Previous Low Back Pain Research Articles

Low Back Pain in Athletes Is Associated with General and Sport Specific Risk Factors: A Comprehensive Review of Longitudinal Studies.

We aimed to examine systematically the available evidence on risk factors of low back pain (LBP) in athletes. We performed search without language restriction in PubMed, Ovid, Google Scholar, Scopus, and CINAHL. Longitudinal studies that examined possible risk factors of LBP in athletes were included in this systematic review. Based on methodological quality of studies, a best-evidence synthesis was conducted. Seven longitudinal studies were included, four of which had high methodological quality. Results showed that previous LBP, decreased lumbar flexion, and decreased lumbar extension are positively associated with LBP. There was moderate evidence for hip flexor tightness and high body weight as a risk factor. We found insufficient evidence for association between forward bending, previous injury, and amount of training per week, active years, age, and sex with LBP. In conclusion this study would provide a list of risk factors for LBP in athletes, though it showed a strong evidence for only a few including decrease lumbar flexion or extension, previous LBP, and high body weight. This review indicated a high heterogeneity of study characteristics including assessed risk factors and statistical techniques might limit the quality of evidence.

The relationship of lumbar multifidus muscle morphology to previous, current, and future low back pain: a 9-year population-based prospective cohort study.

Population based prospective cohort study. We explored the cross-sectional relationships between lumbar multifidus (LM) intramuscular adipose tissue (IMAT) infiltration and low back pain (LBP) at 3 successive time points and investigated the role of IMAT in predicting the occurrence of LBP after 5 and 9 years. Although LBP is a major source of disease burden, the biological determinants of LBP are poorly understood. Participants were 40-year-old adults randomly sampled from a Danish population and followed up at 45 and 49 years of age. At each time point, participants underwent magnetic resonance imaging and reported ever having had LBP, LBP in the previous year, nontrivial LBP in the previous year, or a history of pain radiating into the legs. Pixel intensity and frequencies from T1-weighted magnetic resonance images identified the greatest proportion of LM IMAT at the L4 and L5 spinal levels. IMAT infiltration was categorized as normal/mild, moderate, or severe based on tertile divisions. Associations were explored with crude and adjusted odds ratios (aORs) from logistic regression models. Model covariates included sex, body mass index, and occupational and leisure time physical activity. A total of 401 participants were enrolled, with 331 (83%) and 286 (71%) participants followed up at 5 and 9 years, respectively. The cross-sectional analyses demonstrated that at the age of 40 years, participants with severe IMAT infiltration demonstrated increased odds of ever experiencing LBP (aOR [95% confidence interval, 95% CI] = 3.16 [1.45-6.89]), nontrivial LBP (aOR [95% CI] = 2.82 [1.36-5.81]), LBP in the past year (aOR [95% CI] = 1.95 [1.07-3.53]), and leg pain (aOR [95% CI] = 2.08 [1.19-3.62]). There were no consistent cross-sectional associations between LBP/leg pain and LM IMAT at 45 or 49 years of age and LM IMAT did not predict future LBP or leg pain. The relationship between LM IMAT and LBP/leg pain is inconsistent and may be modified by age. N/A.

Effort-reward imbalance and low back pain among eldercare workers in nursing homes: a cross-sectional study in Kagawa Prefecture, Japan.

To clarify effort-reward imbalance among eldercare workers in nursing homes and to examine the association between the effort-reward imbalance (ERI) and low back pain (LBP) among them. A total of 549 questionnaires were distributed to a random sample comprising 23% of the 79 special elderly nursing homes in Kagawa in 2013. A total of 467 eldercare workers (response rate 85%) participated in this study. Of the 467 eligible respondents, 372 (80%) completed all items of the ERI questionnaire. Complete data were available for 342 (73%) eldercare workers. Of the 342 respondents, 215 (63%) had LBP at the time of the study, and 291 (85%) showed a critical "high cost/low gain" condition as determined by an effort-reward ratio >1. Multiple logistic regression analyses adjusted for age, gender, previous LBP experience, high-risk work and K6 score showed that eldercare workers with a high ERI had a higher risk for LBP than workers with a low ERI (OR, 1.96; 95% CI, 1.02-3.77). Most eldercare workers have a high ERI, and their LBP is associated with their ERI. Balancing effort and reward may be an important factor for improving LBP among eldercare workers in nursing homes.

Improving the selection of true incident cases of low back pain by screening retrospective administrative data

The difficulty in identifying the onset of low back pain (LBP) limits the capacity to determine the incidence of LBP at the population level and, further, to identify risk factors. In the literature, incidence cohorts have been built with patients initially considered LBP-free for 6-12 months prior to their selection. This 'clearance period' might not be sufficient to exclude recurrent patients having experienced previous LBP episodes and might result in a misclassification bias. Using the Canadian province of Quebec's medical administrative physicians' claims database, a cohort of prevalent claims-based recurrent LBP patients was built for 2007. The medical history of 81,329 patients was screened for a period of 11 years. Positive predictive values (PPVs), kappa statistics and a survival function were calculated to determine the optimal clearance period for capturing first-time events. The 2007 annual incidence of adult claims-based recurrent LBP was estimated at 242 per 100,000 persons. Men between 18 and 34 years of age were found to be 1.18 times more at risk than their counterparts. Altogether, the elderly (over 80 years) had 52% more new cases than the 18-34 age group. A very good convergence for PPV and kappa was found for a 7-year clearance period. This allowed determining the annual incidence from 2000 to 2007, showing a decrease of 26%. Screening the medical history of LBP patients can provide more accurate incidence estimates by limiting the over-ascertainment of first-time LBP patients. A 4- to 7-year clearance period should be considered.

Lumbar Muscle Dysfunction During Remission of Unilateral Recurrent Nonspecific Low-back Pain

After cessation of a low-back pain (LBP) episode, alterations in trunk muscle behavior, despite recovery from pain, have been hypothesized to play a pathogenic role in the recurrence of LBP. This study aimed to identify the presence of lumbar muscle dysfunction during the remission of recurrent LBP, while performing a low-load trunk-extension movement. Thirteen participants with unilateral recurrent LBP were tested at least 1 month after cessation of the previous LBP episode and were compared with a healthy control group without any history of LBP (n=13). Also, differences between previously painful and nonpainful sides were examined. Muscle functional magnetic resonance imaging, based on quantitative T2-imaging, was used to examine muscle tissue characteristics (T2 rest) and muscle recruitment (T2 shift) during prone trunk extension. The lumbar multifidus, erector spinae, quadratus lumborum, and psoas were bilaterally visualized on 2 lumbar levels using a T2-weighted (spin-echo multicontrast) magnetic resonance imaging sequence. Linear mixed model analysis revealed a significantly lower T2 rest (P=0.044) and a significantly higher T2 shift (P=0.034) solely for the multifidus in the LBP group compared with the control group. No significant differences between pain sides were found. Lower T2-rest values have been suggested to correlate with a conversion of the multifidus' fiber typing toward the glycolytic muscle spectrum. Elevated T2 shifts correspond with increased levels of metabolic activity in the multifidus in the LBP group, for which several hypotheses can be put forward. Taken together, these findings provide evidence of concurrent alterations in the multifidus structure and activity in individuals with unilateral recurrent LBP, despite being pain free and functionally recovered.

Nonsteroidal anti-inflammatory drugs in the treatment of low back pain

Low back pain (LBP) is amongst the top ten most common conditions presenting to primary care clinicians in the ambulatory setting. Further, it accounts for a significant amount of health care expenditure; indeed, over one third of all disability dollars spent in the United States is attributable to low back pain. In most cases, acute low back pain is a self-limiting disease. There are many evidence-based guidelines for the management of LBP. The most common risk factor for development of LBP is previous LBP, heavy physical work, and psychosocial risk factors. Management of LBP includes identification of red flags, exclusion of specific secondary causes, and comprehensive musculoskeletal/neurological examination of the lower extremities. In uncomplicated LBP, imaging is unnecessary unless symptoms become protracted. Reassurance that LBP will likely resolve and advice to maintain an active lifestyle despite LBP are the cornerstones of management. Medications are provided not because they change the natural history of the disorder, but rather because they enhance the ability of the patient to become more active, and in some cases, to sleep better. The most commonly prescribed medications include nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. Although NSAIDs are a chemically diverse class, their similarities, efficacy, tolerability, and adverse effect profile have more similarities than differences. The most common side effects of NSAIDs are gastrointestinal. Agents with cyclo-oxygenase 2 selectivity are associated with reduced gastrointestinal bleeding, but problematic increases in adverse cardiovascular outcomes continue to spark concern. Fortunately, short-term use of NSAIDs for LBP is generally both safe and effective. This review will focus on the role of NSAIDs in the management of LBP.

The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study

To study the prognosis for pelvic girdle pain, and to explore the association between presence of emotional distress during pregnancy and pelvic girdle syndrome 6 months after delivery. Longitudinal population study. Norway, for the period 1999-2008. A follow-up of 41 421 women in the Norwegian Mother and Child Cohort who reported pelvic girdle pain at 30 weeks of gestation. Data were obtained by self-administered questionnaires in weeks 17 and 30 of gestation, and 6 months after delivery. Pelvic girdle syndrome 6 months after delivery, defined as pain in the anterior pelvis and on both sides in the posterior pelvis. Six months after delivery, 78.0% of the women had recovered, 18.5% reported persistent pain in one or two pelvic locations, 3.0% reported pelvic girdle syndrome and 0.5% reported severe pelvic girdle syndrome. The recovery rates decreased with increasing levels of pain severity in pregnancy. Being emotionally distressed at two time points during pregnancy was associated with the presence of pelvic girdle syndrome (adjusted OR 1.5, 95% CI 1.2-1.9) and severe pelvic girdle syndrome (adjusted OR 1.9, 95% CI 1.1-3.1), after adjustment for pain severity in pregnancy, other medical conditions, body mass index, age at menarche, previous low back pain, and smoking during pregnancy. In this follow-up of women with pelvic girdle pain in pregnancy, the recovery rates after delivery were high. Our findings suggest that the presence of emotional distress during pregnancy is independently associated with the persistence of pelvic girdle pain after delivery.

Clinical and radiological association with positive lumbar discography in patients with chronic low back pain

Study design: Retrospective cohort study.Objectives: To find out (1) if magnetic resonance imaging (MRI) findings associated with positive discography in patients with lumbar discogenic pain are caused by degenerative disc disease (DDD). (2) If clinical risk factors associated with positive discography in patients with lumbar discogenic pain are caused by DDD.Methods: Thirty-three discographies were performed in 20 consecutive patients with chronic low back pain (LBP). All examinations were performed in the lumbar spine between L3 and S1. Patient assessment consisted of a clinical and radiological examination through a protocol that contained data on the history, visual analogue scale for pain (VAS), functional questionnaire (Oswestry), and MRI findings. Discography was considered positive using the Walsh's criteria. We examined the association between MRI and clinical findings with positive discography using logistic regression.Results: Fourteen discographies (42%) were positive and 19 (58%) were negative. The mean age of patients with positive discography was 40.7 years (range, 25–56 years) and negative discography 43.1 years (range, 30–55 years). Men had a positive discography rate of 43.5% and women 40%. Patients with LBP had reduced odds of a positive discography compared with those with LBP and sciatica (OR = .5; 95% CI: 0.1–2.7); however, this association was not statistically significant. Patients with more than four previous episodes of pain versus patients with one to four episodes had greater odds of a positive discography (OR = 3.8; 95% CI: 0.07–184); but this association was not statistically significant. Patients with various pathologies on MRI had greater odds of a positive discography; however, these associations were not statistically significant either.Conclusions: Patients with a chief complaint of LBP associated with sciatica, with more than four episodes of previous LBP exacerbations and the presence of a high intensity zone (HIZ) on MRI have a higher rate of positive discography. These findings are not statistically significant, probably due to a small sample size. During discography, we found the end point resistance to be more prevalent in asymptomatic discs.

Risk factors of chronic neck pain: A prospective study among middle‐aged employees

To study the associations of sociodemographic factors, working conditions, lifestyle and previous pain in the spine with new onset chronic neck pain (NP). The participants were municipal employees free of chronic NP at baseline, aged 40, 45, 50, 55 or 60 years (n = 5277, 80% women). Self-reported data on occupational class, working conditions, body mass index, smoking, exercise, mental well-being, sleep problems, NP and low back pain (LBP) were obtained from baseline questionnaire surveys in 2000-2002. The question on chronic NP was repeated in a follow-up in 2007. Logistic regression analysis was used. The incidence of chronic NP was 15% in women and 9% in men. In multivariable analysis among women, acute NP [odds ratio (OR) 3.8, 95% confidence interval (CI) 2.9-5.1], chronic LBP (1.6, 1.2-2.2), reporting current workplace bullying (OR 1.6, 95% CI 1.1-2.4), earlier bullying at the present workplace (1.6, 1.2-2.0), and earlier bullying in another workplace (1.8, 1.3-2.4), frequent sleep problems (1.5, 1.2-2.0), overweight (1.2, 1.0-1.5), and obesity (1.4, 1.1-1.8) predicted chronic NP at follow-up. Men with acute NP (2.3, 1.4-3.8), chronic LBP (2.3, 1.2-4.3), manual occupational class (1.8, 1.1-3.1) and high work-related emotional exhaustion (1.9, 1.1-3.3) at baseline had an increased risk of new onset chronic NP. We found potentially modifiable predictors of chronic NP among employees: workplace bullying, sleep problems, and high body mass index in women, and work-related emotional exhaustion in men. In both genders, previous acute NP and chronic LBP were predictive of chronic NP.

Age at menarche and pelvic girdle syndrome in pregnancy: a population study of 74 973 women

To study the association of age at menarche with presence of pelvic girdle syndrome in pregnancy. Population study. Norway 1999-2007. A total of 74 973 pregnant women in the Norwegian Mother and Child Cohort Study. Data were obtained by self-administered questionnaires in weeks 17 and 30 of gestation. Pelvic girdle syndrome in pregnancy at 30 weeks of gestation, defined as pain in the pubic symphysis in the anterior pelvis and in both sacroiliac joints in the posterior pelvis. The prevalence of pelvic girdle syndrome was 20.6% (328/1593) in women with menarche before the age of 11, it was 16.3% (3200/22 044) in women with menarche at the age of 12 and 12.7% (1252/9859) in women with menarche after the age of 14 (chi-square test for trend, P < 0.001). The inverse association of age at menarche with pelvic girdle syndrome remained after adjustment for body mass index, maternal age, parity, educational level, previous low back pain, emotional distress and physically demanding work. Women with early menarche and high body mass index had the highest prevalence of pelvic girdle syndrome, but the association of early menarche with pelvic girdle syndrome was similar in women with and without high body mass index. Early menarche was associated with increased prevalence of pelvic girdle syndrome in pregnancy. Factors associated with early menarche may play a role in the development of pelvic girdle pain.

Beliefs About Back Pain

Beliefs about low back pain (LBP) have been widely studied. Research supports the importance of attitudes and beliefs in the development of disability. However, public opinions about LBP have been the subject of few studies to date and more research into public attitudes has been advocated to inform future public health initiatives. To investigate public attitudes and beliefs about LBP, and the association of these with demographic variables. In addition, to determine whether certain group differences in demographic characteristics were useful in predicting individuals with negative attitudes about LBP. A stratified sample of 3400 households were invited to participate in the Jersey Annual Social Survey. One thousand five hundred and seventy-four (46.3%) responded and 1132 (71.9%) were identified as being of working age. Complete responses to the Back Beliefs Questionnaire were provided by 1023 (65.0%). Respondents were grouped according to pain report: no current pain, current pain not LBP, and current LBP. Significant differences existed between subgroups for most demographic characteristics. Moreover, beliefs about LBP differed significantly between the 3 groups [F (2,1019)=17.72, P<0.001]. Further analyses were carried out for the subgroups separately. For the Current LBP group, beliefs differed significantly by educational level [F(2,186)=14.65, P<0.001], perceived general health [F (2,187)=4.42, P<0.05], acceptability of work absence [F (2,189)=10.69, P<0.001], LBP impact on activity [F (2,186)=6.38, P<0.01], and previous LBP absence [t (185)=4.84, P<0.001]. Multiple regression using these characteristics produced an adjusted R of 0.25 [F (4,181)=16.33, P<0.001] for the prediction of back beliefs. Implications for public health initiatives and future research are discussed.

The Spanish version of the “STarT Back Screening Tool” (SBST) in different subgroups

Objective The aim of this study was to translate and culturally adapt the original version of the STarT Back Screening Tool (SBST) to Spanish for different population subgroups. Design Translation and cultural adaptation of a questionnaire. Setting Primary care settings. Method Thirty-eight people distributed by: gender; adults and elderly; and with or without pain. Phases: a) Forward translation (English-Spanish); b) Evaluation of the clarity, the acceptability and the familiarity of the content of the obtained Spanish version by means of cognitive interviews to participants, and c) Translation of the final Spanish version of the questionnaire back into the original language. Results The participants interviewed indicated that most of the items of the questionnaire were clear and comprehensible, showing greater difficulty in understanding in the dimensions of disability and anxiety. Furthermore, the questionnaire was more difficult to undertand by the elderly and patients with a previous non-specific low back pain episode. Conclusion The Spanish version of the SBST questionnaire was obtained, which was shown to be comprehensible and adapted to the general population in Spain. Due to being short and easy to use, it is a potentially useful tool for use in primary care.

Pregnancy and spinal problems

To review recent publications in spinal problems during pregnancy, diagnosis, and management. Pregnancy-related low back pain (LBP) is the most common problem which can occur during pregnancy. Among the various factors of pregnancy-related LBP, previous LBP and LBP during menstruation seem to be significant risk factors of pregnancy-related LBP. Patient counseling and wearing of a nonelastic pelvic belt are effective for the control of pelvic girdle pain. Lumbar pain can be treated with exercise such as water gymnastics during the second and third trimesters. Although rare, pregnancy can cause osteoporotic compression fractures and symptoms in spinal tumors, especially in vertebral hemangiomas. Lumbar disc herniation is the most common spinal disorder during pregnancy and can cause permanent neurologic deficit in pregnant women. Most cases can be treated by conservative management, but operation can also be safely performed maintaining a healthy pregnancy. Recent concern about spinal problems in pregnancy is still pregnancy-related LBP. The further studies about its prevalence, risk factors, and treatment will be expected to continue. In both general spinal diseases and pregnancy-induced spinal diseases, there is no significant difference in treatment between pregnant women and ordinary people. Therefore, if consideration of possible spinal problems, exact diagnosis and adequate treatment are performed, good prognosis may be enough achieved in pregnant women.

Are low back pain and low physical capacity risk indicators for dropout among recently qualified eldercare workers? A follow-up study

A high job turnover and dropout among eldercare workers has led to a significant shortage of qualified manpower in the Danish eldercare sector. The predictive effect of some non-work-related causes for leaving the eldercare sector 2 years after qualification, physical capacity, duration, and severity of previous low back pain, was investigated. A 2-year prospective cohort study of all the Danish eldercare workers, who finished their education during 2004 (n = 6347). Questionnaire data from 2004 were followed up by register data on attachment to labour market, educational status, and association to trade from Statistics Denmark in 2006. Data on physical capacity, duration, and severity of low back pain the last 12 months among the female participants were analysed by multinomial logistic regression to estimate odds-ratios for being either in the eldercare sector, in other health- and welfare sectors, in all other sectors, under education, or outside labour market, 2 years after qualification. Disability due to and duration of low back pain were significant predictors for dropout from the eldercare sector 2 years after qualification. Low physical capacity was not. Data on duration of low back pain suggest a trend towards a dose-response relationship: The longer the duration of low back pain, the higher odds for dropout. Low back pain and disability due to low back pain during the last year of education were independent predictors for dropout from the eldercare sector 2 years after qualification. However, low self-rated physical capacity did not predict job dropout or turnover.

Low back pain during pregnancy in Iranian women: Prevalence and risk factors

ABSTRACTLow back pain (LBP) is a common and often disabling condition that deserves attention. Although LBP during pregnancy is a common clinical problem, only one study was found documenting prevalence of LBP during pregnancy in Iran. No investigation evaluated the diagnostic value of possible risk factors. The aims of the present, cross-sectional study were 1) to ascertain the prevalence of LBP of Iranian women during pregnancy and compare to other ethnic/cultural groups and 2) identify risk factors associated with LBP during pregnancy in Iranian women. One hundred three women were interviewed in the obstetric ward of a university hospital within 48 hours after giving birth. Possible risk factor associations were studied by using nonparametric tests, and sensitivity, specificity, positive and negative predictive, and likelihood ratio values were calculated for the interview questions about previous low back pain, LBP during menstruation, and trauma during pregnancy. The prevalence of LBP during pregnancy was found to be 57.3%, which is similar to most other countries. Pain onset was most frequently reported in the third trimester of pregnancy (40.7%) and was often reported to be in the low back area (71.2%). Almost half of the patients reported their pain as being moderate (44.1%). The logistic regression model demonstrated that the LBP during menstruation predicts a high risk for LBP during the current pregnancy. The study showed that LBP during menstruation and previous LBP may be useful tests for ruling out and ruling in LBP during pregnancy, respectively.

Poststroke Pain – but Multiple Pain Mechanisms

A 42-year-old man presented with acute left hemiplegia due to a right frontotemporal hemorrhagic stroke and left-sided pain. While the initial presentation suggested central poststroke pain, subsequent investigations also implicated heterotopic ossification of the left hip and amplification of previous low back pain by the new central pain. While heterotopic ossification has been commonly associated with brain injury, spinal cord injury or osseous injury, it is only rarely associated with stroke. Poststroke pain may be multifactorial, and discovering the pain mechanisms has important implications for treatment.

The predictive effect of fear-avoidance beliefs on low back pain among newly qualified health care workers with and without previous low back pain: a prospective cohort study

BackgroundHealth care workers have a high prevalence of low back pain (LBP). Although physical exposures in the working environment are linked to an increased risk of LBP, it has been suggested that individual coping strategies, for example fear-avoidance beliefs, could also be important in the development and maintenance of LBP. Accordingly, the main objective of this study was to examine (1) the association between physical work load and LBP, (2) the predictive effect of fear-avoidance beliefs on the development of LBP, and (3) the moderating effect of fear-avoidance beliefs on the association between physical work load and LBP among cases with and without previous LBP.MethodsA questionnaire survey among 5696 newly qualified health care workers who completed a baseline questionnaire shortly before completing their education and a follow-up questionnaire 12 months later. Participants were selected on the following criteria: (a) being female, (b) working in the health care sector (n = 2677). Multinomial logistic regression analysis was used to evaluate the effect of physical work load and fear-avoidance beliefs on the severity of LBP.ResultsFor those with previous LBP, physical work load has an importance, but not among those without previous LBP. In relation to fear-avoidance beliefs, there is a positive relation between it and LBP of than 30 days in both groups, i.e. those without and with previous LBP. No moderating effect of fear-avoidance beliefs on the association between physical work load and LBP was found among cases with and without LBP.ConclusionBoth physical work load and fear-avoidance beliefs matters in those with previous LBP. Only fear-avoidance beliefs matters in those without previous LBP. The study did not find a moderating effect of fear-avoidance beliefs on the association between physical work load and LBP.

Low back pain in 1,100 Iranian pregnant women: prevalence and risk factors

Background Low back pain (LBP) is a common and costly problem in pregnancy. It is one of the main reasons for disability, absence from work, and responsible for huge direct and indirect economical impact. Purpose The purpose of this study was to determine the prevalence and risk factors of LBP during pregnancy. Study design A cross-sectional study was carried out on Iranian pregnant women. Patient sample Eleven hundred randomly selected pregnant women. Outcome measures A structured questionnaire including demographic, lifestyle, as well as prevalence and characteristics of LBP was used. Visual Analog Scale and Oswestry low back disability questionnaires were also used to assess the pain intensity and functional disability, respectively. Methods After ethical approval from Medical Ethics Board at the Mazandaran University of Medical Sciences and Health Services, a cross-sectional study was conducted on 1,100 pregnant women from 18 health centers in Sari district, at northern Iran. Results Point, last-month, last 6-month, last-year, and lifetime prevalence of LBP were 40.2%, 55.9%, 59.4%, 76.2%, and 84.1%, respectively. Prolonged standing and rest were found to be the most significant aggravating and relieving factors (76.3% and 87.7%, respectively). LBP was significantly correlated with history of previous LBP and LBP in previous pregnancy (p=.000 in both cases). Conclusion The prevalence of LBP in pregnant women appears to be high and future research should focus on different preventive strategies during pregnancy.

A prognostic approach to defining chronic pain: Application to knee pain in older adults

A prognostic approach to defining chronic pain has been proposed as an alternative to traditional definitions based on retrospective duration of pain. While this new approach performs well in low back pain (LBP), headache and orofacial pain, it is not known whether it translates to regional pain syndromes with an underlying pathological component, such as osteoarthritis (OA). We investigated the performance of this approach in a population-based cohort of older adults reporting knee pain, with a spectrum of radiographic knee OA. 676 adults (50 years+) attended a research clinic and were followed up at 18 months and 3 years. Risk scores were calculated using pain intensity, pain duration, pain-related activity, number of pain sites and depressive symptoms, measured at baseline and at 18 months. These scores were used to determine the probability of future clinically significant knee pain, defined as Chronic Pain Grade II–IV, at 18 months and at 3 years using logistic regression. Cut-points on the risk score were applied to determine groups at intermediate (probability ⩾0.2), possible (⩾0.5) and probable (⩾0.8) risk of clinically significant knee pain. Discriminative ability of the risk scores, determined by area under the ROC curve, was high (0.78–0.82), varied little by radiographic severity and was superior to pain duration alone. The derived cut-points suggested a lower threshold for each of the risk groups than the previous LBP work. This prognostic approach to defining chronic pain appears to translate well to knee pain. Different cut-points for defining risk groups may be needed for different pain syndromes.

The Nordic maintenance care program – case management of chiropractic patients with low back pain: A survey of Swedish chiropractors

BackgroundChiropractic treatment for low back pain (LBP) can often be divided into two phases: Initial treatment of the problem to attempt to remove pain and bring it back into its pre-clinical or maximum improvement status, and "maintenance care", during which it is attempted to maintain this status. Although the use of chiropractic maintenance care has been described and discussed in the literature, there is no information as to its precise indications. The objective of this study is to investigate if there is agreement among Swedish chiropractors on the overall patient management for various types of LBP-scenarios, with a special emphasis on maintenance care.MethodThe design was a mailed questionnaire survey. Members of the Swedish Chiropractors' Association, who were participants in previous practice-based research, were sent a closed-end questionnaire consisting of nine case scenarios and six clinical management alternatives and the possibility to create one's own alternative, resulting in a "nine-by-seven" table. The research team defined its own pre hoc choice of "clinically logical" answers based on the team's clinical experience. The frequency of findings was compared to the suggestions of the research team.ResultsReplies were received from 59 (60%) of the 99 persons who were invited to take part in the study. A pattern of self-reported clinical management strategies emerged, largely corresponding to the "clinically logical" answers suggested by the research team. In general, patients of concern would be referred out for a second opinion, cases with early recovery and without a history of previous low back pain would be quickly closed, and cases with quick recovery and a history of recurring events would be considered for maintenance care. However, also other management patterns were noted, in particular in the direction of maintenance care.ConclusionTo a reasonable extent, Swedish chiropractors participating in this survey appear to agree on the clinical management for different cases of LBP.