The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews The natural course of low back pain: a systematic critical literature review Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Prognostic factors for perceived recovery or functional improvement in non-specific low back pain: secondary analyses of three randomized clinical trials Long-term prognosis of acute low back pain in patients seen in general practice: a 1-year prospective follow-up study. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care? Spinal mechanical load: a predictor of persistent low back pain? A prospective cohort study Physiotherapists' use of advice and exercise for the management of chronic low back pain: a national survey. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Pain response classification does not predict long-term outcome in patients with low back pain who are sick-listed. Low pressure pain thresholds are associated with, but does not predispose for, low back pain Long-Term Effects of Specific Stabilizing Exercises for First-Episode Low Back Pain Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care. A non-randomized clinical trial to assess the impact of nonrigid, inelastic corsets on spine function in low back pain participants and asymptomatic controls. Individualized chiropractic and integrative care for low back pain: the design of a randomized clinical trial using a mixed-methods approach Does physical activity change predict functional recovery in low back pain? Protocol for a prospective cohort study Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project. An educational approach based on a non-injury model compared with individual symptom-based physical training in chronic LBP. A pragmatic, randomised trial with a one-year follow-up Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies Background Most patients in the secondary care sector consulting for low back pain ( LBP ) seem to have a more or less constant course of pain during the ensuing year . Fewer patients with LBP in the primary care sector report continual pain over a one-year period . However , not much is known about the long-term course of LBP in the general population . A systematic critical literature review was undertaken in order to study the natural course of LBP over time in the general population . Methods A search of articles was performed in Pubmed , Cinahl and Psychinfo using the search terms ‘ epidemiology ’ ; ‘ low back pain ’ or ‘ back pain ’ ; ‘ prospect i ve study ’ or ‘ longitudinal study ’ ; ‘ follow-up ’ , ‘ natural course ’ , ‘ course ’ or ‘ natural history ’ ; ‘ general population ’ or ‘ working population ’ . Inclusion criteria were that one of the objectives was to study the course of (L)BP in the adult population , that the period of follow-up was at least 3 months , and that there were three points of observation or more . The review was undertaken by two independent review ers using three checklists relating to description of studies , quality and outcomes . The course of LBP was established in relation to those who , at baseline , were reported not to have LBP or to have LBP . Would this course be stable , fluctuating , worsening , or improving over time ? A synthesis of results in relation to common patterns was presented in a table and interpreted in a narrative form . Results Eight articles were included . Articles were different on time span , the number of surveys , and the definition of LBP . In six of the seven relevant studies , for those with no LBP at baseline , relatively substantial stable subgroups of people who continued to be LBP free were identified . In six of the seven relevant studies , definite stable subgroups of continued LBP were noted and improvement ( becoming pain free ) was never reported to be a common finding . Conclusion The status of LBP in individuals of the general population appears to be relatively stable over time , perhaps particularly so for those without LBP at baseline Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain The objective of this study was to report on secondary analyses of a merged trial data set aim ed at exploring the potential importance of patient factors associated with clinical ly relevant improvements in non-acute , non-specific low back pain ( LBP ) . From 273 predominantly male army workers ( mean age 39 ± 10.5 years , range 20–56 years , 4 women ) with LBP who were recruited in three r and omized clinical trials , baseline individual patient factors , pain-related factors , work-related psychosocial factors , and psychological factors were evaluated as potential prognostic variables in a short-term ( post-treatment ) and a long-term logistic regression model ( 6 months after treatment ) . We found one dominant prognostic factor for improvement directly after treatment as well as 6 months later : baseline functional disability , expressed in Rol and –Morris Disability Question naire scores . Baseline fear of movement , expressed in Tampa Scale for Kinesiophobia scores , had also significant prognostic value for long-term improvement . Less strongly associated with the outcome , but also included in our final models , were supervisor social support and duration of complaints ( short-term model ) , and co-worker social support and pain radiation ( long-term model ) . Information about initial levels of functional disability and fear-avoidance behaviour can be of value in the treatment of patient population s with characteristics comparable to the current army study population ( e.g. , predominantly male , physically active , working , moderate but chronic back problems ) . Individuals at risk for poor long-term LBP recovery , i.e. , individuals with high initial level of disability and prominent fear-avoidance behaviour , can be distinguished that may need additional cognitive-behavioural treatment OBJECTIVES We aim ed to examine the prognosis of acute low back pain ( LBP ) in patients in general practice and to identify prognostic factors associated with the long-term prognosis based on information immediately available to the GP . METHOD We conducted a prospect i ve cohort study in general practice in Denmark . The patients were those aged 18 - 60 years consulting their GP due to an episode of LBP lasting less than 2 weeks . The GPs collected data regarding 34 exposure variables , including their global assessment of the likelihood of chronic LBP . Outcome variables were collected from the patients after 1 , 6 and 12 months . The outcome measures were days on sick leave , and functional or complete recovery from LBP . RESULTS In total , 503 ( 96 % ) patients were followed during the whole study period . Fifty per cent of the patients on sick leave returned to work within 8 days ; after 1 year , only 2 % remained on sick leave . At the 1-year follow-up , 45 % of the patients continued to complain of LBP . Logistic regression analyses showed that the factors most significantly associated with poor long-term LBP outcome were ( i ) severity of LBP at inclusion , ( ii ) assessment s by the GP of susceptibility to develop chronic LBP and ( iii ) a history of LBP having caused previous sick leave . CONCLUSIONS LBP in general practice has a good prognosis with regard to sick leave , but a high proportion of patients continue to complain of LBP . We were not able to identify objective measures that strongly predict the prognosis of the individual LBP patient . The overall assessment by the GPs seems to be the most important predictor associated with the long-term outcome Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP & NA ; Few studies have investigated whether prognostic indicators , which contribute to the transition from acute to chronic low back pain ( LBP ) , are also those which contribute to continuing persistence of chronic LBP . We compared the contribution of physical , psychological and social indicators to predicting disability after one year between consulters with LBP of less than 3 months duration and more than 3 months duration . Data from two large prospect i ve cohort studies of consecutive patients consulting with LBP in general practice s were merged , providing complete data for 258 cases with acute/subacute LBP and 668 cases with chronic LBP at 12 months follow‐up . There were significant differences between the two LBP groups in baseline characteristics and clinical course of disability , assessed by Rol and Morris Disability Question naire , during the year of follow‐up . Adjusted associations between potential prognostic indicators and disability at 12 months were carried out in the two LBP subgroups . The final multivariable regression models showed that being non‐employed , having widespread pain , a high level of Chronic Pain Grade , and catastrophising were the strongest prognostic indicators for disability at 12 months in both LBP groups . Fear of pain was significantly associated with disability in chronic LBP . Importantly , beyond baseline disability , the effect size of the other prognostic indicators for poor outcome was rather low . These findings must continue to challenge research ers to identify useful early predictors of outcome in persons with disabling back pain , as screening and targeted treatment approaches are dependent upon prognostic indicators with clinical significance Prospect i ve inception cohort . To assess the prognostic value of spinal mechanical load , assessed with the 24-hour schedule ( 24HS ) , in subjects with acute non-specific low back pain ( ALBP ) and to examine the influence of spinal mechanical load on the course of ALBP . In view of the characteristics of the natural course of ALBP , this should be viewed as a persistent condition in many patients rather that a benign self-limiting disease . Therefore , secondary prevention could be beneficial . Spinal mechanical load is a risk factor for ALBP and possibly a ( modifiable ) prognostic factor for persistent ( i.e. recurrent and /or chronic ) LBP . One hundred patients from primary care with ALBP were eligible for inclusion . At 6 months , 88 subjects completed the follow-up . For the follow-up assessment a research assistant , unaware of our interest in the prognostic factors , contacted the subjects by telephone . Question naires were completed focusing on changes in demographic data and on the course and current status of ALBP . Persistent LBP occurred in 60 % subjects . After multivariate regression analysis smoking ( harmful ) and advanced age ( protective ) were associated with persistent LBP . Differences in 24HS scores at baseline and follow-up were univariate-related to persistent LBP . Spinal mechanical load , quantified with the 24HS , is not a prognostic factor for persistent LBP . Modification of spinal mechanical load in terms of 24HS scores could be beneficial for secondary prevention in patients with acute LBP The objective of the study was to establish the specific use of advice and exercise by physiotherapists , for the management of  chronic low back pain ( LBP ) . A question naire was mailed to a r and om sample of 600 members of the Irish Society of Chartered Physiotherapists . Open and closed questions were used to obtain information on treatments provided to chronic LBP patients . Respondents ' treatment goals were also investigated , along with the typical methods used to assess treatment outcome . Four hundred and nineteen of the sample returned the question naire ; 280/419 ( 67 % ) indicated that they currently treated LBP of which 76 % ( n=214 ) were senior grade therapists .  Advice and exercise  , respectively , were the treatments most frequently used for chronic LBP : advice was most commonly delivered as part of an exercise programme , with strengthening ( including core stability ) the most frequently used exercise type .  Supervision of exercise and follow-up advice  were underutilised with respect to the recommendations of relevant clinical guidelines . Pain relief was an important treatment goal . Emphasis on exercise programme  supervision , incorporating reassurance that its safe to stay active and ' hurt does not mean harm ' , must be more effectively disseminated and promoted in practice . The influence of follow-up advice on  exercise adherence warrants further investigation BACKGROUND CONTEXT A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain ( LBP ) illness . Although the relative contributions of structural and psychosocial variables are intensely debated , the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects . These factors dictate the requirement for large sample sizes , extensive structural imaging and extended longitudinal study . Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline . PURPOSE To establish , using a strict patient sample design , the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness . STUDY DESIGN / SETTING A prospect i ve , longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics . PATIENT SAMPLE One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic ( non-lumbar ) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease , to undergo baseline examination , testing and 5-year follow-up . OUTCOME MEASURES Observations were made at 6-month intervals over 4 to 6 years ( mean , 5.3 ) for the after primary outcomes measures : episodes of serious back pain ( visual analogue scale [ VAS ] > or = 6 ) , episodes of occupational disability less than 1 week , episodes of occupational disability for 1 week , remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment . METHODS Lumbar magnetic resonance imaging ( MRI ) , lumbar provocative discography ( in psychometrically normal subjects ) , physical examinations , medical and work histories and psychometric testing were performed at baseline . Imaging and psychometric testing were grade d by blinded examiners . A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data . The interview covered interval medical , occupational and accident or injury histories . RESULTS Psychosocial variables strongly predicted both long- and short-term disability events , duration and health-care visits for LBP problems ( p<0.0001 - 0.004 ) . The likelihood of a sustained remission from the baseline persistent ( sub clinical ) LBP appeared to be linked to occupation factors ( leaving a heavy labor occupation ; p=0.0001 ) , neurophysiologic variables ( chronic nonlumbar pain ; p=0.0002 ) and psychometric profiles at baseline ( DRAM and FABQ-PA ; p=0.003 - 0.002 ) . Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome . A positive provocative discogram at baseline did not predict any future adverse event . CONCLUSION The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables . Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care STUDY DESIGN Prospect i ve cohort study nested in a r and omized clinical trial . OBJECTIVE To investigate the prognostic value of pain response classification at initial physiotherapy examination in patients with low back pain ( LBP ) who are sick-listed . BACKGROUND Recurrent and chronic LBP accounts for a substantial proportion of all absence from work . In predicting outcome in patients with LBP , psychosocial factors are thought to play an important role , while findings from clinical examination seem to be of more limited value . Mechanical evaluation , using repeated end range spinal movements that result in specific pain responses , has been shown to be of some value . METHODS The study included 351 patients sick-listed because of LBP with or without sciatica . Prior to clinical examination , the patients completed a comprehensive question naire including questions on pain , function , and psychosocial factors . The physiotherapy examination included a st and ardized mechanical evaluation . Patients were classified into 3 groups according to their pain response : central ization , peripheralization , or no response . Outcomes were obtained by national register data , medical records , and a postal question naire at 1 year . RESULTS At 1-year follow-up , 65 % of the patients had returned to work . All pain response groups showed significant and clinical ly important improvements in both pain and disability . No significant differences were found between pain response groups in any outcome measure . Results remained unchanged after adjustment for potential confounders . CONCLUSION The prognostic value of pain response classification seems limited in patients sick-listed from work because of LBP Chronic pain is often associated with hyperalgesia in cross-sectional studies . In the present study , a r and om cohort of 40-year-old individuals ( n = 264 ) from the general population was assessed for low back pain ( LBP ) status and pressure pain threshold ( PPT )  , with follow-up assessment 4 and 8 years later . Low PPT at baseline as a potential risk factor for the development of LBP was investigated longitudinally and the association between LBP and hyperalgesia was studied cross-sectionally at baseline and 8-year follow-up . Generalized ( p < 0.03 ) and localized pressure hyperalgesia ( p < 0.02 ) was found in participants with long-lasting LBP , but not with recent LBP ( p > 0.08 ) . Of the participants without recent or long-lasting LBP , those with a low PPT at baseline ( lower 10 % percentile ) had no increased risk of developing LBP ( p > 0.05 ) . The findings indicate that PPT decreases as a consequence of long-lasting pain , whereas a low PPT seems not to constitute a separate risk factor for the development of LBP Study Design . A r and omized clinical trial with 1-year and 3-year telephone question naire follow-ups . Objective . To report a specific exercise intervention ’s long-term effects on recurrence rates in acute , first-episode low back pain patients . Summary of Background Data . The pain and disability associated with an initial episode of acute low back pain ( LBP ) is known to resolve spontaneously in the short-term in the majority of cases . However , the recurrence rate is high , and recurrent disabling episodes remain one of the most costly problems in LBP . A deficit in the multifidus muscle has been identified in acute LBP patients , and does not resolve spontaneously on resolution of painful symptoms and resumption of normal activity . Any relation between this deficit and recurrence rate was investigated in the long-term . Methods . Thirty-nine patients with acute , first-episode LBP were medically managed and r and omly allocated to either a control group or specific exercise group . Medical management included advice and use of medications . Intervention consisted of exercises aim ed at rehabilitating the multifidus in cocontraction with the transversus abdominis muscle . One year and three years after treatment , telephone question naires were conducted with patients . Results . Question naire results revealed that patients from the specific exercise group experienced fewer recurrences of LBP than patients from the control group . One year after treatment , specific exercise group recurrence was 30 % , and control group recurrence was 84 % ( P < 0.001 ) . Two to three years after treatment , specific exercise group recurrence was 35 % , and control group recurrence was 75 % ( P < 0.01 ) . Conclusion . Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone BACKGROUND CONTEXT Treatment guidelines suggest that most acute low back pain ( LBP ) episodes substantially improve within a few weeks and that immediate use of imaging and aggressive therapies should be avoided . PURPOSE Assess the actual practice patterns of imaging , noninvasive therapy , medication use , and surgery in patients with LBP , and compare their costs to those of matched controls without LBP . STUDY DESIGN A retrospective analysis of cl aims data from 40 self-insured employers in the United States . PATIENT SAMPLE The study sample included 211,551 patients , aged 18 to 64 years , with one LBP diagnosis or more ( per Healthcare Effectiveness Data and Information Set specification ) during 2004 to 2006 , identified from a cl aims data base . Patients had continuous eligibility for 12 months or more after their index LBP diagnosis ( study period ) , for 6 months or more before their index diagnosis ( baseline period ) , and no other LBP diagnosis during the baseline period . Patients with LBP were matched to a r and om cohort of patients without LBP by age , gender , employment status , and index year . OUTCOMES MEASURES Physiological measures ( eg , imaging and diagnostic tests ) , functional measures ( eg , pharmacologic and nonpharmacologic treatment for LBP , health-care re source use ) , and direct ( medical and prescription drug ) and indirect ( disability and medically related absenteeism ) costs were assessed within the year after the LBP diagnosis . METHODS Univariate analyses described treatment patterns and compared baseline characteristics and study period costs . RESULTS Patients with LBP had significantly higher rates of baseline comorbidities and re source use compared with controls . Of patients with LBP , 41.6 % had imaging mean ( median ) [ st and ard deviation ] 34.3 ( 0 ) [ 78.6 ] days after the LBP diagnosis . Most patients with LBP ( 69.4 % ) used medications starting 51.9 ( 8) [ 86.2 ] days after the diagnosis . Opioids were commonly prescribed early ( 41.6 % of patients ; after 82.8 ( 25 ) [ 105.9 ] days ) . Of patients with LBP , 2.05 % had surgery during the study period . Patients with LBP were likely to have chiropractic treatment first , followed by pharmacotherapy with muscle relaxants and nonsteroidal anti-inflammatory drugs . Except for less surgery , these findings also held for patients with only nonspecific LBP . Patients with LBP had higher mean direct costs compared with controls ( $ 7,211 vs. $ 2,382 , respectively ; p<.0001 ) , with surgery patients having mean direct costs of $ 33,931 . CONCLUSIONS Contrary to clinical guidelines , many patients with LBP start incurring significant re source use and associated expenses soon after the index diagnosis . Achieving guideline -concordant care will require substantial changes in LBP practice patterns BACKGROUND CONTEXT Although previous studies suggest braces/corsets can reduce acute pain , no prior study has assessed back function after bracing with both self-reported and objective measures . Use of both self-reported and objective measures of spine function together may be important given evidence they assess unique aspects of function . PURPOSE The aim was to assess both self-reported and objective measures of spinal function before , and after , use of a nonrigid , inelastic lumbar brace . STUDY DESIGN / SETTING This was a non-r and omized clinical trial . PATIENT SAMPLE The sample included acute low back pain ( LBP ) participants and asymptomatic controls . OUTCOME MEASURES Oswestry Disability Index ( ODI ) , spinal stiffness , and muscle endurance were the outcome measures . METHODS Three groups were studied : -LBP/-Brace ( n=19 ) , -LBP/+Brace ( n=18 ) , and + LBP/+Brace ( n=17 ) . Both groups of braced participants were instructed to wear the brace continually for 2 weeks with the exception of bedroom and bathroom activities . Before and after the 2-week period , three measures of spinal function were performed : spinal stiffness via motorized indentation of the L3 spinous process , a modified Sorensen test ( timed lumbar extension against gravity ) , and the ODI . Repeated measures analyses of variance were conducted for all three outcomes . RESULTS Among the groups , ODI scores decreased significantly for the + LBP/+Brace group ( p<.001 ) compared with the other two groups . The + LBP/+Brace mean ODI score decreased 3.71 points ( 95 % confidence interval [ CI ] 2.01 - 5.40 ) compared with the -LBP/-Brace group and decreased 3.48 points ( 95 % CI 1.77 - 5.20 ) compared with the -LBP/+Brace group . Change scores for the Sorensen test were significantly increased in the + LBP/+Brace group ( p=.037 ) compared with the -LBP/-Brace group ( 22.47s 95 % CI 8.14 - 36.80 ) . Spinal stiffness did not change significantly between groups . CONCLUSIONS This study demonstrates that lumbar function assessed by self-reported and objective measures does not worsen when nonrigid , inelastic bracing is used for short periods of time for those with , or without , back pain . These data add to the existing literature that suggests short-term use of nonrigid , inelastic bracing for acute LBP does not decrease spinal function when measured separately with subjective or objective tools Background Low back pain ( LBP ) is a prevalent and costly condition in the United States . Evidence suggests there is no one treatment which is best for all patients , but instead several viable treatment options . Additionally , multidisciplinary management of LBP may be more effective than monodisciplinary care . An integrative model that includes both complementary and alternative medicine ( CAM ) and conventional therapies , while also incorporating patient choice , has yet to be tested for chronic LBP.The primary aim of this study is to determine the relative clinical effectiveness of 1 ) monodisciplinary chiropractic care and 2 ) multidisciplinary integrative care in 200 adults with non-acute LBP , in both the short-term ( after 12 weeks ) and long-term ( after 52 weeks ) . The primary outcome measure is patient-rated back pain . Secondary aims compare the treatment approaches in terms of frequency of symptoms , low back disability , fear avoidance , self-efficacy , general health status , improvement , satisfaction , work loss , medication use , lumbar dynamic motion , and torso muscle endurance . Patients ' and providers ' perceptions of treatment will be described using qualitative methods , and cost-effectiveness and cost utility will be assessed . Methods and Design This paper describes the design of a r and omized clinical trial ( RCT ) , with cost-effectiveness and qualitative studies conducted alongside the RCT . Two hundred participants ages 18 and older are being recruited and r and omized to one of two 12-week treatment interventions .  Patient-rated outcome measures are collected via self-report question naires at baseline , and at 4 , 12 , 26 , and 52 weeks post-r and omization . Objective outcome measures are assessed at baseline and 12 weeks by examiners blinded to treatment assignment . Health care cost data is collected by self-report question naires and treatment records during the intervention phase and by monthly phone interviews thereafter . Qualitative interviews , using a semi-structured format , are conducted with patients at the end of the 12-week treatment period and also with providers at the end of the trial . Discussion This mixed- methods r and omized clinical trial assesses clinical effectiveness , cost-effectiveness , and patients ' and providers ' perceptions of care , in treating non-acute LBP through evidence -based individualized care delivered by monodisciplinary or multidisciplinary care teams . Trial registration Clinical Trials.gov Background Activity advice and prescription are commonly used in the management of low back pain ( LBP ) . Although there is evidence for advising patients with LBP to remain active , facilitating both recovery and return to work , to date no research has assessed whether objective measurements of free living physical activity ( PA ) can predict outcome , recovery and course of LBP . Methods An observational longitudinal study will investigate  PA  levels in a cohort of community-dwelling working age adults with acute and sub-acute LBP . Each participant 's  PA level , functional status , mood , fear avoidance behaviours , and levels of pain , psychological distress and occupational activity  will be measured on three occasions during for 1 week periods at baseline , 3 months , and 1 year .  Physical activity levels  will be measured by self report , RT3 triaxial accelerometer , and activity recall question naires . The primary outcome measure of functional recovery will be the Rol and Morris Disability Question naire ( RMDQ ) . Free living PA levels and changes in functional status will be quantified in order to look at predictive relationships between levels and changes in free living PA and functional recovery in a LBP population . Discussion This research will investigate levels and changes in activity levels of an acute LBP cohort and the predictive relationship to LBP recovery . The results will assess whether occupational , psychological and behavioural factors affect the relationship between free living PA and LBP recovery . Results from this research will help to determine the strength of evidence supporting international guidelines that recommend restoration of normal activity in managing LBP.Trial registration [ Clinical Trial Registration Number , ACTRN12609000282280 OBJECTIVE To determine the onset of low back pain ( LBP ) in schoolchildren and to investigate the role of mechanical and psychosocial factors as risk factors for its onset . METHODS A prospect i ve population -based cohort study was conducted of 1046 schoolchildren , aged 11 to 14 years at baseline , identified as being free of LBP , from 39 secondary schools in Northwest Engl and .  New onset of LBP at 1-year follow-up was measured . RESULTS Children who reported high levels of psychosocial difficulties were more likely to develop LBP than their peers ( relative risk : 1.6 ; 95 % confidence interval : 1.1 - 2.3 ) . An excess risk was , in particular , associated with conduct problems ( 2.5 ; 1.7 - 3.7 ) . Similarly , children who reported high numbers of somatic symptoms at baseline were at greater risk of developing LBP : abdominal pain ( 1.8 ; 1.1 - 3.0 ) , headaches ( 1.6 ; 0.97 - 2.8 ) , and sore throats ( 1.5 ; 0.8 - 2.6 ) . In contrast , we have been unable to demonstrate a strong association between daily mechanical load ( schoolbag weight ) and the short-term risk of new-onset LBP ( highest versus lowest quintile : 1.2 ; 0.7 - 2.1 ) . CONCLUSIONS In children who were initially free of LBP , adverse psychosocial factors and the presence of other preexisting somatic pain symptoms were predictive of future LBP , reflecting findings in adults . In contrast , there was little evidence of an increase in short-term risk associated with mechanical load across the range of weights commonly carried by children to school BACKGROUND Better insight into frequent comorbidities in patients with chronic ( ≥ 3 months ) low back pain ( LBP ) may help general practitioners when planning comprehensive care for these patients . OBJECTIVE To prospect ively study the prevalence of psychological , social , musculoskeletal and somatoform disorders in patients presenting with chronic non-specific LBP to general practitioners , in comparison to a contrast group of patients consulting in the same setting . METHODS This case-control study is embedded in a historical cohort , based on a primary care practice -based research network . All the health problems presented by the patients were prospect ively coded according to the international classification of primary care between 1996 and 2013 . The prevalence of psychological , social , musculoskeletal and somatoform disorders presented by the adult patients from 1 year before the onset of chronic LBP to 2 years after onset was compared to that of matched patients consulting without LBP , using conditional logistic regressions . RESULTS The 1511 patients with chronic LBP more often presented musculoskeletal disorders than the contrast group during the year before the onset of LBP and during the second year after it , with odds ratios ( 95%confidence intervals ) of 1.39 ( 1.20 - 1.61 ) and 1.56 ( 1.35 - 1.81 ) , respectively . They did not more often present psychological , social or non-musculoskeletal somatoform disorders . CONCLUSIONS General practitioners should consider all the musculoskeletal symptoms when caring for patients with chronic LBP . Rather than systematic ally screening for specific psychological , social or somatoform disorders , they should consider with the patient how LBP and any type of potential comorbidity interfere with his/her daily functioning Background In the treatment of  chronic back pain  , cognitive methods are attracting increased attention due to evidence of effectiveness similar to that of traditional therapies . The purpose of this study was to compare the effectiveness of performing a cognitive intervention based on a non-injury model with that of a symptom-based physical training method on the outcomes of  low back pain ( LBP ) , activity limitation , LBP attitudes ( fear-avoidance beliefs and back beliefs ) , physical activity levels , sick leave , and quality of life , in chronic LBP patients . Methods The study was a pragmatic , single-blind , r and omised , parallel-group trial . Patients with chronic/recurrent LBP were r and omised to one of the following treatments : 1 . Educational programme : the emphasis was on creating confidence that the back is strong , that loads normally do not cause any damage despite occasional temporary pain , that reducing the focus on the pain might facilitate more natural and less painful movements , and that it is beneficial to stay physically active . 2 . Individual symptom-based physical training programme : directional-preference exercises for those central ising their pain with repetitive movements ; ' stabilising exercises ' for those deemed ' unstable ' based on specific tests ; or intensive dynamic exercises for the remaining patients . Follow-up question naires ( examiner-blinded ) were completed at 2 , 6 and 12 months . The main statistical test was an ANCOVA adjusted for baseline values . Results A total of 207 patients participated with the median age of 39 years ( IQR 33 - 47 ) ; 52 % were female , 105 were r and omised to the educational programme and 102 to the physical training programme .  The two groups were comparable at baseline . For the primary outcome measures , there was a non-significant trend towards activity limitation being reduced mostly in the educational programme group , although of doubtful clinical relevance . Regarding secondary outcomes , improvement in fear-avoidance beliefs was also better in the educational programme group . All other variables were about equally influenced by the two treatments . The median number of treatment sessions was 3 for the educational programme group and 6 for the physical training programme group . Conclusions An educational approach to treatment for chronic LBP result ed in at least as good outcomes as a symptom-based physical training method , despite fewer treatment sessions . Trial registration Clinical trials.gov : # Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied
Conclusions For most clinical tests in LBP there is not consistent evidence for an association with outcome .
Central ization and non-organic signs are exceptions from that .
Background There is a strong tradition of performing a clinical examination of low back pain ( LBP ) patients and this is generally recommended in guidelines .
However , establishing a pathoanatomic diagnosis does not seem possible in most LBP patients and clinical tests may potentially be more relevant as prognostic factors .
The aim of this review of the literature was to systematic ally assess the association between low-tech clinical tests commonly used in adult patients with acute , recurrent or chronic LBP and short- and long-term outcome .