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STUDY DESIGN: This is a secondary analysis of a prospective cohort of 295 patients with acute low back pain presenting to 31 primary care physicians in North Carolina. OBJECTIVE: This study examines the hypothesis that dissatisfaction with job tasks and lack of social support from coworkers and supervisor are associated with poorer low back pain outcomes. SUMMARY OF BACKGROUND DATA: Psychosocial work characteristics are thought to be associated with the occurrence, report, and development of long-term disability from low back pain, but the studies are inconclusive. METHOD.: Three psychosocial work characteristics were separately compared to these outcomes: time to functional recovery, attainment of complete recovery, and clinically relevant change on the Modified Roland Scale. RESULTS: Relative to subjects with more social support from coworkers, subjects with less social support from coworkers have 1.55 (95% CI = 1.04-2.34) times the risk of not attaining complete recovery from low back pain at 8 weeks. For all other outcomes evaluated in this study, there was not an association with the psychosocial work characteristics. Biomechanical demands were found not to modify this association. CONCLUSION: This analysis provides evidence that social support in the workplace from coworkers but not social support from a supervisor or job task satisfaction are likely targets for intervention.

Study Design. A prospective observational cohort was recruited from 208 randomly selected North Carolina practices. Objective. To compare the corse of compensation claimants with gainfully employed patients not so insured fom the time when they first sought care for acute back pain. Summary of Background Data. The human and financial cost attributable to disabling chronic low back pain indemnified by workers' compensation programs continues to escalate. We explored the antecedents to this pehnomenon. Method. Consecutive patients with acute low back pain were interviewed by telephone within 1 week of first seeking care and in follow-up calls after 2, 4, 8, 12, and 24 weeks to monitor functional and work status. Results. Of the 1633 patients enrolled, 505 were insured by workers' compensation. These were compated with 861 who had been employed on any job for pay within 3 months of the onset of their backache but whose care was not so underwritten. Those with compensable back pain were more likely to categorize their tasks as physically demanding and had taken more time off work in the month before the baseline interview (P = 0.02). Recovery of the sense of wellness they enjoyed before this episode of back pain was delayed (Cox Model: Hazard Ratio = 0.822: P

Study DesignThis was a survey of 235 individuals with and 132 individuals without documented low back pain.ObjectivesTo approximate the magnitude of potential reporting biases in estimates of prevalence of and medical care use in low back pain.Summary of Background DataThe use of survey techniques p

Study Design. Prospective cohort study. Objectives. To determine the characteristics of patients who take muscle relaxants for back pain after seeking care and to determine the relationship of muscle relaxant use with recovery from the episode of low back pain. Summary of Background Data. Low back pain is a common condition with a generally favorable short-term prognosis. Physicians in the acute setting commonly prescribe muscle relaxants. The indications for use and outcomes are not clear. Methods. We performed a secondary data analysis of a cohort of 1633 patients who sought care from a variety of practitioners (primary care, physician of chiropractic, orthopedic surgeon, Health Maintenance Organization) for low back pain. Patients were enrolled in the physician’s office and interviewed at baseline, 2, 4, 8, 12, and 24 weeks. Pain, functional status, medication use, health care utilization, and satisfaction with care were assessed. Results. Muscle relaxants were used by 49% of patients; among those who sought care from doctors, 64% used muscle relaxants. Muscle relaxant users were more impaired at baseline. Over time, among patients with greater functional status impairment (Roland disability score > 12) at baseline, muscle relaxant users had somewhat slower recovery from the episode of back pain. This finding persisted after controlling for baseline functional status, age, worker’s compensation status, and use of nonsteroidal inflammatory agents. Conclusions. Use of muscle relaxants was very common among patients with acute low back pain. Muscle relaxant use was not associated with more rapid functional recovery.

Study Design. Four strata of randomly selected health care providers in North Carolina (primary care MDs, Doctors of Chiropractic, orthopedic surgeons, and group model HMO primary care providers) enrolled 1633 consecutive patients with low back pain into a cohort study. Objective. To determine whether race had an independent effect on rate of recovery from low back pain, and whether there was any racial disparity in the treatments provided to patients with low back pain. of Background Data. Little research to date has examined the relation between patient race and recovery from an episode of acute low back pain. Methods. Consecutive patients were enrolled in the provider's office and contacted by telephone at baseline, at 2, 4, 8, 12, and 24 weeks, and at 22 months. Results. Blacks (n = 238) at baseline had higher pain scores on a 10-point scale (5.92 vs 5.25; P < 0.01) and worse functional disability (12.1 vs 11; P = 0.04), as assessed by the 23-point Roland-Morris scale, yet were considered by their health provider as having less severe pain and less likely to have disc disease than white patients (P < 0.05 for all comparisons). Blacks had worse functional disability at most follow-up interviews. Blacks were shown to be less likely to receive radiographs (49% vs 40%) or advanced imaging studies (10% vs 6%), even after controlling for income, education, baseline severity of low back pain, and insurance status (P < 0.05). Doctors of Chiropractic had different practice approaches than MDs, and there was an interaction with patient race. Conclusions. The relation of patient race to outcomes from and care for low back pain is complex. Blacks have slightly worse functional status than whites on presentation and at follow-up assessment. Blacks receive less intense diagnostic and treatment approaches from MDs, although. the severity of their impairment is at least as great.

Study design Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice. Objectives To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain. Summary of background data Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training. Methods Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care. Results No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02). Conclusion Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.

Study Design. A 22-month prospective cohort study. Objectives. To describe the course of an inception cohort of patients with chronic low back pain. Summary of Background Data. Chronic low back pain is a debilitating condition with great medical and social cost. Methods. A cohort of 1246 patients with acute low back pain who sought treatment from 208 Nort Carolina providers was observed. Patients who developed chornic low back pain were identified. Entrycriteria were back pain of less than 10 weeks' duration, no previous care for this episode of low back pain, no previous care for this episode of low back pain, no previou spine surgery, not pregnant, non nonskin malignancy, and access to a telephone. The providers were of four types: primary care medical doctors, doctors of Chiropractic, orthopedic surgeons, and health maintenance organization-based primary care providers. Patients were contacted by telephone shortly after enrollment and at 2, 4, 8, 12, and 24 weeks, with a final interview at 22 months. Patient functional status, care-seeking, and satisfaction were evaluated. Results. Ninety-six patients had chronic, continuous symptoms for 3 months, forming the inception cohort of chronic low back pain. A valid, reliable measure of back-specific functional disability also was used. Predictors of the development of chronicity were poor baseline functional status and sciatica. A more powerful predictor of chronicity was poor functional status at 4 weeks. Two thirds of patients with chronic low back pain at 3 months had functionally disabling symptoms at 22 months, and a majority of these were employed. Satisfaction with care was low. Forty-six patients (2.6% of the entire cohort) underwent surgery, with no statistically significant difference in surgical rates among initial provider stata. Patients who underwent surgery after 3 months had a Roland disability score of 22 months of 10 (7.7, 12.3). Forty-one percent of patients with chronic low back pain see an orthopedic or neurologic surgeon. Chronic low back pain occurs in 7.7% of patients who seek care for acute low back pain, with unremitting pain for 22 months in 4.7%. Conclusion. Once established, chronic low back pain is persistent. Most patients with chronic low back pain seek little care, and a majority are employed. Future research should emphasize maintenance of employment and function.