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PubMed1997

Management of chronic nonspecific low back pain in primary care: a descriptive study.

STUDY DESIGN: A retrospective, descriptive study. OBJECTIVES: To describe the diagnostic and therapeutic procedures for patients with chronic low back pain in primary care. SUMMARY OF BACKGROUND DATA: Most previous studies have described the management of acute low back pain, but little is known about the management of chronic low back pain in primary care. METHODS: Twenty-six general practitioners involved in the Registration Network of Family Practices of the University of Limburg in The Netherlands participated in this study. All patients and general practitioners were asked to complete a retrospective questionnaire, and there was a 12-month follow-up. RESULTS: The total study population consisted of 524 patients with chronic low back pain. Twenty-three percent of the patients had had radiographs taken during the previous 12 months, and 5% had been examined by other imaging techniques. Twenty-nine percent of the study population had not received and therapy at all, 46% had received medication, mostly (36%) nonsteroidal anti-inflammatory drugs (NSAIDs), and for 18% (bed)-rest had been advised. Thirty-six percent of the study population had been referred to a physiotherapist. CONCLUSIONS: The therapeutic management of chronic low back pain seems to lack consistency. Clinical guidelines are needed to improve the management of chronic low back pain in primary care.

Adult↗
PubMed1997

Disorders of the back and spine in construction workers. Prevalence and prognostic value for disability.

STUDY DESIGN: A cohort study on back-related morbidity and its impact on early retirement resulting from disability among employees in the construction industry. OBJECTIVE: To describe the prevalence of back-related morbidity according to different measures in various occupational groups and to assess the prognostic value of these measures for early retirement resulting from disability. METHODS: The results of occupational health examinations conducted in 1986-1988 among 4,958 employees of the German construction industry aged 40-64 years were analyzed. Active follow-up evaluation was carried out between October 1992 and July 1994 to ascertain employment status. RESULTS: Compared with that of white-collar employees, no excess risk for self-reported back pain or sciatica was seen for any of the manual professions. In contrast, the age-adjusted prevalence of clinical findings of the spine was elevated among all employees in manual professions, and the prevalence of a recorded diagnosis related to disorders of the back and spine (ICD-9 position 720-724) was elevated among bricklayers compared with white-collar employees. The relative risk of being granted a disability pension in the follow-up period was 1.6 (95% Confidence Interval [Cl], 1.3-2.1) for persons reporting back pain or sciatica, 1.8 (95% Cl, 1.4-2.2) for persons with an abnormal clinical finding of the spine, and 1.5 (95% Cl, 1.2-1.8) for persons with a recorded medical diagnosis related to disorders of the back or spine (ICD-9 720-724). CONCLUSION: Patterns of morbidity varied according to the evaluated morbidity measure. All three measures qualified as significant predictors of disability and helped to identify high-risk occupations and high-risk employees.

Back Pain↗
PubMed1997

Early physician notification of patient disability risk and clinical guidelines after low back injury: a randomized, controlled trial.

STUDY DESIGN: Back-injured workers with high disability risk scores on a predictive questionnaire participated in a randomized, controlled trial of physician notification, with outcomes follow-up 3 months after injury. OBJECTIVES: To test whether physician intervention improves return to work and self-assessment outcomes for people at relatively high risk for disability. SUMMARY OF BACKGROUND DATA: Only a small number of back-injured workers suffer significant disability. Quick identification of these people would facilitate more efficient targeting and trials of interventions. Controlling variations in practice through practice guidelines has been recommended as a promising strategy for improving care and reducing disability. METHODS: Workers filing back injury reports responded to a disability prediction questionnaire. Those with high risk scores were randomly assigned to control or intervention groups. Patient-designated physicians in the intervention group received two letters identifying the patient's risk and making recommendations for care, including the Agency for Health Care Policy and Research's algorithms for acute low back pain. Predictive accuracy of the questionnaire and efficacy of physician intervention were evaluated on the basis of work status and self-assessments 3 months after injury. RESULTS: Of the 268 workers completing the questionnaire portion of the study, 32 (12%) were out of work because of back pain 3 months after injury. The questionnaire's predictive accuracy included maximum kappa of 0.277 and a receiver operating curve area of 0.78. Fifty-three people completed the physician intervention trial. The intervention had no significant impact on return to work, self-assessed pain, or satisfaction with health care. CONCLUSIONS: Stratification of back-injured people according to disability risk can can increase intervention efficiency by identifying those who require treatment and sparing those who do not. The apparent failure of risk notification and practice guidelines to reduce disability in this study may be improved by different application methods in the future.

Adolescent↗
PubMed1997

Classification of low back pain from dynamic motion characteristics using an artificial neural network.

STUDY DESIGN: Data were collected from 183 subjects who were randomly assigned to the training and test groups. During testing of the classification system, knowledge of the low back pain condition or motion characteristics of the patients in the test group was not made available to the system. OBJECTIVES: To determine specific characteristics of trunk motion associated with different categories of spinal disorders and to determine whether a neural network analysis system can be effective in distinguishing patterns. SUMMARY OF BACKGROUND DATA: Numerous studies have established the difficulty of evaluating lower back pain. Imaging techniques are expensive and ineffective in many cases. A technique for evaluation of lower back pain was developed on the basis of analysis of such dynamic motion features as shape, velocity, and symmetry of movements, using a neural network classification system. METHODS: Dynamic motion data were collected from 183 subjects using a triaxial goniometer. Features of the movement were extracted and provided as input to a two-stage neural network classifier governed by a radial basis function architecture. After training, the output of the classifier was compared with Québec Task Force pain classifications obtained for the patients. Linear and nonlinear classification techniques were compared. RESULTS: The system could determine low back pain classification from motion characteristics. The neural network classifier produced the best results with up to 85% accuracy on novel "validation" data. CONCLUSIONS: A neural network based on kinematic data is an excellent predictive model for classification of lower back pain. Such a system could markedly improve the management of lower back pain in the individual patient.

Adult↗
PubMed1998

Is work status of low back pain patients best described by an automated device or by a questionnaire?

STUDY DESIGN: A prospective cohort study of patients with subacute occupational back pain. OBJECTIVES: To study the relation between a marketed opto-electric device measuring trunk kinematics, a widely used specific functional capacity questionnaire, and work status in back pain patients, and to assess the responsiveness to change in work status of the opto-electric device and the questionnaire. SUMMARY OF BACKGROUND DATA: Several instruments have been developed to evaluate the functional capacities of patients with back pain, but the relation between these instruments and work status has rarely been studied. METHODS: The relation between the opto-electric device, the questionnaire, and work status in patients with back pain was evaluated. The study population was a prospective cohort of patients with subacute back pain who were absent from regular work for more than 4 weeks. All data were compiled blindly on the same day, at study entry (4 weeks after work accident), and at 12, 24, and 52 weeks after the work accident. The validity of the questionnaire and opto-electric device scores was assessed with partial correlation analyses, standardized response mean, logistic regression analyses, and receiver operating characteristics curves. RESULTS: The correlation between the questionnaire and opto-electric device scores was low. The questionnaire scores were significantly related to work status, but the opto-electric device scores were not. The questionnaire was responsive to change in work status, whereas the opto-electric device was not. CONCLUSIONS: The opto-electric device scores were not related to either functional capacity scores (questionnaire) or work status in patients with low back pain, and the opto-electric device was not responsive to change in work status. Conversely, the questionnaire was related to work status and was responsive to change in work status.

Activities of Daily Living↗
PubMed1998

Meteorological conditions and self-report of low back pain.

STUDY DESIGN: Six months of daily low back pain ratings for 94 individuals were tested for the influence of prevailing weather conditions during the spring, summer, and fall seasons. Intergroup differences were tested for study participants who reported weather sensitivity and for those who did not. OBJECTIVES: To investigate the relation between pain ratings and prevailing weather conditions in a population with chronic or recurrent low back pain. SUMMARY OF BACKGROUND DATA: Weather conditions have been reported to influence pain perception in some disease states, including low back pain. Investigations of this relation in chronic or recurrent low back pain have involved varied methodologies, and conflicting results have been reported. METHODS: The effects of eight weather variables reported to influence musculoskeletal pain were tested on daily pain ratings. A post hoc weather sensitivity questionnaire was used to disperse 73 individuals into groups based on perceived weather sensitivity, and group differences were tested. RESULTS: Significant effects on pain scores were found, most notably for temperature and vapor pressure. The magnitude of the effects were small compared with autocorrelation of an individual's own pain scores. Significant differences were found between the group of individuals who were insensitive to weather conditions and that of individuals with perceived sensitivity to cold temperatures. No significant intergroup differences were found for damp, rainy conditions or changes in barometric pressure. CONCLUSIONS: Weather conditions may influence subjective reporting of low back pain significantly. Although the effects are small in magnitude, they should be considered in clinical treatment of the patient with chronic, nonspecific low back pain. Pain scores may demonstrate greater interaction with certain weather conditions in individuals perceiving sensitivity to those conditions.

Adult↗
PubMed1998

Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain.

STUDY DESIGN: A controlled clinical trial. OBJECTIVES: To examine the long-term effect of an informative approach to low back pain. SUMMARY OF BACKGROUND DATA: In management and prevention of low back pain, back school based on an ergonomic approach have played in important role. The effect of such informative interventions is not clear. METHODS: A 5-year follow-up study was done on patients included in a previous study. The outcome was measured by return to work or still on sick leave. The patients were allocated to an intervention group (n = 245) and a control group (n = 244). Only the intervention group was called in for examination and intervention and answered a battery of tests for psychological and health factors. The intervention apart from the clinical examination consisted of education in an "mini back school." The program was based on a new medical model for low back pain. RESULTS: Forty-seven (19%) of the patients in the intervention group, compared with 84 patients (34%) in the control group, were still on sick leave after 5 years (P < 0.001). There were fewer recurrences of sick leave (P < 0.03) in the intervention group than in the control group. Based on Internal Health Locus of Control, number of children, and income, 75% were correctly classified as nonreturners in the intervention group. CONCLUSIONS: This study indicates that subchronic low back pain may be managed successfully with an approach that includes clinical examination combined with information for patients about the nature of the problem, provided in a manner designed to reduce fear and give them reason to resume light activity.

Adolescent↗
PubMed1999

Intertester reliability of a low back pain classification system.

STUDY DESIGN: This prospective study of intertester reliability examined pairs of therapists' ability to agree independently on a patient's low back pain diagnosis. OBJECTIVE: To determine the intertester reliability of a low back pain classification system among experienced and novice clinicians. BACKGROUND: Many of the disparate categorization schemes for patients with low back pain are purely nominal, assigning designations based on the presumptive source of the problem without providing any practical guide for rehabilitation. A useful classification scheme reliably groups patients into treatment-directing categories. METHODS: The study included 204 patients with low back pain referred to 10 clinics across Canada. Paired physiotherapists performed separate physical examinations on each patient. Both examiners then completed a simple ballot choosing one of five pain patterns. RESULTS: Agreement on patient classification by independent examiners was 78.9% (kappa = 0.61). CONCLUSION: This clinically relevant and clearly defined pain pattern system uses key elements of the history and examination to classify patients with low back pain. The pattern provides a framework for initiating active rehabilitation strategy. Using this approach, clinicians agreed on the categorization of 78.9% of mechanical low back pain cases.

Adolescent↗
PubMed1999

Effectiveness of Waddell's nonorganic signs in predicting a delayed return to regular work in patients experiencing acute occupational low back pain.

STUDY DESIGN: Consecutive case series. OBJECTIVE: To determine whether the presence of Waddell's nonorganic signs in occupational, acute low back pain patients predicts a longer time before return to unrestricted regular work. SUMMARY OF BACKGROUND DATA: Waddell's nonorganic signs identify patients with chronic low back pain with a poor prognosis; however, they have not been used as an outcome predictor in patients with occupational, acute low back pain. METHODS: Standardized histories and physical examinations, including Waddell's signs were recorded at the first clinic visit (n = 143) by a single physician who was not blinded to the study's goals or methods. Those with chronic low back pain or complicating medical conditions (n = 88) were excluded. Data from patients exhibiting the nonorganic signs were compared with those from patients without the signs for time to return to regular work without restrictions and medical resource use. RESULTS: Fifty-five patients with acute work-related low back pain were included. One or more of the nonorganic signs were seen in 14 patients (25.5%) at the first appointment. The most common signs were simulated axial loading (78.6%) and simulated rotation (71.4%). Those with any nonorganic sign required a median 58.5 days to return to regular work compared with 15.0 days for those without (P < 0.0001). Patients exhibiting any nonorganic sign compared with those without used more physical therapy (50.0% vs. 12.2%; P < 0.01) and lumbar computed axial tomography (21.4% vs. 0.0%; P = 0.01). CONCLUSIONS: Patients with acute, occupational low back pain exhibiting Waddell's nonorganic signs had a four times lengthier time for return to unrestricted, regular work and a greater use of physical therapy and lumbar computed tomographic scans.

Acute Disease↗
PubMed1999

The reliability and validity of the Biering-Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain.

STUDY DESIGN: A reliability study and case-control study were conducted. OBJECTIVES: To determine the reliability and discriminative validity of the Biering-Sorensen test. SUMMARY OF BACKGROUND DATA: A low Biering-Sorensen score has been found to predict who will have nonspecific low back pain. However, the reliability of the test remains controversial, implying that some studies may have produced results that underestimated the magnitude of the predictive validity of this test. METHODS: Two raters measured the time holding a specific position (holding time) of 63 subjects (23 currently experiencing nonspecific low back pain, 20 who had had an episode, and 20 who were asymptomatic) while they performed the Biering-Sorensen test twice, 15 minutes apart. A standardized protocol was followed. Test-retest reliability was evaluated by calculating intra-class correlation coefficients (ICC 1,1), 95% confidence intervals (CI), and standard errors of the measurement (SEM) for the total group and for the subgroups. A three-way analysis of variance was used to determine whether test order, subject gender, or symptom status affected holding time. RESULTS: High reliability indices were obtained for the Biering-Sorensen test in subjects with current nonspecific low back pain (ICC [1,1], 0.88; 95% CI, 0.73-0.95; SEM, 11.6 seconds), in subjects who had had nonspecific low back pain (ICC [1,1], 0.77; 95% CI, 0.52-0.90; SEM, 17.5 seconds), and in asymptomatic subjects (ICC [1,1], 0.83; 95% CI, 0.62-0.93; SEM, 17.4 seconds). Results of an analysis of variance showed that subjects asymptomatic for low back pain had a significantly longer holding time than the other two groups (P < 0.05). CONCLUSIONS: The Biering-Sorensen test provides reliable measures of position-holding time and can discriminate between subjects with and without nonspecific low back pain.

Adult↗
PubMed1999

Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care.

STUDY DESIGN: A double-blind, randomized controlled trial of a novel educational booklet compared with a traditional booklet for patients seeking treatment in primary care for acute or recurrent low back pain. OBJECTIVE: To test the impact of a novel educational booklet on patients' beliefs about back pain and functional outcome. SUMMARY OF BACKGROUND DATA: The information and advice that health professionals give to patients may be important in health care intervention, but there is little scientific evidence of their effectiveness. A novel patient educational booklet, The Back Book, has been developed to provide evidence-based information and advice consistent with current clinical guidelines. METHODS: One hundred sixty-two patients were given either the experimental booklet or a traditional booklet. The main outcomes studied were fear-avoidance beliefs about physical activity, beliefs about the inevitable consequences of back trouble, the Roland Disability Questionnaire, and visual analogue pain scales. Postal follow-up response at 1 year after initial treatment was 78%. RESULTS: Patients receiving the experimental booklet showed a statistically significant greater early improvement in beliefs which was maintained at 1 year. A greater proportion of patients with an initially high fear-avoidance beliefs score who received the experimental booklet had clinically important improvement in fear-avoidance beliefs about physical activity at 2 weeks, followed by a clinically important improvement in the Roland Disability Questionnaire score at 3 months. There was no effect on pain. CONCLUSION: This trial shows that carefully selected and presented information and advice about back pain can have a positive effect on patients' beliefs and clinical outcomes, and suggests that a study of clinically important effects in individual patients may provide further insights into the management of low back pain.

Adult↗
PubMed2000

Aerobic fitness testing in patients with chronic low back pain: which test is best?

STUDY DESIGN: This is a randomized comparison of three exercise tests in a sample of 30 patients with chronic low back pain. OBJECTIVES: To determine, by comparing three exercise tests, which test yields the highest peak and predicted oxygen consumption in a sample of patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Little is known about the level of aerobic fitness in patients with chronic low back pain, although many rehabilitation programs emphasize aerobic exercise as an important part of their therapy. Measurement of aerobic fitness levels in these patients remains a problem. In healthy individuals, the highest oxygen consumption values come from exercise tests that use the largest muscle groups. For a number of reasons, this may not be true in patients with chronic low back pain. METHODS: In this study, 30 participants with chronic low back pain performed three symptom-limited maximal exercise tests: a treadmill, an upper extremity ergometer, and a bicycle ergometer. The tests were administered in randomized order. Heart rate was continuously monitored and oxygen consumption in terms of mL/kg/minute was measured by indirect calorimetry each 30 seconds. RESULTS: The statistical difference among the tests was highly significant (P < 0.0001). The treadmill test yielded the highest peak and predicted oxygen consumption followed by the bicycle and the upper extremity ergometer test, respectively. CONCLUSIONS: The treadmill test is the best test for measuring aerobic fitness levels in patients with chronic low back pain. It yielded the highest peak oxygen consumption compared with the other tests, coming closest to measuring maximal oxygen consumption.

Adolescent↗
PubMed2000

The role of physical exercise and inactivity in pain recurrence and absenteeism from work after active outpatient rehabilitation for recurrent or chronic low back pain: a follow-up study.

STUDY DESIGN: An observational follow-up. OBJECTIVES: To analyze the role of physical exercise and inactivity on the long-term outcome after active outpatient low back rehabilitation. SUMMARY OF BACKGROUND DATA: There is considerable evidence documenting the efficacy of exercise in the conservative treatment of chronic low back pain, but the role of exercises after the guided treatment period on the long-term success and maintenance of the results is not known. METHODS: One hundred twenty-five patients with low back pain, who had participated in a 12-week active low back rehabilitation program, were asked about subjective pain and disability on the average of 14 months after the treatment. The outcomes were defined as a recurrence of persistent pain and work absenteeism, and a survival or failure analysis was performed between those who had continued exercising and who had been physically inactive. RESULTS: Recurrences of persistent pain during the follow-up period were fewer (P = 0.03) among those who had maintained regular exercise habits after the treatment than among those who had been physically inactive. Similarly, work absenteeism was less (P < 0.01) among physically active than among physically inactive persons. However, patients with good outcome in pain reduction after low back pain rehabilitation were more likely to participate in physical exercise. CONCLUSIONS: Exercises are beneficial after guided treatment in the maintenance of the results of active treatment for recurrent chronic low back pain in the long term, but those with less favorable outcome in rehabilitation are less likely to participate in exercises afterward. In active treatment programs, it is recommended that exercises be incorporated after the guided treatment.

Absenteeism↗
PubMed2000

Deconditioning in patients with chronic low back pain: fact or fiction?

STUDY DESIGN: Prospective case series with historical controls (normative data). OBJECTIVES: To compare aerobic fitness levels in patients with chronic low back pain with those published on a sample of 295 healthy subjects. SUMMARY OF BACKGROUND DATA: Clinical belief holds that patients with chronic low back pain have low fitness levels as a result of inactivity because of pain. Because few studies have investigated the level of aerobic fitness in these patients, however, it remains unclear how fitness levels in patients with chronic low back pain patients compare with those published a sample of the normative population. METHODS: A sample of 50 patients with chronic low back pain with a mean pain duration of 40 months referred to an outpatient pain clinic performed a symptom-limited modified treadmill test. Aerobic fitness levels were determined by indirect calorimetry to measure oxygen consumption (VO2). Predicted maximum oxygen consumption (VO2max) levels were calculated for all subjects. Multiple regression analysis with adjustment for age and sex yielded prediction equations for men and women separately. Ninety-five percent confidence intervals were calculated for predicted mean oxygen consumption (VO2) and the slope of the equations. These were compared to established prediction equations on healthy subjects. RESULTS: Prediction equations for estimated maximum oxygen consumption (VO2max) in patients with chronic low back pain equal those in healthy sedentary men and active women. CONCLUSIONS: Levels of aerobic fitness in patients with chronic low back pain are comparable with those in healthy subjects.

Adult↗
PubMed2000

The Cochrane review of bed rest for acute low back pain and sciatica.

STUDY DESIGN: A systematic review within the Cochrane Collaboration Back Review Group. OBJECTIVES: To assess the effects of advice to rest in bed for patients with acute low back pain (LBP) or sciatica. SUMMARY OF BACKGROUND DATA: Low back pain is a common reason for consulting a health care provider, and advice on daily activities constitutes an important part in the primary care management of low back pain. METHODS: All randomized studies available in systematic searches (electronic databases, contact with authors, and reference lists) were included. Two reviewers independently selected trials for inclusion, assessed the validity of included trials, and extracted data. Investigators were contacted to obtain missing information. RESULTS: Nine trials with a total of 1435 patients were included. Four trials compared bed rest with advice to stay active, and the overall results were heterogeneous. Overall, results from two high-quality studies indicate no difference in pain intensity at the 3-week follow-up (standardized mean difference 0.0; 95% confidence interval [CI] -0.3, 0.2]), and a small difference in functional status in favor of staying active (weighted mean difference 3.2 [on a 0-100 scale] 95% CI 0.6, 5.8). In two high-quality trials no differences were reported in pain intensity between 2-3 days of bed rest and 7 days of bed rest. In another two high-quality trials, no differences were found between bed rest and exercises in pain intensity or functional status. CONCLUSION: Bed rest compared with advice to stay active at best has no effect, and at worst may have slightly harmful effects on LBP. There is not an important difference in the effects of bed rest compared with exercises in the treatment of acute low back pain, or 7 days compared with 2-3 days of bed rest in patients with low back pain of different durations with and without radiating pain.

Activities of Daily Living↗
PubMed2001

Responsiveness of generic and specific measures of health outcome in low back pain.

STUDY DESIGN: A longitudinal study using patient questionnaires was performed. OBJECTIVE: To compare the discriminatory power and responsiveness of the Aberdeen Back Pain Scale (ABPS), the Roland Disability Questionnaire (RDQ), and the EuroQol in patients with low back pain. SUMMARY OF BACKGROUND DATA: A number instruments specific to low back pain have not been compared for measurement properties. The EuroQol is a widely used generic instrument that has not been compared with specific instruments in patients with back pain. METHODS: A questionnaire incorporating the Aberdeen Back Pain Scale, the Roland Disability Questionnaire, and the EuroQol was completed by patients taking part in a clinical trial of exercise treatments for back pain. Patients completed follow-up questionnaires at 6 weeks, 6 months, and 1 year. The discriminatory power of these instruments was assessed against variables relating to activity limitations, medication, and comorbidity. Responsiveness was assessed using standardized response means. RESULTS: The questionnaire was completed by 187 patients taking part in the clinical trial. The Aberdeen instrument was found to be the most powerful at discriminating between different groups of patients on variables relating to activity limitations, medication, and comorbidity. The specific instruments demonstrated good levels of responsiveness, with the Aberdeen instrument producing the largest standardized response means. The Aberdeen instrument was more responsive to the smaller changes experienced by the control group, but was less powerful than the Roland at measuring differences in the levels of change between the two groups of patients at two of the three follow-up assessments in the trial. The EuroQol demonstrated a moderate level of responsiveness. CONCLUSIONS: The two specific instruments are capable of greater levels of discrimination between groups of patients, and are more responsive over time than the generic EuroQol. The Aberdeen instrument performed most satisfactorily in relation to these criteria, but the Roland instrument was more sensitive to differences between the two groups in the clinical trial. The measurement properties of these two instruments reflect their origin: The Aberdeen instrument is based on clinical questions, whereas the Roland instrument is based on the generic Sickness Impact Profile. Instrument content should be carefullyconsidered when selecting instruments for applications, including clinical trials.

Adolescent↗
PubMed2001

The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data.

STUDY DESIGN: Prospective cohort study of randomly selected Veterans Affairs (VA) outpatients. OBJECTIVE: To determine the prevalence of magnetic resonance imaging (MRI) findings in the lumbar spine among persons without current low back pain or sciatica and to examine which findings are related to age or previous back symptoms. SUMMARY OF BACKGROUND INFORMATION: Previous studies of patients without low back pain have not explored the possible association of various MRI findings to past symptoms. METHODS: We randomly selected an age-stratified sample of subjects without low back pain in the past 4 months from clinics at a VA hospital. We collected information on demographics, comorbidity, functional status, and quality of life. MR images were obtained using a standardized protocol through each of the five lumbar disc levels. RESULTS: Of 148 subjects, 69 (46%) had never experienced low back pain. There were 123 subjects (83%) with moderate to severe desiccation of one or more discs, 95 (64%) with one or more bulging discs, and 83 (56%) with loss of disc height. Forty-eight subjects (32%) had at least one disc protrusion and 9 (6%) had one or more disc extrusions. CONCLUSION: Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use. The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.

Adult↗
PubMed2001

2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.

STUDY DESIGN: A randomized controlled multicenter study with a 2-year follow-up by an independent observer. OBJECTIVES: To determine whether fusion of the lower lumbar spine could reduce pain and diminish disability more effectively when compared with nonsurgical treatment in patients with severe chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: The reported results after fusion surgery on patients with CLBP vary considerably, and the evidence of treatment efficacy is weak in the absence of randomized controlled studies. PATIENTS AND METHODS: A total of 294 patients referred to 19 spinal centers from 1992 through 1998 were randomized blindly into four treatment groups. Patients aged 25-65 years with CLBP for at least 2 years and with radiologic evidence of disc degeneration at L4-L5, L5-S1, or both were eligible to participate in the study. The surgical group (n=222) included three different fusion techniques, not analyzed separately in this study. Patients in the nonsurgical group (n=72) were treated with different kinds of physical therapy. The surgical group comprised 49.5% men, and the mean age was 43 years. The corresponding figures for the nonsurgical group were 48.6% and 44 years. The patients had suffered from low back pain for a mean of 7.8 and 8.5 years and been on sick leave due to back pain for a mean of 3.2 and 2.9 years, respectively. The Visual Analogue Scale (VAS) was used to measure pain. The Oswestry Low Back Pain Questionnaire, the Million Score and the General Function Score (GFS) were used to measure disability. The Zung Depression Scale was used to measure depressive symptoms. The overall result was assessed by the patient and by an independent observer. Records from the Swedish Social Insurance were used to evaluate work disability. Patients who changed groups were included in the analyses of significance according to the intention-to-treat principle. RESULTS: At the 2-year follow-up 289 of 294 (98%) patients, including 25 who had changed groups, were examined. Back pain was reduced in the surgical group by 33% (64 to 43), compared with 7% (63 to 58) in the nonsurgical group (P=0.0002). Pain improved most during the first 6 months and then gradually deteriorated. Disability according to Oswestry was reduced by 25% (47 to 36) compared with 6% (48 to 46) among nonsurgical patients (P=0.015), according to Million by 28% (64 to 46) compared with 8% (66 to 60) (P=0.004), and accordingtoGFS by 31% (49 to 34) compared with 4% (48 to 46) (P=0.005). The depressive symptoms, according to Zung, were reduced by 20% (39 to 31) in the surgical group compared with 7% (39 to 36) in the nonsurgical group (P=0.123). In the surgical group 63% (122/195) rated themselves as "much better" or "better" compared with 29% (18/62) in the nonsurgical group (P<0.0001). The "net back to work rate" was significantly in favor of surgical treatment, or 36% vs. 13% (P=0.002). The early complication rate in the surgical group was 17%. CONCLUSION: Lumbar fusion in a well-informed and selected group of patients with severe CLBP can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatment.

Adult↗