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PubMed2004

Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits.

BACKGROUND: Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. HYPOTHESIS: There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. STUDY DESIGN: A cross-sectional study. METHODS: Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABERE's distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. RESULTS: 33% of golfers had previously experienced low back pain. A statistically significant correlation (P <.05) was observed between a history of low back pain with decreased lead hip internal rotation, FABERE's distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. CONCLUSIONS: Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.

Adult↗
PubMed2002

Management of back pain.

PURPOSE: Low back pain (LBP) constitutes one of the most difficult and costly medical problems in industrial countries, with a prevalence of 25 to 30% in an adult lifetime span and an incidence of about 5% per year. METHOD: Based on risk factors cited in the pertinent literature, the evaluation, diagnosis and therapeutic options for LBP are outlined. Especially the latter can be highlighted on the basis of a large number of systematic reviews. RESULTS: Bed rest is no longer regarded as an effective treatment for episodes of acute LBP, except when the patient has evident clinical signs of nerve root compression. Exercise therapy comprises a wide range of concepts and underlying physiological principles. Different concepts are discussed. Evidence suggests no specific effects of exercise therapy in acute LBP. In chronic LBP, exercise as well as combined treatment with several modalities appear to be superior to conventional medical care. In the past decade, reconditioning of the paraspinal muscles is being given increasing importance in research. Several studies indicate the effectiveness of vigorous strengthening of paraspinal and trunk muscles on pain and even disc surgery. Different underlying pathologies seem to respond equally well to this concept. Back school concepts are not proven to have long-term effects on LBP. The literature on electrotherapy and massage in LBP is generally sparse. Nevertheless, some studies suggest the effectiveness of electrotherapy on pain reduction at least in the short term. Spinal mobilization seems to be effective in reducing pain. CONCLUSION: Based on these evidence-based conclusions, the patient's medical history, the investigation and the diagnosis the clinician has to devise an individual treatment plan that takes the deficiencies and requirements of the patient into account.

Evidence-Based Medicine↗
PubMed1992

Contribution of vertebral deformities to chronic back pain and disability. The Study of Osteoporotic Fractures Research Group.

Among 2992 white women aged 65-70 years recruited from population-based listings, we measured radiographic vertebral dimensions of T5-L4 and calculated ratios of heights: anterior/posterior, mid/posterior, and posterior/posterior of either adjacent vertebra. The degree of deformity for each vertebra was analyzed in terms of the number of standard deviations (SD) that ratio differed from the mean ratio calculated for the same vertebral level in this population. We correlated the severity of each woman's worst vertebral deformity with back pain, back disability in six activities of daily living, and height loss since age 25. Only 39.4% of the cohort had no vertebral deformity; 10.2% had a deformity greater than or equal to 4 SD. Vertebral deformities less than 4 SD below the mean were not associated with increased back pain, disability, or loss of height. In contrast, women whose deformity was greater than or equal to 4 SD had a 1.9 (95% CI, 1.5-2.4) times higher risk of moderate to severe back pain and a 2.6 (95% CI, 1.7-3.9) times higher risk of disability involving the back; they were also 2.5 (95% CI, 2.0-3.2) times more likely to have lost greater than or equal to 4 cm in height. All three types of vertebral deformity (wedge, end plate, and crush) were equally associated with these outcomes. Multiple deformities less than 4 SD did not increase the likelihood of these three outcomes, but multiple deformities greater than or equal to 4 SD tended to be associated with increased back pain, disability, and height loss. This large cross-sectional study suggests that vertebral deformities cause substantial pain, disability, or loss of height only if vertebral height ratios fall 4 SD below the normal mean. Much back pain could not be attributed to vertebral deformities, suggesting other causes.

Aged↗
PubMed1999

[Low back pain].

Many people suffer from low back pain in the course of their life, of whom not all seek health care. In the majority of patients who seek care and refrain from work, the problem of pain resolves within a few weeks. It is reason that chronic pain syndromes such as chronic back pain are responsible for enormous costs for health care and society. Also, many diagnostics procedures and durability of rehabilitation makes low back pain as a very expensive disease. All of that are good reasons to make algorithm for diagnostic and treatment of low back pain in Croatian Society for Rheumatology.

Humans↗
PubMed2005

The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability.

The present study examined the contribution of physical pathology, pain-related fear and catastrophizing cognitions to pain intensity and disability in 100 patients with non-specific low back pain. Self-report instruments were completed as part of the intake procedure of patients, while physical pathology was quantified from medical charts using the MEDICS procedure. Results of the multiple regression analyses, adjusted for relevant demographic variables, pain intensity and pain duration, indicated that physical pathology was associated with pain intensity, but not with self-reported physical disability. Disability showed the strongest association with pain intensity. However, pain-related fear and catastrophizing contributed 4-10% additional explained variance to the regression models for pain intensity and disability. Thus, this study confirms the relationship between biological and psychological variables in determining the severity of low back pain complaints, and underscores the necessity for a multidisciplinary approach to diagnostics and intervention.

Activities of Daily Living↗
PubMed1995

A time series analysis of the relationship between ambulatory EMG, pain, and stress in chronic low back pain.

Twenty-one subjects with chronic back pain (CBP) participated in an ambulatory electromyography (EMG) monitoring study to ascertain the relationships between muscle activity, physical activity, psychosocial stress, and pain. A time-series analysis approach was adopted to investigate both immediate and lagged associations between these variables in an attempt to determine potential causal relationships. Results for group relationships showed a significant relationship between physical activity and pain, self-report of stress and pain, but no relationship between EMG activity and pain. A lagged relationship between physical activity and pain was found, suggesting a causal relationship between physical activity and pain. However, no time lag was observed between stress and pain, hence no causal relationship can be elucidated. Analysis at the individual level indicated stronger relationships between several combinations of these variables, highlighting the need to consider the heterogeneity of the CBP population and etiology of CBP. The use of ambulatory monitoring of pain, stress, and EMG is suggested as one avenue to further explore the population's heterogeneity.

Adult↗
PubMed2003

Development of a metric for a day of manageable pain control: derivation of pain severity cut-points for low back pain and osteoarthritis.

The objective of this study was to adapt the concept of 'episode-free day', a metric for measuring symptom relief in daily units, to the clinical outcome literature for persistent pain. The episode-free day metric is widely used in other medical literature, but no analogous measure exists in pain literature. Prior focus groups with this population suggested that a 'Day of Manageable Pain Control' was an appropriate name for the metric. In the present study, in order to derive a statistical criterion for 'Manageable Day', we used Serlin et al.'s (Pain 61 (1995) 277) cut-point derivation method to derive a single cut-point on a 0-10 scale of average pain that divided groups with significant persistent pain optimally on pain-related functional interference. Participants were 194 patients with moderate-severe low back pain (n=96) or osteoarthritis (n=98). For both patient samples, '5' was the cut-point that optimally distinguished groups on pain-related interference. '5-8' and '5-7' were double cut-point solutions that optimally divided LBP and OA samples into three categories (e.g. lowest, medium and highest average pain), respectively. Derived cut-points were confirmed using a variety of measures of functional disability. Together with research that showed that average pain ratings of approximately 5 and below permit increased function and quality of life in patients with moderate to severe low back pain and osteoarthritis, our findings provide support for the use of 0-5 on a 0-10 numeric average pain severity scale as one possible criterion for a Manageable Day.

Activities of Daily Living↗
PubMed2005

Efficacy of etoricoxib 60 mg/day and diclofenac 150 mg/day in reduction of pain and disability in patients with chronic low back pain: results of a 4-week, multinational, randomized, double-blind study.

BACKGROUND AND METHODS: The efficacy and safety of etoricoxib 60 mg/day in patients with established chronic low back pain (CLBP) were compared with those of diclofenac 150 mg/day in a 4-week, multicentre, randomized, double-blind, parallel-group trial. Four hundred and forty-six adult patients with CLBP (Quebec Task Force on Spinal Disorders Class 1 or 2) and with worsening pain upon discontinuation of pre-study analgesic medication were enrolled in the study. The study primary efficacy endpoint was change from baseline in Low Back Pain Intensity Scale (LBP-IS) score over the 4-week treatment period. Secondary and other efficacy endpoints included: changes in Roland and Morris Disability Questionnaire (RMDQ), Patient Global Assessment of Response to Therapy (PGART) and Low Back Pain Bothersomeness Scale (LBP-BS) scores. Early efficacy was assessed using PGART and LBP-IS scores 4 h after the first dose on the mornings of Days 1, 2 and 3. The overall safety and tolerability of etoricoxib 60 mg/day during 4 weeks of treatment were also assessed. RESULTS: The least-squares mean time-weighted change from baseline LBP-IS score over 4 weeks was -32.94 mm (95% CI -36.25, -29.63) for etoricoxib, indicating substantial efficacy in relief of pain. The treatment difference for the primary outcome was 2.51 mm (95% CI -1.50, 6.51), fulfilling the prespecified equivalence criterion of 95% confidence interval wholly within +/- 10 mm. Etoricoxib improved all secondary and other efficacy outcomes. There were no statistically significant between-group differences in the proportion of patients with one or more clinical adverse events (AEs) (etoricoxib 35%, diclofenac 39%), or the proportion of patients who discontinued due to AEs (etoricoxib 7%, diclofenac 5%). CONCLUSIONS: The results of this study confirm that, for adult patients with CLBP, etoricoxib 60 mg once daily over 4 weeks is effective for relief of pain and improvement of physical function and comparable to high-dose diclofenac 150 mg daily.

Adult↗
PubMed2004

Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain.

UNLABELLED: The long-term effect of percutaneous electrical nerve stimulation (PENS) on chronic low back pain (LBP) is unclear. We evaluated the number of sessions for which PENS should be performed to alleviate chronic LBP and how long analgesia is sustained. Patients underwent treatment on a twice-weekly schedule for 8 wk. Group A (n = 18) received PENS for 8 wk, group B (n = 17) received PENS for the first 4 wk and transcutaneous electrical nerve stimulation (TENS) for the second 4 wk, and group C (n = 18) received TENS for 8 wk. Pain level, degree of physical impairment, and the daily intake of nonsteroidal antiinflammatory drugs (NSAIDs) were assessed before the first treatment, 3 days after Week 2, Week 4, and Week 8 treatments, and at 1 and 2 mo after the sessions. During PENS therapy, the pain level decreased significantly from Week 2 in Groups A and B (P < 0.05 or 0.01), and physical impairment and required NSAIDs decreased significantly from Week 4 (P < 0.05 or 0.01) in Group A but only at Week 4 in Group B (P < 0.05 or 0.01). These effects were sustained until 1-mo follow-up (P < 0.01) in Group A but not in Group B; these effects were not observed at 2-mo follow-up even in Group A. In Group C, pain level decreased significantly only at Week 8 (P < 0.05). Our results indicate that repeated PENS is more effective than TENS for chronic LBP but must be continued to sustain the analgesic effect. IMPLICATIONS: A cumulative analgesic effect was observed in patients with chronic low back pain (LBP) after repeated percutaneous electrical nerve stimulation (PENS), but this effect gradually faded after the treatment was terminated. Results indicate that although PENS is effective for chronic LBP, treatments need to be continued to sustain analgesia.

Adult↗
PubMed1985

Cross-validation of the Back Pain Classification Scale with chronic, intractable pain patients.

The current study investigated the utility of the Back Pain Classification Scale with chronic, intractable low back pain and headache patients. Subjects consisted of 50 chronic low back pain and 50 chronic headache patients referred to a university based Pain Center for evaluation. Data indicated that subjects were a representative sample of severely intractable chronic pain patients typically referred for Pain Center evaluation and treatment. Each was administered the Back Pain Classification Scale as part of a thorough physical and psychological/behavioral evaluation. All subjects were classified by blind review of medical records into one of two categories: (1) presence of psychopathologically based pain complaint with little or no pathophysiological findings and (2) presence of pathophysiologically based pain complaints with little or no psychopathological findings. Subjects were also independently classified from blind review of their scores on the Back Pain Classification Scale into one of these two categories. Findings revealed that the Back Pain Classification Scale accurately predicted the actual classification of 80% of the low back pain patients (i.e., 30% above baseline prediction rate) and only 60% of the chronic headache patients (i.e., only equal to the baseline prediction rate). Furthermore, the scale was found to be most accurate in predicting low back pain patients with primary psychopathologically based pain. It was concluded that the Back Pain Classification Scale was an empirically valid instrument to use with chronic low back pain patients, but not with chronic headache patients. This lack of utility with chronic headache patients was also viewed as support for the construct validity of the scale. Wider use of the scale with chronic low back pain patients was suggested.

Adult↗
PubMed1993

Prediction of pain in patients with chronic low back pain: effects of inaccurate prediction and pain-related anxiety.

This study investigated predictions of pain intensity, reports of pain and anxiety, frequency of pain-related anxiety symptoms, and range of motion, in 43 patients exposed to pain during a physical examination. All patients had primary complaints of low back pain. The pain stimuli used for this study included back and/or leg pain produced by repeatedly raising the extended leg of the patient to the point of pain tolerance. Generally, findings demonstrated that (a) predictions of pain were a function of discrepancies between previous predictions and experiences of pain, (b) patients reporting greater pain-related anxiety showed a tendency to overpredict new pain events, but corrected their predictions readily, (c) patients reporting less pain-related anxiety displayed a persistent tendency to underpredict pain, and (d) higher predictions of pain, independent of pain reports, related to less range of motion during a procedure that involved painful movement. Discussion focuses on differences between these results and those of previous studies and the implications of inaccurate prediction for continued pain and disability.

Adult↗
PubMedDate not supplied

The use of bone scan to investigate back pain in children and adolescents.

Children with back pain frequently undergo detailed investigation because of the perception that a high percentage will have a treatable spinal condition. The purposes of this study was (i) to determine the percentage of children with disabling back pain presenting to our institution who had a diagnosis (i.e., to explain their back pain), (ii) to evaluate the clinical markers that should alert clinicians to underlying pathology, (iii) and to determine the prognosis of children with back pain and no specific diagnosis. This study was a retrospective analysis of consecutive children undergoing single-photon emission computed tomography for a primary complaint of back pain. Data collection included chart review, radiographic analysis, and clinical follow-up with the Roland and Morris scale for pain and disability. Two hundred and seventeen patients with an average age of 13 years (range, 2.7-17.7) were reviewed on average 4.4 years after presentation (range, 1.1-7.2 years). One hundred and seventy children (78.3%) had no specific diagnosis to explain their back pain, 15 children (6.9%) had spondylosis, 10 children (4.6%) had tumor, and the remaining 22 children (10.1%) had various diagnoses including infection, Scheuermann's kyphosis, herniated disc, kidney disease, facet arthritis, degenerative disc disease, congenital anomalies, and tethered cord. Factors associated with positive diagnoses were constant pain and male gender. Night pain, constant pain, and duration of symptoms <3 months were associated with the diagnosis of a tumor. Although the majority of children presenting with persistent back pain had no demonstrable cause, of 132 contactable patients 94 (71%) had persisting pain at the time of clinical follow-up. In conclusion, the majority of children with disabling back pain has no demonstrable cause and the majority will continue to have pain years after initial presentation.

Adolescent↗
PubMed1995

Sudden onset of back pain.

Patients attending a back pain clinic completed a structured interview, with particular reference to whether onset of the first episode of back pain was sudden or insidious. They were classified into four diagnostic groups. A significantly higher proportion of patients who had experienced a sudden onset of pain suffered from sciatic pain with positive root tension signs than was the case with patients whose pain had started more insidiously (50.8% vs. 20.6%; P < 0.001). These patients were also more likely to be male, to have been lifting or twisting with a weight, and to have been confined to bed or hospitalised, and have undergone manipulations, than patients with insidious onset of their pain.

Acute Disease↗
PubMed2004

Back pain--individual and genetic factors.

BACKGROUND: In research, back pain can be classified in several ways. This presentation will deal with 'self-reported back pain', which is a proxy measure of 'having back pain'. The terms 'individual factors' cover many aspects of human life. They also interact with external factors, such as work and environment. Back pain is prevalent at all ages, although the incidence (onset) probably is highest in the early teens. Causative and modifying factors may differ throughout life and it is not sure that the etiology of 'back pain' remains the same. If we are to prevent and treat back pain in an efficient way, it is essential that we understand the circumstances that bring it on or prevent it from getting better. The mode of action would depend on whether the responsibility lies mainly with the individual, for example through a change of life-style, or with others, for example by altering the work place. METHOD: My presentation will consist of three elements, evidence obtained from: (1). systematic literature reviews, (2). epidemiologic studies, and (3). genetic epidemiologic studies. All the information presented is based on own work and pertains to children/adolescents and adults, mostly in relation to low back pain (LBP). The evidence will be reviewed in the light of 'the weight of evidence' on the topics of: genetics, sedentary life-style, type of work and imaging findings. Also factors relating to social class and physical/psychological robustness will be discussed. RESULTS: There is evidence for a relatively strong genetic component to LBP, both in the young and in adults. Hard work is strongly linked to LBP and there is a moderate link with abnormal imaging findings (spinal pathology in the young and discal degeneration in both the young and the adults). In addition, a weak psychological and psychological constitution appears to be of interest, at least in the young. However, there is no evidence for a causal link between a sedentary life-style and LBP, neither in the young nor in the adults. CONCLUSIONS: Some myths in the area of back pain are dispelled by the evidence in relation to personal and genetic factors and some new elements need considering. It is suggested that we should look for populations at risk, rather than looking for risk factors. Populations at risk would consist of people with a weak psychological and physiological constitution, who more easily than others may develop long lasting back pain as well as other CLINICAL SIGNIFICANCE: Early identification of high risk populations will allow for a selective primary and secondary preventive approach.

Adolescent↗
PubMedDate not supplied

Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life.

BACKGROUND CONTEXT: Multidisciplinary biopsychosocial rehabilitation has been shown in controlled studies to improve pain and function in patients with chronic back pain. However, specialized back pain rehabilitation centers are rare and only a few patients can participate on this therapy. Implementation of multidisciplinary rehabilitation services in community medicine may enhance both early availability and treatment capacity for comprehensive back pain rehabilitation. PURPOSE: To compare the outcome of a multidisciplinary rehabilitation program (MRP) that was organized by cooperation of local health-care providers in the community with that of the usual care by independent physicians for patients with chronic low back pain. STUDY DESIGN: A comparison between the outcomes (follow-up time of 6 months) of treatment for chronic back pain in the community in a prospective intervention group versus a prospective observational usual care group. PATIENT SAMPLE: All patients were recruited from independent physicians in the community of a selected region who participated voluntarily in the study. Patients were included in the study if they were seeking treatment of pain in the back with possible irradiation into the legs, the pain persisted for at least 3 months without decreasing intensity and there was no indication for surgical intervention. OUTCOME MEASURES: Outcome was assessed from patients' responses in self-report questionnaires at baseline and after an interval of 6 months. For outcome, we evaluated the health-related quality of life (German version of Short Form [SF] 36), the average pain severity (Numeric Rating Scale), the pain-related interference of function (German version of Brief Pain Inventory), depression (Allgemeine Depressionsskele), time off from work within 3 months before entering and leaving the study and the self-appraisal of improvement. METHODS: In a baseline group, the independent physicians treated the patients with usual care. In the intervention group, the patients were referred by the independent physicians to the study coordinator in the outpatient facilities of the Departments of Neurology or Orthopedics for inclusion in the MRP. The MRP was organized by cooperation of local health-care providers in the community with different specialties (sport teachers, clinical psychologist, physiotherapist and physician) who were experienced in the management of back pain. The MRP (4 hours per day, 3 days per week, 20 days) included 1.5 hours restorative exercise therapy, 0.5 hours physiotherapy, 1 hour cognitive-behavioral therapy, 0.5 hours progressive muscle relaxation and 0.5 hours education. RESULTS: Complete data sets were obtained from 157 patients in the usual care group (documented by 35 independent physicians) and 51 patients in the MRP group. Patients of the MRP group improved in the physical and mental health domains of the SF-36 more than patients treated by usual care (p<.05). Furthermore, days off work were more (p<.05) reduced by the MRP (16+/-35 days) than by usual care (-2+/-39 days). Finally, overall appraisal of successful outcome was better (p<.01) after MRP (54% of patients) as compared with usual care (24% of patients). However, the pain intensity (NRS), the pain-related interference with function (Brief Pain Inventory; BPI) and the depression scores (ADS) did not differ significantly between both groups. CONCLUSIONS: MRP is promising to improve health-related quality of life for patients with chronic back pain in the community. Before implementation of MRP in the repertoire of community medicine, superiority of MRP over usual care should be confirmed by a randomized controlled trial.

Chronic Disease↗
PubMed1998

Follow-up of patients with low back pain during pregnancy.

OBJECTIVE: To identify the long-term risk for low back pain among women with previous severe low back pain during pregnancy. METHODS: In a previous prospective study, 79 pregnant women developed low back pain severe enough to require sick leave. Twelve years later a questionnaire was sent to 62 of these women and 84 controls who did not develop severe low back pain during pregnancy. The questionnaire asked about occupation, low back pain in general and during later pregnancies, and sick leave due to low back pain. There were also questions regarding use of oral contraceptives and its possible relation to low back pain. RESULTS: The response rate was 84% in the back pain group and 80% among controls. The two groups were similar according to the percentage of women having had another pregnancy (33 of 52 [63%] versus 39 of 67 [58%]) but ten (19%) of the women with previous low back pain stated they had refrained from another pregnancy because of their fear of low back pain compared with only one control. Almost all women (31 of 33) with previous severe low back pain experienced the same symptoms in a subsequent pregnancy, compared with 17 of 39 (44%) controls. Even when they were not pregnant, women with previous low back pain suffered more often and used more sick leave due to low back pain (44 of 52 versus 43 of 67, chi2 = 5.68, P < .05). The location (sacroiliac joint or lumbar affection) of the previous low back pain did not affect the long-term prognosis. In a logistic regression model, previous low back pain during pregnancy was the only independent risk factor for low back pain during a subsequent pregnancy, whereas an occupation involving physical demand did not affect the results. However, together with previous low back pain during pregnancy, heavy occupation increased the risk for current nonpregnant low back pain. CONCLUSION: Women with severe low back pain during pregnancy have an extremely high risk for experiencing a new episode of severe low back pain during another pregnancy and when not pregnant.

Adult↗
PubMed2006

Movement coordination of the lumbar spine and hip during a picking up activity in low back pain subjects.

The effect of low back pain, with or without nerve root signs, on the joint coordination and kinematics of the lumbar spine and hips during everyday activities, such as picking up an object from the floor, are largely unknown. An experimental study was designed to compare lumbar spine and hip joint kinematics and coordination in subjects with and without sub-acute low back pain, while picking up an object in a sitting position. A three-dimensional real-time electromagnetic tracking device was used to measure movements of the lumbar spine and hips. Sixty participants with subacute low back pain, with or without straight leg raise signs, and twenty healthy asymptomatic participants were recruited. The ranges of motions of lumbar spine and hips were determined. Movement coordination between the two regions was examined by cross-correlation. Results showed that mobility was significantly reduced in subjects with back pain, who compensated for limited motion through various strategies. The contribution of the lumbar spine relative to that of the hip was, however, found to be similar in all groups. The lumbar spine-hip joint coordination was substantially altered in subjects with back pain, in particular, those with a positive straight leg raise sign. We conclude that changes in the lumbar and hip kinematics were related to back pain and limitation in straight leg raise. Lumbar-hip coordination was mainly affected by the presence of positive straight leg raise sign when picking up an object in a sitting position.

Adult↗
PubMed1992

Guidelines for managing low back pain: a policy checklist.

Back injuries devour one-third of health care benefits and workers' compensation, yet corporate strategies vary widely in their approach to back pain prevention, treatment and rehabilitation. These recommendations provide a benchmark for evaluation policies on low back pain. They emphasize a sports medicine approach, focused on returning workers to activity as soon as possible.

Back Pain↗