, our management of these patients is gradually improving. Conservative therapy remains the mainstay treatment of chronic LBP. If this has failed, surgical options may be considered in the carefully selected patient. Fusion is the most established treatment option for this condition. Disc arthroplasty is being increasingly considered. Class I studies critically evaluating established and evolving technologies continue to help shape our understanding of the surgical options for this condition.

Chronic Disease↗