Management Of Low Back Pain Research Articles

Comparison of Feng spinal mobilization with Maitland mobilization in management of chronic nonspecific low back pain: A cohort study.

Feng spinal mobilization (FSM) is one of the most widely practiced techniques in traditional Chinese osteopathy, especially in China. However, whether this FSM technique is more effective than the Maitland posteroanterior mobilization (MM), which is widely used all over the world, is still unknown. The purpose of this study was to retrospectively analyze and compare the efficacy of these 2 treatments in patients with chronic nonspecific low back pain (CNLBP) as to provide a basis for the clinical treatment of chronic low back pain. A total of 83 patients, including 43 patients in the FSM group and 40 in the MM group, were enrolled in this cohort study. FSM or MM was performed on patients 3 times during a period of 2 weeks. Changes in the subjective and objective measurements were measured before and after the third treatment. The subjective symptoms recorded included the visual analogue scale (VAS), Oswestry disability index, and Patient Health Questionnaire-9. The objective symptoms, including the lumbar range of motion (ROM), and straight leg raise (SLR) height were also checked for any changes. The VAS scores were reassessed at the 1-year follow-up visit. The results showed that 2 weeks of FSM treatment significantly improved CNLBP patients modified Schober test (P < .05), extension ROM (P < .01), and SLR height (P < .05) while MM treatment did not. Both treatments significantly decreased the values of VAS, Oswestry disability index, and Patient Health Questionnaire-9 (P < .01). Compared to the MM treatment, the FSM treatment showed a much more significant improvement in VAS score (P < .01), range of motion of extension (P < .01), and SLR of both sides (P < .05). At the 1-year follow-up, VAS scores in both groups decreased significantly compared to pretreatments; however, there was no significant difference between the 2 groups. Our data suggested that the FSM treatment can provide better efficacy than MM in CNLBP patients, improving the VAS scores, lumbar extension ROM, and SLR height in a shorter time.

Physiotherapists’ attitudes and beliefs about self-management as part of their management for low back pain

BackgroundPerceptually, there is a discrepancy between research evidence and clinical physiotherapy practice for supporting self-management in people with low back pain (LBP). ObjectiveThis study aimed to explore physiotherapists’ understanding of LBP; ascertain their knowledge of self-management concepts; and explore their attitudes and beliefs about supporting self-management for LBP within present physiotherapy practice in private and hospital settings. DesignInterpretive Description qualitative methodology, involving in-depth data interpretation to clinical practice, was used. MethodsSemi-structured interviews with physiotherapists throughout New Zealand were conducted via video conferencing. Data was analysed and themes were defined. ResultsSeventeen physiotherapists (24–65 years old), with between one and 40+ years of experience, participated. Four main themes were defined: 1) Evolving understanding of LBP, 2) apportioning responsibility, 3) self-management is important, 4) understanding self-management. ConclusionNovel findings from this research demonstrate examples of attitudes and beliefs that determine when and how self-management for people with LBP is implemented. Due to these attitudes and beliefs, physiotherapists may not consistently provide supported self-management for people with LBP. Participants had good understanding of LBP but lacked a contemporary knowledge of the natural history and tended to apportion responsibility for persistent or recurrent episodes to the person with LBP. Physiotherapists should be encouraged to assimilate more contemporary research evidence into their expectations of recovery for LBP. Further education about the role of physiotherapists in supporting self-management, the core components of self-management, including engagement, and reflection upon individual unconscious bias should be encouraged.

Critical Appraisal of Current Acute LBP Management and the Role of a Multimodal Analgesia: A Narrative Review.

Acute low back pain (LBP) stands as a leading cause of activity limitation and work absenteeism, and its associated healthcare expenditures are expected to become substantial when acute LBP develops into a chronic and even refractory condition. Therefore, early intervention is crucial to prevent progression to chronic pain, for which the management is particularly challenging and the most effective pharmacological therapy is still controversial. Current guideline treatment recommendations vary and are mostly driven by expertise with opinion differing across different interventions. Thus, it is difficult to formulate evidence-based guidance when the relatively few randomized clinical trials have explored the diagnosis and management of LBP while employing different selection criteria, statistical analyses, and outcome measurements. This narrative review aims to provide a critical appraisal of current acute LBP management by discussing the unmet needs and areas of improvement from bench-to-bedside, and proposes multimodal analgesia as the way forward to attain an effective and prolonged pain relief and functional recovery in patients with acute LBP.

Management of low back pain by primary care physiotherapists using the pain and disability drivers management model: An improver analysis.

Management of low back pain by primary care physiotherapists using the pain and disability drivers management model: An improver analysis.

Examples of Biases Affecting the Management of Low Back Pain

Examples of Biases Affecting the Management of Low Back Pain

The Benefit of Epidural Transforaminal Injection of Ozone in Comparison With Transforaminal Steroids Injection in the Management of Chronic Low Back Pain in Lebanese Population: One-Year Retrospective Study.

Background Chronic low back pain (CLBP) is one of the most common complaints affecting the population worldwide including in Lebanon. Until 15 years ago, surgery was the treatment of choice. However, conservative measures are now preferred because of the large number of post-surgical complications, in addition to the many conditions where surgery cannot be performed. Objective The aim of our study is to determine the effectiveness of transformational epidural injection of ozone (TFEOI) in the management of CLBP among the Lebanese population in the Nabatieh area in comparison with patients who received transformational epidural steroid injection (TFESI). Methods A one-year (2016-2017) retrospective study where 100 patients with CLBP were selected from two hospitals (Alnajdah, and Ragheb Harb hospitals) and divided into two groups. Fifty patients were treated with Ozone injections while the other 50 were treated with steroid injections. For each patient, we recorded the type of pain, irradiation, paresthesia, and the type of injection given (steroid or Ozone). We used the patients' files and contacted them via phone calls. The results of this study were reached based on Vas Score and Mac Nab criteria which are subjective questionnaires. Results The study showed that the TFESI was effective for a short duration (86% of results were excellent and good after one month of injection, but they decreased to 16% after six months). On the other hand, TFEOI was effective over both short and long duration (82% excellent and good after one month, 64% excellent and good after six months). Conclusion Results from this study provide that ozone injection has high benefits in the management of CLBP in the Lebanese population.

Lumbar Stabilization Exercises Combined with Therapeutic Yoga in the Management of Chronic Low Back Pain

This study aims to evaluate the combined effectiveness of specific stabilization exercises with yoga training for chronic low back pain patients in minimizing pain and improving their lumbar stability and functional ability. Totally 36 patients participated in this study which was performed as a Pre-test and post-test experimental study design. The outcome measure used was VAS, Roland Morri’s back pain questionnaire (RMQ). Specialized Lumbar stabilization exercises combined with therapeutic Yoga were provided to the patients. There was a significant difference in the gain score for the exercise with yoga for the VAS and RMQ. In the patient, the VAS score has decreased from the mean (standard deviation), pre–test (8/10) to post-test (3/10) which shows the difference. There was a significant difference in the Pain score (11) for the exercise with yoga for the Roland – Morris low back pain questionnaire. In the patient, RMQ scores have increased from the mean (standard deviation), pre–test (16/24) to post–test (5/24). This study reveals that specific stabilization exercises with yoga therapy training programs resulted in improvement. Progressive training appears to be an effective intervention to reduce low back pain and has a positive effect on improving strength. The study supports the lumbar spine stabilizing exercises combined with yoga therapy as an effective approach in minimizing pain and improving functional capacity.

The Foundations for Chronic Low Back Pain Management may Start in Early Life. Exploring the Role of Caregiver Parental Leave on Future Low Back Pain in the Offspring

Chronic low back pain is difficult to treat and despite increased spending on health services, clinical outcomes for people with low back pain have not improved. Innovative, large scale initiatives seem necessary to stem the cost of low back pain. Psychological health contributes to the development and persistence of chronic low back pain and psychological interventions are important in the management of low back pain. Given the contribution of psychological health to low back pain development and management, it raises the question; can we support psychological health in later life by bolstering emotional development in early life, and reduce the burden of this common condition? Positive early life experiences, including those induced by extended paid parental leave, could bolster emotional development and support the psychological health necessary to manage low back pain in later life. We present the current state of evidence demonstrating the potential value of increasing support for parent-child relationships in early life to reduce the burden of low back pain in future generations. The current evidence is limited to cross-sectional associations, but strong preclinical data clearly shows the potential negative impacts of maternal separation on rodent pup health that compels consideration in human populations. PerspectiveThe benefits stemming from enhanced child development include stable emotional foundations, possibly improving psychological health and low back pain management in the future. This perspective raises questions for future studies – within the context of low back pain, what ingredients bolster stable psychological health? And are these ingredients influenced by parental leave?

Racial and ethnic differences in the use of lumbar imaging, opioid analgesics and spinal surgery for low back pain: A systematic review and meta-analysis.

There is a substantial gap between evidence and clinical care for low back pain (LBP) worldwide despite recommendations of best practice specified in clinical practice guidelines. The aim of this systematic review was to identify disparities associated with race or ethnicity in the use of lumbar imaging, opioid analgesics, and spinal surgery in people with LBP. We included observational studies which compared the use of lumbar imaging, opioid analgesics, and spinal surgery for the management of non-serious LBP between people from different racial/ethnic populations. We searched in MEDLINE, EMBASE and CINAHL from January 2000 to June 2021. Risk of bias of included studies was appraised in six domains. For each type of care, we pooled data stratified by race and ethnicity using random effects models. We identified 13 eligible studies; all conducted in the United States. Hispanic/Latino (OR 0.69, 95%CI 0.49-0.96) and Black/African American (OR 0.59, 95%CI 0.46-0.75) people with LBP were less likely to be prescribed opioid analgesics than White people. Black/African Americans were less likely to undergo or be recommended spinal surgery for LBP (OR 0.47, 95%CI 0.33-0.67) than White people. There was a lack of high certainty evidence on racial/ethnic disparities in the use of lumbar imaging. This review reveals lower rate of the use of guideline-discordant care, especially opioid prescription and spinal surgery, in racial/ethnic minority populations with LBP in the United States. Future studies in other countries evaluating care equity for LBP are warranted. PROSPERO Registration ID: CRD42021260668. This systematic review and meta-analysis revealed that people with low back pain from the minority racial/ethnic backgrounds were less likely to be prescribed opioid analgesics and undergo spinal surgery than the majority counterparts. Strategic interventions to improve the access to, and the value of, clinical care for minority populations with low back pain are warranted.

Postural Control of Patients with Low Back Pain Under Dual-Task Conditions.

Low back pain is a major global public health problem, but the current intervention effect is not ideal. A large body of previous literature suggests that patients with chronic low back pain may have abnormal postural control, which is more evident in the dual task situation. In recent years, research on postural control in patients with low back pain under dual-task conditions has gradually become a hot topic. However, the results obtained from these studies were not entirely consistent. In this review, we summarized relevant studies on the performance of postural control in patients with low back pain under dual-task conditions, analyze it from the perspective of the theoretical model of dual-task interaction, the specific research paradigm of dual task, the performance of postural control, and the related factors affecting postural control performance, etc. It was reasonable to assume that patients with low back pain might have a certain degree of abnormal postural control, and this abnormality was affected by comprehensive factors such as age, cognitive resource capacity, attention needs, complex sensorimotor integration, external environment, etc. Furthermore, postural control performance in low back pain patients under dual-task conditions was further influenced by the nature and complexity of the different tasks. In general, the more attention resources were needed, the external environmental conditions were worse, and the age-related functions were degenerate, etc., the weaker posture control ability was. In short, a deeper understanding of postural control in patients with low back pain under dual-task conditions may shed light on more references for the rehabilitation and management of low back pain, as well as some new ideas for scientific research on cognition and postural control.

Role of Caudal Epidural Steroid in the Management of Low Back Pain in Telangana Population, India

Background: Low back pain (LBP) is a common condition seen in adult patients causing significant functional andpsychological disability in addition to the variable amount of pain.Method: Every patient was studied with x-rays, MRI of lumbosacral region and degree of pain was assessed byVAS scale. Routine blood investigations were done in every patient to rule out any otherpossible causes for thiscondition.Results: 95 patients with LBP were included in this study. Among these 16 (16.8%) either had annular tears orno abnormality in MRI leading to acute back pain, 14 (14.7%) had spondylolisthesis, 25 (26.5%) had lumbar canalstenosis, 40 (42.1%) had degeneration of disc. As per VAS (Visual Analogue Score) at 3rd month -14 patients of AcuteLBP, 12 patients with spondylolisthesis, 13 patients with lumbar canal stenosis, 26 patients with degenerative discdisease had significant improvement.Conclusion: Present study used X-rays, MRI and VAS analogue Scorein addition to systematic clinical examinationfor evaluation of the low back pain patients. Patients who were resistant to conservative measures were treatedwith epidural steroid injection before subjecting them to any surgical intervention. Thisis important for theOrthopedicians to treat such patients efficiently with minimal invasion without subjecting them to more invasivemeasures like open surgical procedures.

Effect of Adding Functional Dry Cupping Treatment Based Thoracolumbar Fascia Stretching to a Conventional Physiotherapeutic Management of Non-Specific Chronic Low Back Pain in District Level Cricketers - An Annotated Bibliographic Review

[Purpose] The most frequent site of injury in fast bowlers is the low back due to repetitively hyper extendingthe trunk before releasing the ball. The lumbopelvic stability is reduced over a period of time as a result ofreduced mobility of thoracolumbar fascia (TLF) giving rise to chronic low back pain (cLBP). In addition toconventional exercises, cupping therapy is also most widely used today as a complementary therapy for thereduction of low back pain.The purpose of this study was to review the current available literature on effectof dry cupping treatment in managing the cLBP. [Relevance] Information gained by this study would help infinding out effectiveness of adding dry cupping to the treatment protocol of non specific cLBP. [Participants]Eight full text articles were included for this review. [Methods] A literature search was performed using GoogleScholar with the term Cupping therapy, thoracolumbar fascia, low back pain and cricketers. The articles werechecked thoroughly and were reviewed. [Results] Significant increase in lumbar flexion ROM and decrease inpain reduction was found in group receiving dry cupping treatment. [Conclusion] Dry cupping proved to bebeneficial in improving low back pain and can be used as an adjunct to conventional physiotherapy management.[Implications] Incorporating dry cupping in management of non specific cLBP would show better results thanconventional exercises alone for cases of cLBP in cricketers.

Impact of Multifidus Muscle Morphometry on the Clinical Evolution of Chronic Low Back Pain

Purpose: The multifidus muscle is an important extensor muscle of the lumbar spine. It plays a major role in the stability and realization of axial rotation movements of the thoraco-lumbar spine. Its atrophy by fatty degeneration would be at the origin of the occurrence of chronic low back pain which constitutes a public health problem in Senegal. Taking into account its anatomy is essential for the etiopathogenic analysis and the treatment of low back pain. The purpose of our work was to investigate the impact of multifidus muscle morphometry on the anatomy-clinical evolution of low back pain. Material and method: this was a prospective study over a period of 30 months from November 2019 to May 2022. It involved 100 patients seen in the neurology department of Fann Hospital for chronic low back pain and who had already had a scanner falling within the criteria for low back pain. We used 3D Slicer, SPSS 20, Excel 2016 software to model and analyze the morphometric data of the multifidus muscle after physiotherapy and control lumbar scans. Results: The sex ratio was 2.23. The average age of the patients was 45 ± 7 years. On the initial CT scan, according to the Hadar classification, we noted a predominance of grade 2 with 56% in L5/S1, followed by grade 1 with 32% and grade 3 with 14%. In L4/L5, the majority of patients, 67%, had grade 1. A conflicting circumferential disc bulge with the roots predominating in L5/S1 was present in 94% of men (p-value = 0.02). Before physiotherapy, the average volume of the multifidus was 193 mm3 ± 39, after physiotherapy it was 203 mm3 ± 42 with a progression rate of 5.2%. Clinically, severe type pain had regressed from 86% before physiotherapy to 0% after physiotherapy (p-value = 0.03). Conclusion: Taking into account the morphometry of the multifidus is an essential element in the management of chronic low back pain.

Неинвазивная нейромодуляция как метод обезболивания в комплексной терапии хронической боли в нижней части спины

Aim: To describe the Russian and foreign experience in the use of non-invasive neuromodulation for pain management in patients with chronic lower back pain (LBP); to present various neuromodulation techniques and other rehabilitation methods which can be used in combination with neuromodulation in patients with LBP; to describe neuromodulation parameters and programs for an optimal analgesic effect. Key points. LBP is a common (affecting 7.5 % of the world population) and socially significant condition (one of the leading causes of disability worldwide). The efficiency of drug pain management in chronic LBP is approximately 40 %, therefore, non-drug treatment options are required. The neuropathic component of chronic LBP is associated with reorganization in cortex brain structures Hence, neural stimulation is a most promising approach to chronic LBP management, while transcranial direct current electrotherapy stimulation (TEdC) and rhythmic transcranial magnetic stimulation (rTMS) are the most efficient and safest neural stimulation methods. rTMS is an efficient and safe approach to the management both of nociceptive and neuropathic pain, which is a common component of chronic conditions, in particular of LBP. The main area of exposure is motor cortex areas (М1). As compared to TEdC, rTMS is better tolerated by patients and demonstrates better pain management results. Conclusion. Pain syndrome is a significant limitation to rehabilitation in patients with LBP, and drug pain management is inefficient. We suggest that anaesthetic neuromodulation be included into a complex therapy of such patients. The most widely used and efficient neuromodulation techniques are TEdC and rTMS. Keywords: lower back pain, rehabilitation, transcranial magnetic stimulation, neuropathic pain.

KNOWLEDGE OF RURAL POPULATION ABOUT LOW BACK PAIN AND ITS RELATED RISK FACTORS- CROSS SECTIONAL STUDY

Background and purpose :Low back pain (LBP) has been reported as a worldwide health problem, affecting individuals physically, socio-economically and psychologically [1]. The global burden of low back pain is the highest ranked condition contributing to years of living with disability.The general public, including patients living with LBP, lack knowledge about the causes and contributing factors of LBP [22].This implies that during management of LBP, patients’ knowledge about their pain should be identified and followed by education regarding their pain.This study aims to find out knowledge of rural population about low back pain and its related risk factors Methodology :This was a cross sectional study conducted on villagers visiting VikhePatil Hospital, Ahmednagar, in a duration of 6 months. The sampling method was convenient sampling with sample size of 100. A self -administered questionnaire consisting of 4 sections in Marathi language was designed. In the first three section, participants were asked about definition of Low back pain. In the fourth section, participants have to answer a 15 question quiz, focusing on general facts, symptoms, risk factors, diagnosis and treatment options for low back pain. After approval of ethical committee, consent form were collected from the subjects. The questionnaire was given to subjects according to the inclusion criteria. Result &amp; Conclusion:- The study had 100 subjects. Approximately 58% were males, with 31% between 30-39 age .66% of samples identified the underlying mechanism of low back pain as there is some compression of nerve passing through the vertebra,57% believed cartilage on the ends of vertebra wears down over time.The majority 58% had their source of information about low back pain from other patients suffering from low back pain,54% from the internet and social media, 48% had personal experience and 82% sample knew a relative or a friend suffering with low back pain. The result of the study concluded that the rural population visiting the VikhePatil Hospital exhibited good knowledge about Low back pain and its risk factors. Some misconceptions about the general facts and risk factors were identified.

Letter to the Editor: An Updated Overview of Low Back Pain Management.

Letter to the Editor: An Updated Overview of Low Back Pain Management.

Prevalence and Management of Low Back Pain Among Health Workers in a Privately Owned Teaching Hospital in Nigeria

Aim: This study assessed the prevalence and management of LBP among health workers in a private teaching hospital in South West Nigeria. Background: Healthcare workers (HCWs) often experience low back pain (LBP) more than any other category of workers. While a lot has been documented about the prevalence of LBP among different categories of workers, little is known about how health workers manage LBP. Objectives: This study aimed to assess the prevalence and management of LBP among health workers in a private teaching hospital in South West Nigeria. Associations between variables: (a) sociodemographic variables (i.e., age, gender) and the prevalence of low back pain, and (b) interference with activities of daily living across different categories of health workers, were evaluated. Methods: A cross-sectional design was employed in this study. One hundred and eighty-nine HCWs were randomly selected from the wards and units of the hospital. The LBP questionnaire and the Nordic Musculoskeletal questionnaire were used for data collection. Data were analysed using descriptive (mean and percentages) and inferential (chi-square and ANOVA) statistics. Results: The prevalence of LBP among health workers was found to be 87.3%. Moreover, most of the health workers massage their back (78.3%), engage in exercise (72.0%), and use analgesics (69.3%) as a means of managing LBP. Furthermore, there was no significant relationship between gender (X2 = 0.31, P&gt;0.05), age (X2 = 1.52, P&gt;0.05), marital status (X2 = 2.93, P&gt;0.05) of HCWs and prevalence of LBP. However, a significant difference was reported in the mean interference of LBP with activities of daily living across the different categories of healthcare workers that participated in the study (F= (7,181) 3.58, P = 0.01). Conclusion: The prevalence of LBP is high among HCWs that participated in the study. Therefore, it is recommended that HCWs might use massage, engage in exercise, and take analgesics as a means to combat LBP.

The prevalence of lower back pain and absenteeism and their associations with self-reported exercise patterns in workers at a South African poultry abattoir

Lower back pain (LBP) is the most prevalent musculoskeletal condition in many industries, including the meat-processing industry, with previous research confirming that workers in poultry abattoirs are at risk of developing LBP. Lower back pain is a major cause of sickness absenteeism, and regular exercise is considered beneficial to manage LBP among workers. Little is known about LBP and poultry abattoir workers in South Africa. The purpose of the study therefore was to describe LBP among these workers and explore possible associations between LBP and specific job designations, exercise patterns and sickness absenteeism. A descriptive study with an analytical component was conducted among workers at a poultry abattoir in South Africa. A structured questionnaire was used to collect the data regarding back pain experienced in the previous 12 months. The results indicated a 12-month prevalence of LBP of 77.6% (95% CI 70.6%; 83.3%), while 24.2% had to reduce work activities because of their LBP symptoms. However, more than half of the workers with LBP (59.4%) were not absent from work due to LBP. There was no significant association between LBP and exercises with 40.0% indicating that they exercised on a regular basis. This study indicated a high prevalence of LBP among workers whose job designation has an increased risk for musculoskeletal disorders, as reported in previous research. Work-related factors, such as job designations with repetitive movements should be identified and addressed in the management of LBP. Even though this study did not find a significant association between LBP and exercises, nearly half of workers indicated that they exercise on a regular basis. Additional research is needed to study the effect of exercise on LBP among workers in poultry abattoirs in South Africa.

Evaluation of the Level of Dural Sac Tip in Saudi Population: A Magnetic Resonance Imaging Study.

Background For the success of procedures such as caudal block, craniospinal irradiation (CSI), and management of lower back pain and to minimize the risk of dural puncture the exact level of dural sac (DS) termination should be known. Objective The evaluation of DS tip location in the Saudi population and exploring possible significant factors that could be used as predictors in clinical prognosis. Methods A total of 200 patients' lumbar sagittal Weighted T2 Magnetic Resonance Imaging (MRI) study were randomly selected from a single-center hospital in-between 2020 and 2021. The DS tip location was determined by generating a perpendicular line from the longitudinal axis of its termination to the corresponding level. Then naming it after an intervertebral disk or a corresponding vertebrate that is divided into three thirds (upper, middle, and lower). Results In most cases, the level of DS termination is at the middle part of S2 (26.5%), followed by the upper part of S2 (25.1%), and the lower part of S2 (20%). In Saudi nationals, the DS tip was in the middle S2 level at 21.5%, upper S2 level at 19.1%, and lower S2 level at 17%. Factors such asage, sex, cause of referral, and nationality had no statistical significance in relation to DS tip location. Conclusion The DS termination level in the Saudi population ranges from disk between L5-S1 to the lower third of S3. Moreover, nationality, age, and cause of referral were not significant in determining the DS termination level. Therefore, it is still important to individualize patients' treatment by using MRI for each case that requires it.

The role of spinal surgery in the treatment of low back pain.

Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide. Acute LBP is frequently self-resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors. Chronic LBP should be managed with a holistic biopsychosocial approach of generally non-surgical measures. Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent. Spinal surgery for back pain has increased substantially over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third-party payers to this increase, and their involvement in published research, requires careful consideration.