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Future directions for The Spine Journal: managing and reporting conflict of interest issues Eugene J. Carragee, MD, Eric L. Hurwitz, DC, PhD*, Bradley K. Weiner, MD, Christopher M. Bono, MD, David J. Rothman, PhD Department of Orthopedic Surgery, Stanford Medicine Outpatient Center, Stanford University School of Medicine, Redwood City, CA 94063, USA Office of Public Health Studies, Department of Public Health Sciences, John A. Burns School of Medicine, University of Hawaii, M anoa, Honolulu, HI 96822, USA Department of Orthopedic Surgery, The Methodist Hospital, Houston, TX 77030, USA Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA Department of Social Medicine and Department of History, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA Received 11 August 2011; accepted 18 August 2011

Commentary on Bronfort G, Maiers MJ, Evans RL, et al. Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial. Spine J 2011;11:585–598 ( in this issue ).

Magnetic resonance (MR) imaging is frequently used to evaluate first-time episodes of serious low back pain (LBP). Common degenerative findings are often interpreted as recent developments and the probable anatomic cause of the new symptoms. To date no prospective study has established a baseline MR status of the lumbar spine in subjects without significant LBP problems and prospectively surveyed these subjects for acute changes shortly after new and serious LBP episodes. This method can identify new versus old MR findings possibly associated with the acute symptomatic episode.To determine if new and serious episodes of LBP are associated with new and relevant findings on MRI.Prospective observational study with baseline and post-LBP MRI monitoring of 200 subjects over 5 years.Clinical outcomes: LBP intensity (visual analogue scale), Oswestry Disability Index, and work loss. MRI outcomes: disc degeneration, herniation, annular fissures, end plate changes, facet arthrosis, canal stenosis, spondylolisthesis, and root impingement.200 subjects with a lifetime history of no significant LBP problems, and a high risk for new LBP episodes were studied at baseline with physical examination, plain radiographs, and MR imaging. Subjects were followed every 6 months for 5 years with a detailed telephone interview. Subjects with a new severe LBP episode (LBPor=6/10,1 week) were assessed for new diagnostic tests. New MR imaging, taken within 6 to 12 weeks of the start of a new LBP episode, was compared with baseline (asymptomatic) images. Two independent and blinded readers evaluated each baseline and follow-up study.During the 5-year observation period of 200 subjects, 51 (25%) subjects were evaluated with a lumbar MRI for clinically serious LBP episodes, and 3/51 (6%) had a primary radicular complaint. These 51 subjects had 67 MR scans. Of 51 subjects, 43 (84%) had either unchanged MR or showed regression of baseline changes. The most common progressive findings were disc signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two subjects, both with primary radicular complaints, had new findings of probable clinical significance (4%). Subjects having another MR were more likely to have had chronic pain at baseline (odds ratio [OR]=3.19; 95% confidence interval [CI] 1.61-6.32), to smoke (OR=5.81; 95% CI 1.99-16.45), have baseline psychological distress (OR 2.27; 95% CI 1.15-4.49), and have previous disputed compensation claims (OR=2.35; 95% CI 0.97-5.69). Subjects involved in current compensation claims were also more likely to have an MR scan to evaluate the LBP episode (risk ratio=4.75, p.001), but were unlikely to have significant new findings. New findings were not more frequent in subjects with LBP episodes developing after minor trauma than when LBP developed spontaneously.Findings on MR imaging within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events. Primary radicular syndromes may have new root compression findings associated with root irritation.

Although many researchers and practitioners believe that patients' positive expectations of their treatment favorably influence clinical outcomes, there is little scientific evidence to support this belief.To describe the level of patients' initial confidence in the success of their assigned treatment, by treatment group and other factors; and to estimate the effects of treatment confidence on subsequent changes in low-back pain and related disability. STUDY DESIGN AND PATIENT SAMPLE: Randomized clinical trial involving 681 patients treated for low-back pain in a managed-care facility in Southern California.Treatment confidence; and changes in three clinical measures of low-back pain: average pain, most severe pain and back-pain-related disability.Patients were randomly assigned to one of four treatment groups: medical care with and without physical therapy, and chiropractic care with and without physical modalities. Information was collected by questionnaires at baseline, 2 weeks, 6 weeks and 6 months. Treatment confidence was measured just after randomization on a scale of 0 to 10.Treatment confidence was lowest, on average, for patients assigned to medical care only and highest for patients assigned to medical care plus physical therapy. Other predictors of high treatment confidence were having acute pain and being older, female and nonwhite. Although treatment confidence was only weakly associated with subsequent changes in low-back pain or disability in the total sample, high treatment confidence was associated with greater improvement among patients assigned to medical care plus physical therapy.Initial confidence in treatment for low-back pain varies by type of care and other factors. Higher confidence may have some beneficial effect on the course of low-back pain in certain patients, but this effect may depend on the type of interaction between client and provider.