A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities

STUDY DESIGN: Consensus process. OBJECTIVES: Reexamining and redirecting the research agenda for low back pain in primary care. SUMMARY OF BACKGROUND DATA: Most research, publications, and funding have traditionally been directed toward specialty and biologically oriented investigations of "spinal disorders" from biomedical and biomechanical perspectives. Beginning in the mid-1980s, primary care researchers began to investigate this field in earnest, focusing on lower back pain as a pain syndrome within an individual, family, and community context. Unfortunately, more progress has been made on what should not be done in diagnosing and treating lower back pain than on what should be done. METHODS: This was a modified group process designed to reach consensus among an international group of primary care lower back pain researchers. RESULTS: Nearly all of the research priorities from the initial 1995 forum are still thought to be important, although only modest progress has been made on most of them. The priorities perceived to be the most feasible to investigate and the ones in which the greatest strides have been achieved are in methodologic rather than substantive areas. Identifying subgroups of people with lower back pain is still given top ranking in 1997, but the priorities have changed dramatically. Greater emphasis is given to finding predictors and risk factors for lower back pain chronicity, improving self-care strategies, and stimulating self-reliance. New items now make up 50% of the top 10 priorities. In general, the additions reflect a greater emphasis on expanding methodologic avenues of inquiry. CONCLUSIONS: Methodologic advances, the enlistment of new techniques and disciplines, and redirected research efforts may facilitate progress in the diagnosis and treatment of lower back pain.     

Essential promoter elements are located within the 5'' untranslated region of human insulin-like growth factor-I exon I

The connection between work-related exposures and the onset of back injury or pain is complex and not clearly understood. This paper raises design issues related to the planning and conduct of cohort studies of industrial low back pain (or injury)(LBP), with care given to definition and measurement of exposure and outcome events. These issues include sample size, outcome definition, study biases, and practical considerations when seeking and maintaining company collaboration with a research effort. Without resolving these issues, the authors conclude: (1) cohort studies of worksite-based LBP are needed to elucidate the causal associations between work tasks and LBP onset, (2) both acute and cumulative exposures should be assessed as risk factors for low back injury or pain, and (3) attention should be paid to the planning of such studies and minimization of potential biases that can limit the validity of the results. These design issues will benefit researchers and companies engaged in the planning and conduct of cohort studies of industrial LBP.     

The course of back pain in primary care

STUDY DESIGN: Review paper of outcome studies among primary care back pain patients. OBJECTIVES: To determine the short-term and long-term pain and functional outcomes of patients with back pain who are seeking treatment in primary care settings. SUMMARY OF BACKGROUND DATA: Back pain has been viewed as running either an acute or a chronic course, but most patients experience recurrent back pain. This review summarizes outcome studies in light of the episodic course of back pain. METHODS: Studies reporting pain and functional outcome data for consecutive primary care patients with back pain were reviewed. RESULTS: Back pain among primary care patients typically is a recurrent condition for which definitions of acute and chronic pain based on a single episode are inadequate. Because a majority of patients experience recurrences, describing only the outcome of the initial back pain episode may convey a more favorable picture of long-term outcome than warranted. For the short-term follow-up evaluation, most patients improve considerably during the first 4 weeks after seeking treatment. Sixty-six percent to 75% continue to experience at least mild back pain 1 month after seeking care. At 1 month, approximately 33% report continuing pain of at least moderate intensity, whereas 20-25% report substantial activity limitations. For the long-term follow-up (1 year or more) period, approximately 33% report intermittent or persistent pain of at least moderate intensity, one in seven continue to report back pain of severe intensity, and one in five report substantial activity limitations. CONCLUSION: Results from existing studies suggest that back pain among primary care patients typically runs a recurrent course characterized by variation and change, rather than an acute, self-limiting course.     

Educational and behavioral interventions for back pain in primary care

STUDY DESIGN AND OBJECTIVES: A review of the literature was undertaken to identify and summarize randomized trials of educational, cognitive, and behavioral interventions for people with chronic low back pain. SUMMARY OF BACKGROUND DATA: Studies of back schools have varied widely in patient characteristics, back school length and content, and comparison treatment. The available evidence suggests that back schools do not affect long-term outcomes of people with back pain. METHODS: MEDLINE and PsycLIT databases were searched to identify randomized trials of cognitive and behavioral treatments for chronic low back pain. Outcome data were extracted from articles that met the meta-analysis inclusion criteria. RESULTS: The meta-analysis found that cognitive and behavioral treatments were superior to control conditions after treatment on measures of chronic low back pain, pain behavior, and disability. Follow-up comparisons of cognitive and behavioral treatments versus control conditions were not available. This meta-analysis did not find cognitive and behavioral therapies to differ from other active treatments on specific outcome measures, although only a few studies were available for each measure. CONCLUSION: It may be useful to incorporate cognitive-behavioral interventions in primary care settings, but additional research is needed to evaluate their efficacy in improving specific outcomes.     

Community studies of the health service implications of low back pain

STUDY DESIGN: Retrospective study using primary care physician case notes and a self-report questionnaire on the same randomly selected population sample. OBJECTIVES: To assess the prevalence, management, and outcomes of low back pain in the community, comparing, in the same random sample of registered patients, self-report questionnaire data and primary care physicians' records. SUMMARY OF BACKGROUND DATA: The financial and resource implications of low back pain are extensive. Data on consultations, investigations, and the management of low back pain are fragmentary and there are no comparisons estimating prevalence from case notes and self-report. METHODS: A retrospective study of prevalence, management, referral, and outcome covering the previous 12 months was carried out in three general practices using case notes and a self-report postal questionnaire on a sample of 900 patients over 18 years. RESULTS: Lifetime prevalence of low back pain was 62%. Annual prevalence was 48%, with 16% reporting low back pain at the time of report. Twenty-four percent consulted their primary care physician for low back pain, of whom 17% were referred to a hospital specialist. The annual consultation rate of patients with low back pain was similar to the rate for patients with chronic conditions. The activities of daily living were restricted in less than half, with few taking sick leave. The general health status of those reporting recent low back pain was significantly lower than those not reporting low back pain. Most felt that low back pain was self-limiting and would not consult health professionals for future episodes. There were substantial discrepancies between case notes recorded at consultation with the primary care physician and self-report regarding consultation and investigations. CONCLUSIONS: Prevalence rates were comparable with those reported in other studies. The significant discrepancies between data sources suggest patient recall bias or underrecording in case notes. The low consultation rate, time off, and day-to-day disability indicate that most episodes are self-limiting.     

Efficacy of traction for nonspecific low back pain. 12-week and 6-month results of a randomized clinical trial

STUDY DESIGN: A randomized clinical trial. OBJECTIVES: To assess the efficacy of motorized continuous traction for low back pain. SUMMARY OF BACKGROUND DATA: The available studies on the efficacy of lumbar traction do not allow clear conclusions because of severe methodologic flaws. The current trial aimed to overcome these shortcomings. METHODS: Patients with at least 6 weeks of nonspecific low back pain were selected. High-dose traction was compared with sham (or low-dose) traction. Sham traction was given with a specially developed brace that becomes tighter in the back during traction. This was experienced as if real traction were exerted. The patients and the outcome assessor were unaware of treatment allocation. Outcome measures were: patient's global perceived effect, severity of main complaints, functional status, pain, range of motion, work absence, and medical treatment. Results for the outcome measures at 12 weeks and 6 months after randomization are presented. RESULTS: One hundred and fifty-one patients were randomly allocated to one of the two treatment methods. Intention-to-treat analysis of the 12-week and 6-month results showed no statistically significant differences between the groups on all outcome measures: all 95% confidence intervals included the value zero. The number of patients lost to follow-up study was very low. Other analyses showed the same results. CONCLUSIONS: Most common flaws of earlier studies on traction therapy could be overcome. This trial did not support the claim that traction is efficacious for patients with low back pain.     

Outcome measures for low back pain research. A proposal for standardized use

STUDY DESIGN: An international group of back pain researchers considered recommendations for standardized measures in clinical outcomes research in patients with back pain. OBJECTIVES: To promote more standardization of outcome measurement in clinical trials and other types of outcomes research, including meta-analyses, cost-effectiveness analyses, and multicenter studies. SUMMARY OF BACKGROUND DATA: Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Because back pain is rarely fatal or completely cured, outcome assessment is complex and involves multiple dimensions. These include symptoms, function, general well-being, work disability, and satisfaction with care. METHODS: The panel considered several factors in recommending a standard battery of outcome measures. These included reliability, validity, responsiveness, and practicality of the measures. In addition, compatibility with widely used and promoted batteries such, as the American Academy of Orthopaedic Surgeons Lumbar Cluster were considered to minimize the need for changes when these instruments are used. RESULTS: First, a six-item set was proposed, which is sufficiently brief that it could be used in routine care settings for quality improvement and for research purposes. An expanded outcome set, which would provide more precise measurement for research purposes, includes measures of severity and frequency of symptoms, either the Roland or the Oswestry Disability Scale, either the SF-12 or the EuroQol measure of general health status, a question about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care. CONCLUSION: Standardized measurement of outcomes would facilitate scientific advances in clinical care. A short, 6-item questionnaire and a somewhat expanded, more precise battery of questionnaires can be recommended. Although many considerations support such recommendations, more data on responsiveness and the minimally important change in scores are needed for most of the instruments.     

Understanding prognosis to improve rehabilitation: the example of lateral elbow pain

OBJECTIVE: A systematic overview of evidence aimed at determining the clinical course of lateral elbow pain and prognostic factors that affect elbow pain duration and outcomes. DATA SOURCES: Online bibliographic database searches from 1983 to 1994; information requests from selected authors and bibliography screenings. STUDY SELECTION: One author reviewed 424 articles; 40 met the following eligibility criteria: any study with primary data on soft tissue injuries specific to the elbow which referred to prognosis or reported use of any outcome measure. DATA ABSTRACTION: Strength of evidence grade based on clinical epidemiological validity assessment. Criteria included in the validity assessment included case definition, patient selection, follow-up, outcome, prognostic factors, and analysis. All eligible studies were independently assessed by two investigators. DATA SYNTHESIS: Four studies (10%) were judged to provide moderate strength of evidence; no studies were graded as providing strong evidence on prognosis. All four moderate-quality studies were clinical trials of short duration. One study indicated that site of lesion and prior occurrence may be predictive of poorer outcome in patients with lateral epicondylitis. CONCLUSION: The majority of studies on lateral elbow pain were limited by methodological weaknesses in selection and definition of the study population, length of follow-up, and analysis of prognostic factors. Estimates of duration were only available from weaker studies with longer follow-up times; significant subject heterogeneity in the weaker studies prevented a determination of usual clinical course. More methodologically rigorous research on prognosis could assist clinicians in patient care and evaluation of interventions.     

Effects of interventions in health care settings on physical activity or cardiorespiratory fitness

INTRODUCTION: This paper reviews studies of physical activity interventions in health care settings to determine effects on physical activity and/or fitness and characteristics of successful interventions. METHODS: Studies testing interventions to promote physical activity in health care settings for primary prevention (patients without disease) and secondary prevention (patients with cardiovascular disease [CVD]) were identified by computerized search methods and reference lists of reviews and articles. Inclusion criteria included assignment to intervention and control groups, physical activity or cardiorespiratory fitness outcome measures, and, for the secondary prevention studies, measurement 12 or more months after randomization. The number of studies with statistically significant effects was determined overall as well as for studies testing interventions with various characteristics. RESULTS: Twelve studies of primary prevention were identified, seven of which were randomized. Three of four randomized studies with short-term measurement (4 weeks to 3 months after randomization), and two of five randomized studies with long-term measurement (6 months after randomization) achieved significant effect on physical activity. Twenty-four randomized studies of CVD secondary prevention were identified; 13 achieved significant effects on activity and/or fitness at twelve or more months. Studies with measurement at two time points showed decaying effects over time, particularly if the intervention were discontinued. Successful interventions contained multiple contacts, behavioral approaches, supervised exercise, provision of equipment, and/or continuing intervention. Many studies had methodologic problems such as low follow-up rates. CONCLUSION: Interventions in health care settings can increase physical activity for both primary and secondary prevention. Long-term effects are more likely with continuing intervention and multiple intervention components such as supervised exercise, provision of equipment, and behavioral approaches. Recommendations for additional research are given.     

Moving beyond efficacy and effectiveness in child and adolescent intervention research.

This Special Section of the Journal of Consulting and Clinical Psychology focuses on research that extends beyond documenting the efficacy and effectiveness of specific psychological treatments or preventive interventions for children and youths. In the past 30 years, there have been remarkable advances in the development and evaluation of psychological treatments and preventive interventions for a wide range of child and adolescent problems. At the same time, only a small percentage of youths who suffer from emotional and behavioral problems receive psychological services, and many of these services are not evidence-based. This article discusses key features of the Special Section studies, which examine important issues related to (a) disseminating treatments in diverse community settings (i.e., investigating the transportability of treatment), (b) personalizing mental health care (i.e., investigating predictors and moderators of treatment outcome), and (c) developing evidence-based explanations of treatment (i.e., investigating mediators of treatment). Key issues that are raised in the specific studies are discussed, and important considerations for future research are highlighted. Moving the field forward requires innovation, complex research designs, and a willingness to develop treatment models that reach beyond the current body of treatment outcome and prevention research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A population-based, randomized clinical trial on back pain management

STUDY DESIGN: Population-based randomized clinical trial. OBJECTIVES: To develop and test a model of management of subacute back pain, to prevent prolonged disability. SUMMARY OF BACKGROUND DATA: The present management of back pain seems inadequate, and development of innovative models has been urged. METHODS: A model for the treatment of subacute work-related back pain has been developed and evaluated in a population-based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow-up. RESULTS: The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19-4.89; P < 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18-3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group. CONCLUSIONS: Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.     

Use of traditional and orthodox health services in urban Zimbabwe

BACKGROUND: Health care in Zimbabwe is provided by both orthodox and traditional care providers. With formal medical services under economic strain it is important to understand the extent of consulting with traditional care providers and their effectiveness. METHODS: A cross-sectional community survey recorded consultations and self-treatment for episodes of illness among 1251 individuals in 222 households randomly selected in two high-density suburbs of Harare, Zimbabwe. Three dependent variables (illness experience, consultation behaviour and choice of care provider) were analysed against a range of sociodemographic, episode-related and outcome measures. RESULTS: More than one-third of the sample had experienced an illness and 83% of these had led to consultation. Medical services were consulted eight times more often than traditional ones. Non-consulting behaviour was associated with lack of money or low perceived significance of problems. Physical problems were usually taken to medical clinics where their outcome was better, but non-specific pain and other problems did no better with medical or traditional care. CONCLUSIONS: While members of the community appear to recognize physical problems and take them to medical care, traditional and orthodox medical consultations appear to be equally effective for non-specific pain or non-specific physical problems. The role of traditional medicine in relation to non-specific physical problems and psychological problems is one which deserves further examination from both clinical and administrative perspectives. Poverty appears to be associated with poorer outcomes; this is a potentially important issue in times of increasing economic hardship.     

Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project

BACKGROUND: Low back pain is a common reason for visiting a physician. Authors of guidelines and insurance payers are currently scrutinizing use of radiography and computed tomography (CT) or magnetic resonance imaging (MRI). OBJECTIVE: To study the determinants of the use of lumbar spine radiography and either CT or MRI in patients with acute low back pain. DESIGN: Prospective cohort study. SETTING: Community-based practices in North Carolina in six strata: urban primary care physicians, rural primary care physicians, urban chiropractors, rural chiropractors, orthopedic surgeons, and practitioners at a group-model health maintenance organization. PATIENTS: 1580 patients with acute low back pain. MEASUREMENTS: Telephone interviews done after the index office visit and at 2, 4, 8, 12, and 24 weeks or until complete recovery; survey of practitioners; and chart abstraction. RESULTS: During the acute back pain episode, 46% of patients had radiography and 9% had CT or MRI. Patient variables related to use of radiography included pain that began more than 2 weeks before the index visit and no previous episodes of low back pain. Practitioner variables associated with use of radiography were being a chiropractor or orthopedic surgeon and having a solo practice. Use of CT or MRI was associated with white race, neurologic deficit at baseline, sciatica, poor functional status at baseline, and small group-practice size. Practitioners' responses to clinical vignettes were associated with aggregate practitioner behavior: In the vignettes and in real life, practitioners were more likely to order CT for patients with sciatica. However, a practitioner's response to a vignette did not predict that practitioner's use of CT or MRI for similar patients in his or her own practice. CONCLUSION: Radiography is commonly used as a diagnostic test for patients with acute back pain. Clinical factors and provider specialty are major correlates of the use of imaging studies.     

A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care

STUDY DESIGN: Randomized, controlled trial. OBJECTIVE: To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. BACKGROUND DATA: Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. METHODS: Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. RESULTS: Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. CONCLUSIONS: Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.     

Pain drawing in the evaluation of low back pain

Pain drawings were obtained from three groups of patients: 51 with lumbar disc herniation; 55 with lumbar stenosis, and 42 with benign low back pain. On grid assessment, patients with disc herniation and stenosis who complained of radiating pain or intermittent claudication had a significantly larger number of grids for the extremities than those with benign low back pain. In studies of the relation between the characteristics of the pain drawing and the outcome of treatment, most patients with 19 grids or less, or a score of 3 points or less, had a satisfactory outcome. Those with more grids or a higher score tended to be unsatisfactory. Pain drawing permits differentiation of the three patterns of pain and is useful for predicting the outcome of treatment.     

Epidemiologic study on the prevalence of low back pain in health personnel exposed to manual handling tasks]

An epidemiological study on the prevalence rate of low back pain among health care workers exposed to manual handling tasks and physical work load was performed. A representative sample (n. 1053) of nursing staff working at the San Matteo Hospital in Pavia was studied using a questionnaire with the purpose of evaluating the prevalence rate of low back pain and related risk factors. 86.4% of the subjects admitted having suffered from back pain at some stage in their life and 71.0% complained of back pain in the 3 months prior to answering the questionnaire. Multivariate logistic regression analysis revealed a significant correlation between low back pain, female gender and specific nursing activities. A significant correlation was found between smoking (> 20 cigarettes per day) and the presence of low back pain, due to intervertebral disk pathology. A statistically significant difference (p < 0.0001) was found in the average degree of disability between healthy nurses (1.3), those with low back pain taking analgesic drugs (5.9) and nurses suffering from low back pain without taking drugs (3.8).     

One-footed and externally disturbed two-footed postural control in patients with chronic low back pain and healthy control subjects. A controlled study with follow-up

STUDY DESIGN: A study of postural control during one-footed and externally disturbed two-footed stance among healthy control subjects and patients with chronic low back pain at the beginning of a functional back restoration program and 6 months later at follow-up examination. OBJECTIVES: To study postural control cross-sectionally among control subjects and patients with low back pain, and to evaluate the effects of functional restoration on the postural control parameters in a follow-up examination. SUMMARY OF BACKGROUND DATA: Deficits of motor skills and coordination have been reported in association with musculoskeletal disorders. It has been found that patients with chronic low back pain have impaired psychomotor control, but the impairment is reversible with successful low back rehabilitation. It is insufficiently known how functional activation and intensive physical training affect postural control. METHODS: Sixty-one healthy volunteers (32 men, 29 women) and altogether 99 patients with low back pain participated in the study. Sixty-eight patients (33 men, 35 women) had moderate and 31 (18 men, 13 women) had severe low back pain. Postural stability was measured with a force platform. In two-footed stance, vibration stimulation on calf and back muscles was used to disturb the balance. Center point of force-velocity (cm/sec), average position shift in anteroposterior direction (cm), and maximal position shift in lateral direction (cm) were used as the parameters. RESULTS: Reliability of all tests was acceptable. Center point of force-velocity was the most sensitive parameter and the one-footed measurement the most sensitivetest for evaluating postural stability. At the beginning, the patients with severe low back pain had poorer one-footed postural control compared with the control subjects (P = 0.0003). The subgroup of patients with moderate low back pain participated in the restoration program. The outcome of the restoration program was considered good if the disability because of low back pain (Oswestry index) decreased during the restoration program and poor if the disability increased or did not change. The one-footed postural stability remained primarily at the same level as the initial results in the control and good outcome groups, but became significantly poorer in the poor outcome group. The difference between poor outcome and control groups was statistically significant (P = 0.04). CONCLUSIONS: Impaired postural stability seems to be one factor in multidimensional symptomatology of patients with chronic low back trouble. Postural stability is easily disturbed in case of impairment in strength, coordination, or effective coupling of muscles in the lumbar and pelvic area. Patients with chronic low back pain seem to experience impairment in these functions, which should be taken into consideration when back rehabilitation programs are planned.