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1.  Does McKenzie Therapy Improve Outcomes for Back Pain? 
Journal of Athletic Training  2006;41(1):117-119.
Reference: Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother20045020921615574109.
Clinical Question: What is the clinical evidence base for McKenzie therapy in management of back pain?
Data Sources: Studies were identified using a computer-based literature search of 7 databases: MEDLINE, EMBASE, DARE, CINAHL, PEDro, the Cochrane Register of Clinical Trials (CENTRAL), and the Cochrane Database of Systematic Reviews. Search terms included McKenzie therapy, McKenzie treatment, and McKenzie method. Studies published before September 2003 were eligible.
Study Selection: To be included in the review, each study had to fulfill the following criteria: (1) the study was a randomized or quasi-randomized controlled trial, (2) the subjects' primary complaint was nonspecific low back pain or neck pain with or without radiation to the extremities, (3) the authors investigated the efficacy of the McKenzie method/McKenzie treatment in comparison with no treatment, sham treatment, or another treatment, (4) individualized patient treatment and treatment were specified according to McKenzie principles, and (5) the authors reported at least one of the outcome measures of pain, disability, quality of life, work status, global perceived effect, medication use, medical visits, or recurrence. Studies were included with no language restriction and with subjects of all age groups, of either sex, and with any duration of symptoms. Studies were excluded if subjects had any of the following spinal conditions: cauda equina syndrome, cord compression, infection, fracture, neoplasm, inflammatory disease, pregnancy, any form of headache, whiplash-associated disorders, vertigo/dizziness, or vertebrobasilar insufficiency.
Data Extraction: Data were independently extracted from each study by 2 investigators using a standardized data extraction form. The standardized data extraction form and experience level of the investigators were not included in the review. In studies with more than 2 treatment groups, the treatment contrast of more relevance to current Australian physiotherapy was selected.
Data were also extracted for short-, intermediate-, and long-term follow-up based on the criteria suggested by the Cochrane Back Review Group. Short-term follow-up was defined as less than 3 months from onset of treatment. Intermediate-term follow-up was defined as at least 3 months and less than 12 months from onset of treatment. Long-term follow-up was defined as equal to or greater than 12 months.
All eligible studies were rated for methodologic quality using the PEDro scale. The PEDro scale is a checklist that examines the “believability and the interpretability of trial quality.”1 The 11-item checklist yields a maximum score of 10 if all criteria are satisfied. The first item on the scale (Eligibility Criteria) is not scored. The PEDro scores were extracted from the PEDro database. If a study had not been entered into the database and scored, it was reviewed and scored by an experienced PEDro rater.
Main Results: Normalized data for pain and disability were given possible total scores of 100. The article's scores on the PEDro scale were average, ranging from 4 to 8 of 10. The most common flaw in the methods, which occurred in all 6 studies, was the failure to blind both the patient and therapist. Four of the 6 did not blind the researcher interpreting the data. For both pain and disability at short-term (<3 months) follow-up, individual study results for low back pain favored McKenzie therapy compared with the following: nonsteroidal anti-inflammatory drugs, educational booklet, back massage with back care advice, strength training with therapist supervision, spinal mobilization, or general mobility exercises. Trends favored McKenzie therapy at intermediate-term (3–12 months) follow-up for pain and disability, as well as work absences. The McKenzie treatment group in the cervical spine study had less pain and disability at both short- and intermediate-term follow-up than did the exercise group, although the effect sizes were small. The same McKenzie treatment group tended to have fewer health care contacts in the ensuing 12 months than the comparison exercise group.
The results suggest that McKenzie therapy provides a reduction in short-term pain (mean reduction of 8.6 on a 100-point scale) compared with the therapies mentioned above. A second (sensitivity) analysis was conducted to include data from 3 studies that were initially excluded because of lack of individualized treatment. The sensitivity analysis was used to determine if the exclusion of these studies would significantly alter the conclusion of the review. Instead, the sensitivity analysis strengthened the evidence supporting the notion that McKenzie therapy is more effective in short-term pain relief than other therapies (reduction of 11.4 on a 100-point scale).
Conclusions: This review provides evidence that McKenzie therapy results in a decrease in short-term (<3 months) pain and disability for low back pain patients compared with other standard treatments, such as nonsteroidal anti-inflammatory drugs, educational booklet, back massage with back care advice, strength training with therapist supervision, and spinal mobilization. No statistical differences were found between McKenzie therapy and other therapies at intermediate-term (3–12 months) follow-up. Data are insufficient on long-term (>12 months) outcomes or outcomes other than pain and disability (eg, quality of life). To date, no authors have compared McKenzie therapy with placebo or no treatment. Also, few data are available on the McKenzie method and its effect on neck pain. Future researchers should focus on these issues.
PMCID: PMC1421491  PMID: 16619104
spine; rehabilitation
2.  Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences 
BMJ : British Medical Journal  1999;319(7205):279-283.
To evaluate effectiveness of an exercise programme in a community setting for patients with low back pain to encourage a return to normal activities.
Randomised controlled trial of progressive exercise programme compared with usual primary care management. Patients’ preferences for type of management were elicited independently of randomisation.
187 patients aged 18-60 years with mechanical low back pain of 4 weeks to 6 months’ duration.
Exercise classes led by a physiotherapist that included strengthening exercises for all main muscle groups, stretching exercises, relaxation session, and brief education on back care. A cognitive-behavioural approach was used.
Main outcome measures
Assessments of debilitating effects of back pain before and after intervention and at 6 months and 1 year later. Measures included Roland disability questionnaire, Aberdeen back pain scale, pain diaries, and use of healthcare services.
At 6 weeks after randomisation, the intervention group improved marginally more than the control group on the disability questionnaire and reported less distressing pain. At 6 months and 1 year, the intervention group showed significantly greater improvement in the disability questionnaire score (mean difference in changes 1.35, 95% confidence interval 0.13 to 2.57). At 1 year, the intervention group also showed significantly greater improvement in the Aberdeen back pain scale (4.44, 1.01 to 7.87) and reported only 378 days off work compared with 607 in the control group. The intervention group used fewer healthcare resources. Outcome was not influenced by patients’ preferences.
The exercise class was more clinically effective than traditional general practitioner management, regardless of patient preference, and was cost effective.
Key messagesPatients with back pain need to return to normal activities as soon as possible but are often afraid that movement or activity may be harmfulAn exercise programme led by a physiotherapist in the community and based on cognitive-behavioural principles helped patients to cope better with their pain and function better even one year laterPatients’ preferences for type of management did not affect outcomePatients in the intervention group tended to use fewer healthcare resources and took fewer days off workThis type of exercise programme should be more widely available
PMCID: PMC28176  PMID: 10426734
3.  Patient-Centered Evaluation of Outcomes from Rehabilitation for Chronic Disabling Spinal Disorders: The Impact of Personal Goal Achievement on Patient Satisfaction 
The multiplicity of bio-psychosocial and economic facets of chronic disabling back and/or neck pain complicates treatment outcomes measurement. Our previous work showed that personal functional goal achievement contributed more toward patient satisfaction with outcome than did traditional self-reports of pain and physical function or measured strength, flexibility and endurance among functional restoration program (FRP) graduates with chronic disabling back and/or neck pain.
The primary goal was to compare the impact on patient satisfaction of pain and functional goal achievement versus self-reports of pain and physical function.
This was an observational study of all patients with chronic disabling back and/or neck pain completing an FRP between 6/08 and 5/09.
Prior to treatment, participants recorded personal 3-month goals for: pain, work, recreation and activities of daily living. At least 3 months later, all graduates were sent a follow-up survey displaying the patient’s pretreatment functional goals and eliciting the patient’s assessment of functional goal achievement; current pain magnitude, “satisfaction with the overall results for your pain problem;” and responses to the SF-36v2 Physical Functioning subscale (PF-10).
Pain goal achievement was calculated as the difference between the pre-treatment pain goal and follow-up pain magnitude. Linear regression was used to evaluate the associations between satisfaction and four variables (follow-up pain; PF-10; pain goal achievement; function goal achievement), individually and then together in a full model.
Of the 82 patients surveyed, 62 responded completely. Mean age was 44 years, with 48% female and 35% on worker’s compensation. The model R2 combining all four variables explained 0.6033 of the variance in satisfaction. Each variable by itself was significantly related to patient satisfaction at p < .001, but the overlap in association was large. The unique contributions (R2) to the variation in satisfaction were: function goal achievement: 0.0471; PF-10 score: 0.0229; pain magnitude: 0.0178; and pain goal achievement: 0.0020.
At least 3 months after treatment, function goal achievement had by far the greatest impact on patient satisfaction, followed by PF-10 score, pain magnitude, and finally, pain goal achievement. Functional goal achievement has great potential as a tool for patient-centered treatment decision-making and outcomes measurement for people with chronic disabling back and/or neck pain and their health care providers.
PMCID: PMC3989540  PMID: 23067862
goal achievement; functional restoration; rehabilitation; chronic low back pain; patient satisfaction
4.  Population based intervention to change back pain beliefs and disability: three part evaluation 
BMJ : British Medical Journal  2001;322(7301):1516-1520.
To evaluate the effectiveness of a population based, state-wide public health intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and costs of compensation.
Quasi-experimental, non-randomised, non-equivalent, before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of claims database.
Two states in Australia.
4730 members of general population before and two and two and a half years after campaign started, in a ratio of 2:1:1; 2556 general practitioners before and two years after campaign onset.
Main outcome measures
Back beliefs questionnaire, knowledge and attitude statements about back pain, incidence of workers' financial compensation claims for back problems, rate of days compensated, and medical payments for claims related to back pain and other claims.
In the intervention state beliefs about back pain became more positive between successive surveys (mean improvement in questionnaire score 1.9 (95% confidence interval 1.3 to 2.5), P<0.001 and 3.2 (2.6 to 3.9), P<0.001, between baseline and the second and third survey, respectively). Beliefs about back pain also improved among doctors. There was a clear decline in number of claims for back pain, rates of days compensated, and medical payments for claims for back pain over the duration of the campaign.
A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers' compensation costs related to back pain.
What is already known on this topicThe number of people with disability from back pain has risen rapidly in the past 50 yearsMost attempts to limit this disability include modification of occupational risk factors or dealing with the problem once it has developedPatients' attitudes and beliefs play an important part in the development of such chronic disabilityWhat this study addsA population based primary prevention intervention that provided explicit advice about back pain improved beliefs about back pain in the general population and knowledge and attitudes in general practitionersThe number of workers' compensation claims for back pain decreased and the rate of days compensated and medical payments for back claims were reduced
PMCID: PMC33390  PMID: 11420272
5.  Exploring integrative medicine for back and neck pain - a pragmatic randomised clinical pilot trial 
A model for integrative medicine (IM) adapted to Swedish primary care was previously developed. The aim of this study was to explore the feasibility of a pragmatic randomised clinical trial to investigate the effectiveness of the IM model versus conventional primary care in the management of patients with non-specific back/neck pain. Specific objectives included the exploration of recruitment and retention rates, patient and care characteristics, clinical differences and effect sizes between groups, selected outcome measures and power calculations to inform the basis of a full-scale trial.
Eighty patients with back/neck pain of at least two weeks duration were randomised to the two types of care. Outcome measures were standardised health related quality of life (the eight domains of SF-36) complemented by a set of exploratory "IM tailored" outcomes targeting self-rated disability, stress and well-being (0-10 scales); days in pain (0-14); and the use of analgesics and health care over the last two weeks (yes/no). Data on clinical management were derived from medical records. Outcome changes from baseline to follow-up after 16 weeks were used to explore the differences between the groups.
Seventy-five percent (80/107) of screened patients in general practice were eligible and feasible to enrol into the trial. Eighty-two percent (36/44) of the integrative and 75% (27/36) of the conventional care group completed follow-up after 16 weeks. Most patients had back/neck pain of at least three months duration. Conventional care typically comprised advice and prescription of analgesics, occasionally complemented with sick leave or a written referral to physiotherapy. IM care generally integrated seven treatment sessions from two different types of complementary therapies with conventional care over ten weeks. The study was underpowered to detect any statistically significant differences between the groups. One SF-36 domain showed a clinically relevant difference between groups that was also supported by a small distribution based effect size, i.e. vitality (-7.3 points, Cohen's d -0.34) which was in favour of IM. There was a clinical trend between groups showing that IM contributed to less use of prescription and non-prescription analgesics (-11.7 and - 9.7 percent units respectively) compared to conventional care. Exploring clinically relevant differences and the SF-36 as the basis for a main outcome measure showed that the sample sizes needed per arm to adequately power a full-scale trial depended on the target domain, i.e. ranging from 60 (vitality) to 339 (role emotion).
This pilot study investigated the implementation of IM in the primary care management of non-specific back and neck pain. Recruiting patients and implementing IM in routine clinical practice was feasible. The results warrant further exploration into different perspectives and relevant combinations of outcome measures including the use of health resources, drugs and cost-effectiveness to help understand the relevance of IM in primary care. Future research should prioritise larger scale studies considering variability, pain duration and small to moderate treatment effects.
Trial registration
Clinical trials NCT00565942
PMCID: PMC2749805  PMID: 19735542
6.  Short term treatment versus long term management of neck and back disability in older adults utilizing spinal manipulative therapy and supervised exercise: a parallel-group randomized clinical trial evaluating relative effectiveness and harms 
Back and neck disability are frequent in older adults resulting in loss of function and independence. Exercise therapy and manual therapy, like spinal manipulative therapy (SMT), have evidence of short and intermediate term effectiveness for spinal disability in the general population and growing evidence in older adults. For older populations experiencing chronic spinal conditions, long term management may be more appropriate to maintain improvement and minimize the impact of future exacerbations. Research is limited comparing short courses of treatment to long term management of spinal disability.
The primary aim is to compare the relative effectiveness of 12 weeks versus 36 weeks of SMT and supervised rehabilitative exercise (SRE) in older adults with back and neck disability.
Randomized, mixed-methods, comparative effectiveness trial conducted at a university-affiliated research clinic in the Minneapolis/St. Paul, Minnesota metropolitan area.
Independently ambulatory community dwelling adults ≥ 65 years of age with back and neck disability of minimum 12 weeks duration (n = 200).
12 weeks SMT + SRE or 36 weeks SMT + SRE.
Blocked 1:1 allocation; computer generated scheme, concealed in sequentially numbered, opaque, sealed envelopes.
Functional outcome examiners are blinded to treatment allocation; physical nature of the treatments prevents blinding of participants and providers to treatment assignment.
Primary endpoint
36 weeks post-randomization.
Data collection
Self-report questionnaires administered at 2 baseline visits and 4, 12, 24, 36, 52, and 78 weeks post-randomization. Primary outcomes include back and neck disability, measured by the Oswestry Disability Index and Neck Disability Index. Secondary outcomes include pain, general health status, improvement, self-efficacy, kinesiophobia, satisfaction, and medication use. Functional outcome assessment occurs at baseline and week 37 for hand grip strength, short physical performance battery, and accelerometry. Individual qualitative interviews are conducted when treatment ends. Data on expectations, falls, side effects, and adverse events are systematically collected.
Primary analysis
Linear mixed-model method for repeated measures to test for between-group differences with baseline values as covariates.
Treatments that address the management of spinal disability in older adults may have far reaching implications for patient outcomes, clinical guidelines, and healthcare policy.
Trial registry; Identifier: NCT01057706.
PMCID: PMC4255336  PMID: 25478141
Neck disability; Back disability; Spinal manipulative therapy; Exercise therapy; Older adults; Mixed-methods; Comparative effectiveness
7.  Surgery versus conservative care for neck pain: a systematic review 
European Spine Journal  2012;22(1):87-95.
General practitioners refer patients with continued neck pain that do not respond well to conservative care frequently to secondary care for further assessment. Are surgical interventions to the cervical spine effective when compared to conservative care for patients with neck pain?
Systematic review.
The search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to June 2011. Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of adults with neck pain, which evaluated at least one clinically relevant primary outcome measure (e.g. pain, functional status, recovery), were included. In addition, treatments had to include surgery and conservative care. Two authors independently assessed risk of bias using the criteria recommended by the CBRG and extracted the data. The quality of the evidence was rated using the GRADE method.
Patients included had neck pain with or without radiculopathy or myelopathy. In total, three RCTs and six CCTs were identified comparing different surgical interventions with conservative care, of which one had a low risk of bias. Overall there is very low quality of evidence available on the effectiveness of surgery compared to conservative care in neck pain patients showing overall no differences.
Most studies on surgical techniques comparing these to conservative care showed a high risk of bias. The benefit of surgery over conservative care is not clearly demonstrated.
PMCID: PMC3540296  PMID: 23104514
Systematic review; Randomised controlled trials; Surgery; Conservative care
8.  Electrical stimulation for chronic non-specific low back pain in a working-age population: a 12-week double blinded randomized controlled trial 
Non-invasive electrotherapy is commonly used for treatment of chronic low back pain. Evidence for efficacy of most electrotherapy modalities is weak or lacking. This study aims to execute a high-quality, double-blinded randomized controlled clinical trial comparing 1) H-Wave® Device stimulation plus usual care with 2) transcutaneous electrical nerve stimulation (TENS) plus usual care, and 3) Sham electrotherapy plus usual care to determine comparative efficacy for treatment of chronic non-specific low back pain patients.
Patients- Chronic non-specific low back pain patients between ages of 18–65 years, with pain of at least 3 months duration and minimal current 5/10 VAS pain. Patients will have no significant signs or symptoms of lumbosacral nerve impingement, malignancy, spinal stenosis, or mood disorders.
Study design- Double blind RCT with 3 arms and 38 subjects per arm. Randomization by permuted blocks of random length, stratified by Workers Compensation claim (yes vs. no), and use of opioids. The null hypothesis of this study is that there are no statistically significant differences in functional improvement between treatment types during and at the end of a 12-week week treatment period.
Data collection- Subjective data will be collected using Filemaker Pro™ database management collection tools. Objective data will be obtained through functional assessments. Data will be collected at enrollment and at 1, 4, 8, and 12 weeks for each participant by a blinded assessor.
Interventions- H-Wave® device stimulation (Intervention A) plus usual care, transcutaneous electrical nerve stimulation (TENS) (Intervention B) plus usual care, and sham electrotherapy plus usual care (control). Each treatment arm will have identical numbers of visits (4) and researcher contact time (approximately 15 hours).
Outcomes- Primary outcome measure: Oswestry Disability Index. Secondary measures include: Rowland Morris Instrument, VAS pain score, functional evaluation including strength when pushing and pulling, pain free range of motion in flexion and extension. Outcome measures assessed at baseline, 1, 4, 8, and 12 weeks. Treatment failure will be defined if patient terminates assigned treatment arm for non-efficacy or undergoes invasive procedure or other excluded cointerventions. Data will be analyzed using intention-to-treat analysis and adjusted for covariates related to LBP (e.g. age) as needed.
Study strengths include complex randomization, treatment group allocation concealment, double blinding, controlling for co-interventions, rigorous inclusion criteria, assessment of compliance, plans for limiting dropout, identical assessment methods and timing for each treatment arm, and planned intention-to-treat analyses.
PMCID: PMC3626857  PMID: 23537462
Chronic low back pain; Transcutaneous electrical nerve stimulation; Double-blind randomized controlled trial; H-wave; TENS; Usual care
9.  Expectations for Recovery Important in the Prognosis of Whiplash Injuries 
PLoS Medicine  2008;5(5):e105.
Individuals' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations. The role of expectations in recovery from traumatic neck pain, in particular whiplash-associated disorders (WAD), has not been assessed to date to our knowledge. The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD.
Methods and Findings
We used a prospective cohort study composed of insurance claimants in Sweden. The participants were car occupants who filed a neck injury claim (i.e., for WAD) to one of two insurance companies between 15 January 2004 and 12 January 2005 (n = 1,032). Postal questionnaires were completed shortly (average 23 d) after the collision and then again 6 mo later. Expectations for recovery were measured with a numerical rating scale (NRS) at baseline, where 0 corresponds to “unlikely to make a full recovery” and 10 to “very likely to make a full recovery.” The scale was reverse coded and trichotomised into NRS 0, 1–4, and 5–10. The main outcome measure was self-perceived disability at 6 mo postinjury, measured with the Pain Disability Index, and categorised into no/low, moderate, and high disability. Multivariable polytomous logistic regression was used for the analysis. There was a dose response relationship between recovery expectations and disability. After controlling for severity of physical and mental symptoms, individuals who stated that they were less likely to make a full recovery (NRS 5–10), were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery (odds ratio [OR] 4.2 [95% confidence interval (CI) 2.1 to 8.5]. For the intermediate category (NRS 1–4), the OR was 2.1 (95% CI 1.2 to 3.2). Associations between expectations and disability were also found among individuals with moderate disability.
Individuals' expectations for recovery are important in prognosis, even after controlling for symptom severity. Interventions designed to increase patients' expectations may be beneficial and should be examined further in controlled studies.
Lena Holm and colleagues show that in people who had a whiplash injury after a car crash there was an association between expectation of disability and actual disability six months later.
Editors' Summary
The disability associated with injury is a major source of distress for patients, and can be costly to the health care system and employers when persons fail to recover quickly and are unable to return to work. Finding ways to help people recover quickly and get back to optimal health is important. Some of the most common injuries causing disability and time off work result from whiplash—the sudden hyperextension or “whipping” of the neck, which can occur from a motor vehicle crash. It has long been recognized that psychological factors (such as the ability to cope, how “in control” one feels about one's life) are as important as physical symptoms in how disabling an injury can be. There is now growing evidence that a person's feelings about their ability to recover from injury plays a part in actual recovery. Studies from Europe and North America have shown with conditions like low back pain and minor head injury that a patient's feelings about the possibility of getting better are related to how well they do. Less is known about how important these psychological factors are in recovery from disorders due to whiplash associated disorders.
Why Was This Study Done?
The authors wanted to find out whether there was a relationship between people's expectations for their recovery from whiplash associated disorders and their actual recovery six months later. So, for example, they wondered if a person with whiplash who felt they were very unlikely to recover from their injury, actually did not recover (and vice versa).
What Did the Researchers Do and Find?
The authors had access to an unusual set of health information—insurance claims by people who had been involved in car collisions to two insurance companies in Sweden. They identified about 1,000 adult insurance claimants over one year and mailed them a questionnaire that asked for details about the collision as well as information about the claimant: their demographic profile, health history, and the types of pain and symptoms experienced since the crash. The questionnaire also asked the claimant how likely they thought they were to make a full recovery from their injuries.
For those who said they had whiplash associated disorders, the authors followed up with another questionnaire six months later, which asked for information about any disability, pain, or other symptoms that the claimant was still experiencing because of the injury. Of those who had completed the first questionnaire, 82% were followed up.
Only about a quarter of claimants with whiplash associated disorders said they expected to make a full recovery. Perhaps not surprisingly, those with only mild pain, compared to those with intense pain, were more likely to think so. Persons who said they were less likely to make a full recovery were four times more likely to report high levels of disability six months later. Even for persons (or individuals) people with moderate levels of disability six months after injury, their expectations for recovery were similarly linked to how well they did: the lower the expectations for recovery, the higher the disability. These findings were true even after taking into account how severe signs and symptoms the person had, and how well the person was coping psychologically.
What Do These Findings Mean?
The findings indicate that those with the lowest expectations for recovery after their whiplash injury will have the poorest recovery, and those with the highest expectations will have the best recovery. They also suggest that a patient's expectations about getting better are as important as his or her physical symptoms. The authors say that the more we can influence patients to believe they will make a full recovery, the better chance they will have to recover completely. This means that it may be beneficial for healthcare providers to give support and/or education to patients with whiplash associated disorders that increases their positive feelings toward recovery. The authors call for more studies into whether these types of targeted interventions would be of benefit.
Additional Information
Please access these Web sites via the online version of this summary at
Information about research on injuries and rehabilitation can be found at the Web sites of organisations devoted to studying the health of workers, such as the Institute for Work and Health in Canada, the Finnish Institute of Occupational Health, and the US National Institute for Occupational Safety and Health
The Wikipedia entry for medical aspects of whiplash describes the four grades of whiplash disorder, but does not cover the debate about the credibility of whiplash disorder (please note that Wikipedia is an online encyclopedia that anyone can edit)
The Sjukvardsradgivningen Web site provides information about whiplash-related disorders, common signs and symptoms, recovery and prognosis, and treatments (in Swedish)
PMCID: PMC2375948  PMID: 18479182
10.  Effect of individually tailored biopsychosocial workplace interventions on chronic musculoskeletal pain, stress and work ability among laboratory technicians: randomized controlled trial protocol 
Among laboratory technicians, the prevalence of neck and shoulder pain is widespread possibly due to typical daily work tasks such as pipetting, preparing vial samples for analysis, and data processing on a computer including mouse work - all tasks that require precision in motor control and may result in extended periods of time spent in static positions.
In populations characterized by intense chronic musculoskeletal pain and diagnosed conditions in conjunction with psycho-physiological symptoms such as stress-related pain and soreness and other disabling conditions, multifactorial approaches applying a combination of individually tailored physical and cognitive strategies targeting the areas most needed, may be an effective solution to the physical and mental health challenges.
The aim of this study is therefore to investigate the effect of an individually tailored biopsychosocial intervention strategy on musculoskeletal pain, stress and work disability in lab technicians with a history of musculoskeletal pain at a single worksite in Denmark.
In this single-blind two-armed parallel-group randomized controlled trial with allocation concealment, participants receive either an individualized multifactorial intervention or “usual care” for 10 weeks at the worksite. Inclusion criteria: 1) female laboratory technician (18-67 years of age) and 2) Pain intensity ≥ 3 (0-10 Visual Analogue Scale) lasting ≥3 months with a frequency of ≥ 3 days per week in one or more of the following regions: i) upper back i) low back iii) neck, iv) shoulder, v) elbow and/or vi) hand. Exclusion criteria: 1) life-threatening disease and 2) pregnancy. Stress, as measured by Cohen´s perceived stress questionnaire is not an inclusion criteria, thus participants can participate regardless of their stress level.
We will implement an individualized intervention addressing biopsychosocial elements of musculoskeletal pain with the following components; i) increasing physical capacity through strength- and motor control training; ii) lowering or preventing development of stress through mindfulness practice and learning de-catastrophizing pain management strategies through cognitive training.
The primary outcome at 10-week follow-up is the between-group difference in intensity of perceived musculoskeletal pain during the last week (average value of back, neck, shoulder, elbow and hand) assessed by questionnaire (modified visual analogue scale 0-10).
This study will provide experimental evidence to guide workplace initiatives designed towards reducing chronic musculoskeletal pain and stress.
Trial registration number NCT02047669.
PMCID: PMC4325961  PMID: 25519844
Musculoskeletal disorders; Occupational health and performance; Neck pain; Shoulder pain; Elbow pain; Hand pain; Wrist pain; Repetitive work; Stress; Work ability
11.  On the course of low back pain in general practice: a one year follow up study 
OBJECTIVES—Knowledge on the clinical course of low back pain presented in general practice is poor. Preceding studies offer a fragmentary view only, whereas further knowledge is important to enable the assessment of the prognosis. The object of this study is to investigate the course of low back pain presented in general practice to enable the assessment of the prognosis.
METHODS—A one year follow up study on the clinical course of low back pain in consecutive cases receiving usual care in general practice. During a period of two years 15 general practitioners from Amsterdam and surrounding areas included consecutive patients with both chronic and recent onset low back pain. After the initial visit, each patient was monitored for a period of 12 months. The follow up consisted of monthly postal questionnaires on the course of the low back pain and the related disability.
RESULTS—A total of 443 of 605 patients identified were included in the follow up, which was fully completed by 269 patients. In general, patients with less serious low back pain participated less often or did not complete the follow up. At 12 weeks 35% and at the end of the follow up 10% of the population, respectively, still suffered from low back pain. Both the pain and the disability seemed to diminish quickly after the initial visit, and both seemed to stabilise at a lower level if the low back pain did not disappear completely. About three of four patients, whose pain disappeared before the end of the follow up, endured one or more relapses within a year. The median time to a relapse was about seven weeks, and its median duration about six weeks. Both the pain and the disability turned out to be less severe during relapses. The median time to recovery for patients whose low back pain developed more than seven weeks before the initial visit, was four weeks longer than for patients with more recently developed low back pain at the initial visit.
CONCLUSIONS—The clinical course of low back pain presented in general practice, for the most patients, clearly is less favourable than expected. It takes more than just a few weeks to recover, and relapses occur within a year in most cases. Fortunately, both the pain and the disability quickly diminish, even if the low back pain does not resolve within a few weeks.

 Keywords: backache; prognosis; follow up study; general practice
PMCID: PMC1752458  PMID: 9536816
12.  Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain 
BMJ : British Medical Journal  2006;333(7569):623.
Objective To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care.
Design Pragmatic, open, randomised controlled trial.
Setting Three private acupuncture clinics and 18 general practices in York, England.
Participants 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration.
Interventions 10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients).
Main outcome measures The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction.
Results 39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported.
Conclusions Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain.
Trial registration ISRCTN80764175.
PMCID: PMC1570824  PMID: 16980316
13.  The association between neck pain, the Neck Disability Index and cervical ranges of motion: a narrative review 
The Neck Disability Index (NDI) and Cervical Ranges of Motion (CROM) are measurement tools that are used for neck pain patients.
To review the literature to determine how the NDI is associated with neck pain and CROM outcomes.
Computer based searches of 5 databases were performed and supplemented by internet and hand searching of article references and “related citations.”
The search yielded 23 studies that met the inclusion and exclusion criteria and these were summarized into four categories: NDI, NDI and other questionnaires, whiplash and NDI and cervical range of motion and NDI. The NDI was shown to be a well validated and reliable self-reported questionnaire, especially when compared to other questionnaires, in both neck pain and whiplash (WAD) patients. There are very few studies that discuss the NDI and cervical range of motion.
This review outlines the strength of the NDI as a self-reported neck disability questionnaire, but also demonstrates a need for further research to explore the association between the NDI, neck pain and cervical ranges of motion.
PMCID: PMC3154067  PMID: 21886283
neck pain; neck disability index; range of motion; whiplash; douleur au couleur; indice d’invalidité du cou; portée du mouvement cervical; coup de fouet cervical
14.  Pedometer-Based Internet-Mediated Intervention For Adults With Chronic Low Back Pain: Randomized Controlled Trial 
Chronic pain, especially back pain, is a prevalent condition that is associated with disability, poor health status, anxiety and depression, decreased quality of life, and increased health services use and costs. Current evidence suggests that exercise is an effective strategy for managing chronic pain. However, there are few clinical programs that use generally available tools and a relatively low-cost approach to help patients with chronic back pain initiate and maintain an exercise program.
The objective of the study was to determine whether a pedometer-based, Internet-mediated intervention can reduce chronic back pain-related disability.
A parallel group randomized controlled trial was conducted with 1:1 allocation to the intervention or usual care group. 229 veterans with nonspecific chronic back pain were recruited from one Department of Veterans Affairs (VA) health care system. Participants randomized to the intervention received an uploading pedometer and had access to a website that provided automated walking goals, feedback, motivational messages, and social support through an e-community (n=111). Usual care participants (n=118) also received the uploading pedometer but did not receive the automated feedback or have access to the website. The primary outcome was measured using the Roland Morris Disability Questionnaire (RDQ) at 6 months (secondary) and 12 months (primary) with a difference in mean scores of at least 2 considered clinically meaningful. Both a complete case and all case analysis, using linear mixed effects models, were conducted to assess differences between study groups at both time points.
Baseline mean RDQ scores were greater than 9 in both groups. Primary outcome data were provided by approximately 90% of intervention and usual care participants at both 6 and 12 months. At 6 months, average RDQ scores were 7.2 for intervention participants compared to 9.2 for usual care, an adjusted difference of 1.6 (95% CI 0.3-2.8, P=.02) for the complete case analysis and 1.2 (95% CI -0.09 to 2.5, P=.07) for the all case analysis. A post hoc analysis of patients with baseline RDQ scores ≥4 revealed even larger adjusted differences between groups at 6 months but at 12 months the differences were no longer statistically significant.
Intervention participants, compared with those receiving usual care, reported a greater decrease in back pain-related disability in the 6 months following study enrollment. Between-group differences were especially prominent for patients reporting greater baseline levels of disability but did not persist over 12 months. Primarily, automated interventions may be an efficient way to assist patients with managing chronic back pain; additional support may be needed to ensure continuing improvements.
Trial Registration NCT00694018; (Archived by WebCite at
PMCID: PMC3758050  PMID: 23969029
chronic pain; Internet; randomized controlled trial; exercise therapy
15.  Indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain: protocol of an inter-examiner reliability study among manual therapists 
Manual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown.
This study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists’ decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen’s kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability.
This study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.
PMCID: PMC4074830  PMID: 24982754
Manual therapy; Motion assessment; Diagnostics; Decision-making; Reliability; Clinical reasoning; Neck pain; Back pain
16.  Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study 
Objective To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.
Design Cohort study with one year follow-up.
Setting Primary care clinics in Sydney, Australia.
Participants An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.
Main outcome measures Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.
Results The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.
Conclusions In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.
PMCID: PMC2483884  PMID: 18614473
17.  Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study 
BMJ : British Medical Journal  2008;337(7662):154-157.
Objective To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.
Design Cohort study with one year follow-up.
Setting Primary care clinics in Sydney, Australia.
Participants An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.
Main outcome measures Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.
Results The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.
Conclusions In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.
PMCID: PMC2483884  PMID: 18614473
18.  Impact of musculoskeletal co-morbidity of neck and upper extremities on healthcare utilisation and sickness absence for low back pain 
Aims: To describe the presence of musculoskeletal co-morbidity of the neck and upper extremities among industrial workers with low back pain, and to examine whether it has an impact on healthcare utilisation and sickness absence for low back pain.
Methods: A self administered questionnaire was used to collect data from 505 industrial workers (response 86%).
Results: The 12 month prevalence of low back pain was 50%. Among subjects with low back pain the 12 month prevalence of musculoskeletal co-morbidity of the neck and upper extremities was 68%. Among workers with low back pain, subjects with high pain intensity or disabling low back pain were more likely to have musculoskeletal co-morbidity. In comparison to the subjects who report back pain only, subjects with co-morbidity showed worse general health and health related quality of life. No impact of upper extremity co-morbidity was found on healthcare utilisation, and sickness absence due to low back pain.
Conclusions: This study provides no evidence that musculoskeletal co-morbidity of the neck and upper extremities influences the choice to seek care or take sick leave due to low back pain among industrial manual workers. For occupational health practitioners the finding of a high co-morbidity is important to consider when implementing workplace interventions aimed at the reduction of specific musculoskeletal complaints, since the controls for one musculoskeletal complaint may impact adversely on another musculoskeletal complaint. Researchers who perform low back pain intervention studies using generic health measures, should take into account the impact of musculoskeletal co-morbidity on these measures.
PMCID: PMC1740669  PMID: 15377765
19.  Agreement between 2 pain visual analogue scales, by age and area of complaint in neck and low back pain subjects: the standard pen and paper VAS versus plastic mechanical sliderule VAS 
This study endeavoured to determine the agreement between the standard pencil and paper pain VAS (pVAS) and a relatively newly designed plastic mechanical (slide-rule) VAS (mVAS) in assessing cervical and lumbar pain intensity in cervical pain vs low back pain (LBP) patients stratified by age (< 65 years of age (yoa) and ≥ 65 yoa).
Design Architecture:
This was a concurrent validity study assessing the agreement between the gold standard pVAS and the experimental mVAS.
Sample Size:
A sample size estimate revealed that a minimum of 9 subjects for each of 4 age-complaint subgroups (< 65 yoa) neck pain, ≥ 65 yoa neck pain, <65 yoa low back pain, ≥ 65 yoa low back pain) would be necessary.
Sample Profile:
All adults (≥ 18 yrs of age) presenting to the Canadian Memorial Chiropractic College’s Herbert K. Lee Outpatient Clinic with low back (LBP) pain or neck pain were considered eligible for the study. Three (3) essentially asymptomatic subjects were also recruited in order to provide a complete spectrum of pain severities.
Outcome Measure:
Pain intensity was measured in centimetres (to nearest one tenth) on the pVAS and in ten units on the mVAS (to the nearest one tenth unit).
The pVAS was administered by including it with either the standard intake forms which all new patients are required to complete, or by presenting it to patients visiting the Clinic for a subsequent treatment. The subject made a visual estimation of his/her pain intensity and marked it on the pVAS accordingly. The response was then measured in centimetres. One of the investigators presented the mVAS to the subject after arrival in the examination room. The mVAS instrument was presented to the subject with instructions as to how to indicate his/her level of present pain intensity. Every attempt was made to ensure that no less than five minutes and no more than 15 minutes elapsed between the completion of the two forms of Visual Analogue Scale. The data were categorized according to the subjects’ ages (≥ 65 years of age (yoa) or < 65 yoa) and their areas of complaint (neck pain or low back pain).
Statistical Analysis Strategy:
Intraclass Correlation Coefficient (ICC) analyses were performed to determine the index of agreement between the mVAS and pVAS for each of the age and complaint categories. 95% Confidence Intervals (95% CI) were calculated for each ICC value. A clinically acceptable level of agreement was judged by the investigators to be ICC ≥ 0.85; a 95% CI no wider than ± 0.25 was considered to provide statistical significance.
The Intraclass Correlation Coefficient (ICC) analysis revealed an ICC of 0.86 with a 95% CI of ± 0.25 for the group under 65 yoa with neck pain, and an ICC of 0.87 with a 95% CI of ± 0.13 for the group under 65 yoa with low back pain. ICC’s (± 95 CI) of 0.60 (± 0.64) and 0.93 (± 0.2) were calculated for the ≥ 65 yoa neck pain group and ≥ 65 yoa LBP group, respectively.
The results of this study suggest that for the most part, there is statistically significant and clinically acceptable agreement between the pencil and paper VAS (pVAS) and a mechanical VAS (mVAS). The areas of complaint assessed (neck versus low back), did not appear to affect the level of agreement within each age category; only the older male neck pain and younger female LBP groups, however, yielded clinically unacceptable levels of agreement.
PMCID: PMC2485285
visual analogue scale (VAS); pain measurement; patient outcome assessment; pain; chiropractic
20.  Use of Outcome Measures in Managing Neck Pain: An International Multidisciplinary Survey 
To determine the outcome measures practice patterns in the neck pain management of various health disciplines.
A survey of 381 clinicians treating patients with neck pain was conducted.
Respondents were more commonly male (54%) and either chiropractors (44%) or physiotherapists (32%). The survey was international (24 countries with Canada having the largest response (44%)). The most common assessment was a single-item pain assessment (numeric or visual analog) used by 75% of respondents. Respondents sometimes or routinely used the Neck Disability Index (49%), the Patient Specific Functional Scale (28%), and the Disabilities of the Arm, Shoulder and Hand (32%). Work status was recorded in terms of time lost by more than 50% of respondents, but standardized measures of work limitations or functional capacity testing were rarely used. The majority of respondents never used fear of movement, psychological distress, quality of life, participation measures, or global ratings of change (< 10% routinely use). Use of impairment measurers was prevalent, but the type selected was variable. Quantitative sensory testing was used sometimes or routinely by 53% of respondents, whereas 26% never used it. Ratings of segmental joint mobility were commonly used to assess motion (44% routinely use), whereas 66% of respondents never used inclinometry. Neck muscle strength, postural alignment and upper extremity coordination were assessed sometimes or routinely by a majority of respondents (>56%). With the exception of numeric pain ratings and verbal reporting of work status, all outcomes measures were less frequently used by physicians. Years of practice did not affect practice patterns, but reimbursement did affect selection of some outcome measures.
Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggessts overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement in practice. International consensus and better clinical measurement evidence are needed to support this.
PMCID: PMC3793628  PMID: 24115972
Survey; neck pain; outcome measure; practice patterns; profession.
21.  Multimodal Chiropractic Care of Pain and Disability for a Patient Diagnosed With Benign Joint Hypermobility Syndrome: A Case Report 
The purpose of this case report is to describe multimodal chiropractic care of a female patient diagnosed with benign joint hypermobility syndrome (BJHS) and a history of chronic spine pain.
Clinical features
A 23-year-old white female presented for chiropractic care with chronic low back pain, neck pain, and headaches. The patient was diagnosed with BJHS, including joint hypermobility of her thumbs, elbows, right knee, and lumbopelvic region. A 6-year history of low back pain and varicose veins in her posterior thighs and knees were additional significant diagnostic findings of BJHS.
Interventions and outcomes
The treatment consisted of spinal and extremity manipulation, Graston technique, and postisometric relaxation combined with sensory motor stimulation and scapular stabilization exercises. The patient was seen 15 times over an 18-week period. After 18 weeks of care, the Revised Oswestry Low Back Questionnaire and Headache Disability Index demonstrated clinically important improvements with her low back pain and headache; but little change was noted in her neck pain as measured by the Neck Disability Index.
This patient with BJHS who had decreased disability and spine pain improved after a course of multimodal chiropractic care.
PMCID: PMC3976499  PMID: 24711783
Manipulation; Chiropractic; Joint hypermobility; Low back pain; Neck pain
22.  A Novel Tool for the Assessment of Pain: Validation in Low Back Pain 
PLoS Medicine  2009;6(4):e1000047.
Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain.
Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology.
Methods and Findings
Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs.
We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.
Editors' Summary
Pain, although unpleasant, is essential for survival. Whenever the body is damaged, nerve cells detecting the injury send an electrical message via the spinal cord to the brain and, as a result, action is taken to prevent further damage. Usually pain is short-lived, but sometimes it continues for weeks, months, or years. Long-lasting (chronic) pain can be caused by an ongoing, often inflammatory condition (for example, arthritis) or by damage to the nervous system itself—experts call this “neuropathic” pain. Damage to the brain or spinal cord causes central neuropathic pain; damage to the nerves that convey information from distant parts of the body to the spinal cord causes peripheral neuropathic pain. One example of peripheral neuropathic pain is “radicular” low back pain (also called sciatica). This is pain that radiates from the back into the legs. By contrast, axial back pain (the most common type of low back pain) is confined to the lower back and is non-neuropathic.
Why Was This Study Done?
Chronic pain is very common—nearly 10% of American adults have frequent back pain, for example—and there are many treatments for it, including rest, regulated exercise (physical therapy), pain-killing drugs (analgesics), and surgery. However, the best treatment for any individual depends on the exact nature of their pain, so it is important to assess their pain carefully before starting treatment. This is usually done by scoring overall pain intensity, but this assessment does not reflect the characteristics of the pain (for example, whether it occurs spontaneously or in response to external stimuli) or the complex biological processes involved in pain generation. An assessment designed to take such factors into account might improve treatment outcomes and could be useful in the development of new therapies. In this study, the researchers develop and test a new, standardized tool for the assessment of chronic pain that, by examining many symptoms and signs, aims to distinguish between pain subtypes.
What Did the Researchers Do and Find?
One hundred thirty patients with several types of peripheral neuropathic pain and 57 patients with non-neuropathic (axial) low back pain completed a structured interview of 16 questions and a standardized bedside examination of 23 tests. Patients were asked, for example, to choose words that described their pain from a list provided by the researchers and to grade the intensity of particular aspects of their pain from zero (no pain) to ten (the maximum imaginable pain). Bedside tests included measurements of responses to light touch, pinprick, and vibration—chronic pain often alters responses to harmless stimuli. Using “hierarchical cluster analysis,” the researchers identified six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain based on the patterns of symptoms and signs revealed by the interviews and physical tests. They then used “classification tree analysis” to identify the six questions and ten physical tests that discriminated best between pain subtypes and combined these items into a tool for a Standardized Evaluation of Pain (StEP). Finally, the researchers asked whether StEP, which took 10–15 minutes, could identify patients with radicular back pain and discriminate them from those with axial back pain in an independent group of 137 patients with chronic low back pain. StEP, they report, accurately diagnosed these two conditions and was well accepted by the patients.
What Do These Findings Mean?
These findings indicate that a standardized assessment of pain-related signs and symptoms can provide a simple, quick diagnostic procedure that distinguishes between radicular (neuropathic) and axial (non-neuropathic) low back pain. This distinction is crucial because these types of back pain are best treated in different ways. In addition, the findings suggest that it might be possible to identify additional pain subtypes using StEP. Because these subtypes may represent conditions in which different pain mechanisms are acting, classifying patients in this way might eventually enable physicians to tailor treatments for chronic pain to the specific needs of individual patients rather than, as at present, largely guessing which of the available treatments is likely to work best.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Giorgio Cruccu and and Andrea Truini
The US National Institute of Neurological Disorders and Stroke provides a primer on pain in English and Spanish
In its 2006 report on the health status of the US, the National Center for Health Statistics provides a special feature on the epidemiology of pain, including back pain
The Pain Treatment Topics Web site is a resource, sponsored partly by associations and manufacturers, that provides information on all aspects of pain and its treatment for health care professionals and their patients
Medline Plus provides a brief description of pain and of back pain and links to further information on both topics (in English and Spanish)
The MedlinePlus Medical Encyclopedia also has a page on low back pain (in English and Spanish)
PMCID: PMC2661253  PMID: 19360087
23.  Effectiveness of Iyengar yoga in treating spinal (back and neck) pain: A systematic review 
Considerable amount of money spent in health care is used for treatments of lifestyle related, chronic health conditions, which come from behaviors that contribute to morbidity and mortality of the population. Back and neck pain are two of the most common musculoskeletal problems in modern society that have significant cost in health care. Yoga, as a branch of complementary alternative medicine, has emerged and is showing to be an effective treatment against nonspecific spinal pain. Recent studies have shown positive outcome of yoga in general on reducing pain and functional disability of the spine. The objective of this study is to conduct a systematic review of the existing research within Iyengar yoga method and its effectiveness on relieving back and neck pain (defined as spinal pain). Database research form the following sources (Cochrane library, NCBI PubMed, the Clinical Trial Registry of the Indian Council of Medical Research, Google Scholar, EMBASE, CINAHL, and PsychINFO) demonstrated inclusion and exclusion criteria that selected only Iyengar yoga interventions, which in turn, identified six randomized control trials dedicated to compare the effectiveness of yoga for back and neck pain versus other care. The difference between the groups on the postintervention pain or functional disability intensity assessment was, in all six studies, favoring the yoga group, which projected a decrease in back and neck pain. Overall six studies with 570 patients showed, that Iyengar yoga is an effective means for both back and neck pain in comparison to control groups. This systematic review found strong evidence for short-term effectiveness, but little evidence for long-term effectiveness of yoga for chronic spine pain in the patient-centered outcomes.
PMCID: PMC4278133  PMID: 25558128
Back pain; complementary alternative medicine; effectiveness; Iyengar yoga; neck pain; randomized control trials; spine pain
24.  Naturopathic Care for Chronic Low Back Pain: A Randomized Trial 
PLoS ONE  2007;2(9):e919.
Chronic low back pain represents a substantial cost to employers through benefits coverage and days missed due to incapacity. We sought to explore the effectiveness of Naturopathic care on chronic low back pain.
This study was a randomized clinical trial. We randomized 75 postal employees with low back pain of longer than six weeks duration to receive Naturopathic care (n = 39) or standardized physiotherapy (n = 36) over a period of 12 weeks. The study was conducted in clinics on-site in postal outlets. Participants in the Naturopathic care group received dietary counseling, deep breathing relaxation techniques and acupuncture. The control intervention received education and instruction on physiotherapy exercises using an approved education booklet. We measured low back pain using the Oswestry disability questionnaire as the primary outcome measure, and quality of life using the SF-36 in addition to low back range of motion, weight loss, and Body Mass Index as secondary outcomes.
Sixty-nine participants (92%) completed eight weeks or greater of the trial. Participants in the Naturopathic care group reported significantly lower back pain (−6.89, 95% CI. −9.23 to −3.54, p = <0.0001) as measured by the Oswestry questionnaire. Quality of life was also significantly improved in the group receiving Naturopathic care in all domains except for vitality. Differences for the aggregate physical component of the SF-36 was 8.47 (95% CI, 5.05 to 11.87, p = <0.0001) and for the aggregate mental component was 7.0 (95% CI, 2.25 to 11.75, p = 0.0045). All secondary outcomes were also significantly improved in the group receiving Naturopathic care: spinal flexion (p<0.0001), weight-loss (p = 0.0052) and Body Mass Index (−0.52, 95% CI, −0.96 to −0.08, p = 0.01).
Naturopathic care provided significantly greater improvement than physiotherapy advice for patients with chronic low back pain.
Trial Registration ISRCTN41920953
PMCID: PMC1976391  PMID: 17878954
25.  Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: A prospective, multicenter, cohort study 
Observational studies have previously shown that adverse events following manipulation to the neck and/or back are relatively common, although these reactions tend to be mild in intensity and self-limiting. However, no prospective study has examined the incidence of adverse reactions following spinal adjustments using upper cervical techniques, and the impact of this care on clinical outcomes.
Consecutive new patients from the offices of 83 chiropractors were recruited for this practice-based study. Clinical outcome measures included 1) Neck pain disability index (100-point scale), 2) Oswestry back pain index (100-point scale), 3) 11-point numerical rating scale (NRS) for neck, headache, midback, and low back pain, 4) treatment satisfaction, and 5) Symptomatic Reactions (SR). Data were collected at baseline, and after approximately 2 weeks of care. A patient reaching sub-clinical status for pain and disability was defined as a follow-up score <3 NRS and <10%, respectively. A SR is defined as a new complaint not present at baseline or a worsening of the presenting complaint by >30% based on an 11-point numeric rating scale occurring <24 hours after any upper cervical procedure.
A total of 1,090 patients completed the study having 4,920 (4.5 per patient) office visits requiring 2,653 (2.4 per patient) upper cervical adjustments over 17 days. Three hundred thirty- eight (31.0%) patients had SRs meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%). Outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability (p <0.001) following care with a high level (mean = 9.1/10) of patient satisfaction. The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.
Upper cervical chiropractic care may have a fairly common occurrence of mild intensity SRs short in duration (<24 hours), and rarely severe in intensity; however, outcome assessments were significantly improved with less than 3 weeks of care with a high level of patient satisfaction. Although our findings need to be confirmed in subsequent randomized studies for definitive risk-benefit assessment, the preliminary data shows that the benefits of upper cervical chiropractic care may outweigh the potential risks.
PMCID: PMC3204272  PMID: 21974915
Chiropractic; Adverse Effects; Symptomatic Reactions; Manipulation; Upper Cervical

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