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Study Design: Prospective, longitudinal case-crossover study.Objective: The aim of this study was to determine whether physical activities trigger flare-ups of pain during the course of acute low back pain (LBP).Summary Of Background Data: .: There exist no evidence-based estimates for the transient risk of pain flare-ups associated with specific physical activities, during acute LBP.Methods: Participants with LBP of duration <3 months completed frequent, Internet-based serial assessments at both 3- and 7-day intervals for 6 weeks. At each assessment, participants reported whether they had engaged in specific physical activity exposures, or experienced stress or depression, during the past 24 hours. Participants also reported whether they were currently experiencing a LBP flare-up, defined as "a period of increased pain lasting at least 2 hours, when your pain intensity is distinctly worse than it has been recently." Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for associations between potential triggers during the past 24 hours, and the risk of LBP flare-ups, using conditional logistic regression.Results: Of 48 participants followed longitudinally, 30 participants had both case ("flare") and control periods and contributed data to the case-crossover analysis. There were 81 flare periods and 247 control periods, an average of 11 periods per participant. Prolonged sitting (>6 hours) was the only activity that was significantly associated with flare-ups(OR 4.4, 95% CI 2.0-9.7; P < 0.001). Having either stress or depression was also significantly associated with greater risk of flare-ups (OR 2.5, 95% CI 1.0-6.0; P = 0.04). In multivariable analyses, prolonged sitting (OR 4.2, 95% CI 1.9-9.1; P < 0.001), physical therapy (PT) (OR 0.4, 95% CI 0.1-1.0; P = 0.05), and stress/depression (OR 2.8, 95% CI 1.2-6.7; P = 0.02) were independently and significantly associated with LBP flare-up risk.Conclusion: Among participants with acute LBP, prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups. PT was a deterrent of flare-ups.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

Study Design. Case series. Objective. This study compared the locations of arm pain, sensory symptoms, and subjective complaints of arm weakness in patients with cervical radiculopathy from MRI confirmed C6 and C7 nerve root compression. Summary of Background Data. Cervical radiculopathy is defined as arm pain, sensory and motor symptoms caused by irritation of a cervical nerve root. The C6 and C7 roots are most commonly involved, and differentiating symptoms associated with each root has proven difficult. Cervical MRI allows accurate identification of nerve root compression and therefore makes it possible to explore symptom patterns that may differentiate C6 from C7 radiculopathy. Methods. A total of 122 patients with symptoms suggestive of cervical radiculopathy were recruited. Of these, 30 patients had MRI confirmed C6 and 39 patients C7 nerve root compression. By completing a study questionnaire, patients reported specific arm weakness, and marked the location of arm pain and tingling/numbness on graphic representations of the arm. Marked areas were interpreted by superimposing a grid that divided the arm into 54 distinct areas. The frequencies of reported symptoms with C6 and C7 were totaled and then compared with likelihood rations. Power analysis calculated that 27 patients would be needed in each group based on the assumption that a 30 percentage point difference in frequency of specific symptom would be clinically useful for differentiating C6 from C7 radiculopathy. Results. Arm pain and sensory symptoms were diffuse, and were not distinctly different for C6 or C7 radiculopathy. Some weakness was reported by 41 percent of patients, with specific descriptions of weakness having limited value for differentiating between radiculopathies. Conclusion. The location of pain and sensory symptoms, and specific weakness complaints associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting root involvement based on symptoms. [ABSTRACT FROM AUTHOR]

Background: Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery. Questions/purposes: We asked two research questions: (1) Does higher baseline leg pain intensity predict subsequent lumbar surgery? (2) Can other previously identified 'candidate' predictors of nonoperative treatment failure be replicated? Methods: Between January 2008 and March 2009, 154 participants with acute lumbosacral radicular pain were enrolled in a prospective database; 128 participants (83%) received nonoperative treatment and 26 (17%) received surgery over 2-year followup. Ninety-four nonoperative participants (73%) responded to followup questionnaires. We examined associations between previously identified 'candidate' predictors and treatment failure defined as (1) subsequent surgery; (2) persistent leg pain on a visual analog scale; (3) persistent disability on the Oswestry Disability Index; or (4) participant-reported lack of recovery over 2-year followup. Confounding variables including sociodemographics, clinical factors, and imaging characteristics were evaluated using an exploratory bivariate analysis followed by a multivariate analysis. Results: With the numbers available, higher baseline leg pain intensity was not an independent predictor of subsequent surgery (adjusted odds ratio [aOR], 1.22 per point of baseline leg pain; 95% confidence interval [CI], 0.98-1.53; p = 0.08). Prior low back pain (aOR, 4.79; 95% CI, 1.01-22.7; p = 0.05) and a positive straight leg raise test (aOR, 4.38; 95% CI, 1.60-11.9; p = 0.004) predicted subsequent surgery. Workers compensation claims predicted persistent leg pain (aOR, 9.04; 95% CI, 1.01-81; p = 0.05) and disability (aOR, 5.99; 95% CI, 1.09-32.7; p = 0.04). Female sex predicted persistent disability (aOR, 3.16; 95% CI, 1.03-9.69; p = 0.05) and perceived lack of recovery (aOR, 2.44; 95% CI, 1.02-5.84; p = 0.05). Conclusions: Higher baseline leg pain intensity was not confirmed as a predictor of subsequent surgery. However, the directionality of the association seen was consistent with prior reports, suggesting Type II error as a possible explanation; larger studies are needed to further examine this relationship. Clinicians should be aware of potential factors that may predict nonoperative treatment failure, including prior low back pain or a positive straight leg raise test as predictors of subsequent surgery, workers compensation claims as predictors of persistent leg pain and disability, and female sex as a predictor of persistent disability and lack of recovery. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Study Design. Comparative study using combined data from 2 prospective cohort studies. Objective. To expose the differences between the clinical characteristics of neurogenic claudication from magnetic resonance image-documented lumbar spinal stenosis (LSS) and lumbosacral radicular syndrome from acute, magnetic resonance image-documented, lumbar disc herniation (LDH). Summary of Background Data. LSS and LDH are the common lumbar disorders that produce lower extremity pain. Though known factors such as pain induced by walking for LSS and the rapid onset of symptoms for LDH are useful for differentiating these disorders, exploration of differences in other factors has received limited study. Methods. This study included participants aged 60 yr or older from 2 previous studies. One examined walking limitations caused by LSS and the second the natural history of LDH in elderly adults. The clinical features of both groups were compared by calculating means, medians, and standard deviations for continuous variables, and frequencies for categorical variables. χ² test was used to explore differences between LSS and LDH for categorical variables, and Student t test or Mann-Whitney test for continuous variables. Results. Participants with LSS had more medical comorbidity, less intense leg pain, and less disability than those with LDH. Leg pain was more common in the anterior thigh, anterior knee and shin in LDH, and in the posterior knee in LSS. Trunk flexion was more impaired in LDH. Positive straight leg raising and femoral stretch signs were common in LDH, and rare in LSS. Abnormal Achilles reflexes were noted more frequently in LSS. Conclusion. In addition to established factors, greater leg pain intensity, greater disability, and pain in the anterior leg are more common in the elderly with LDH than in the elderly with LSS. Normal trunk flexion, absence of nerve root tension signs and abnormal Achilles reflexes are more common in LSS. [ABSTRACT FROM AUTHOR]

The article discusses a study on the performance characteristics of single physical examination on patients with lumbosacral radicular pain using magnetic resonance imaging (MRI) on midlumbar, low lumbar and level-specific nerve root impingement. Patients with lower extremity radiating pain for less than 12 weeks were eligible to participate. It concludes that physical examination can provide useful diagnostic information for detecting midlumbar, low lumbar and level-specific nerve root impingement on MRI.

It is now 2 decades since Mayer et al published their Volvo Award-winning paper entitled "Objective assessment of spine function following industrial injury: a prospective study with comparison group and one-year follow-up." Their landmark paper reported that return to work rates of patients that underwent a "functional restoration" treatment program were double that of a comparative group of patients that were denied treatment by their insurers. These results were considered extraordinary and inspired both debate and enthusiasm. Our goal is to review this landmark study, report on its strengths and weaknesses, and review the studies that have attempted to replicate this work in other settings. We also highlight its contribution to our current knowledge about the treatment of back pain and disability. The major weaknesses of the paper of Mayer et al are the possibility of selection bias in the development of their cohort of patients and the lack of a true randomized controlled study design. These factors may have inflated the rates of return to work. Regardless, their reported results were robust, and cannot be easily dismissed. During the last 20 years, this treatment model has received considerable study worldwide, and it is generally agreed that it is superior to standard care for reducing work absence in patients with chronic low back pain. Additionally, the concepts underlying functional restoration have been found to be highly relevant to patients with chronic low back pain, medical providers, and disability systems and continue to gain acceptance and integration into the care of patients throughout the industrialized world.

Study Design: Consecutive case series of patients with C6 and C7 radiculopathies., Objectives: To explore the clinical utility and reliability of manual muscle testing of forearm pronation strength in C6 and C7 radiculopathies., Summary of Background Data: EMG evidence of denervation of the pronator teres was the most common finding in C6 radiculopathies, and frequently present in C7 radiculopathies. Clinical evaluation of the pronator teres through manual muscle testing of forearm pronation has never been explored; therefore, its clinical utility is unknown as compared with the muscle groups that are traditionally evaluated., Methods: Fifty-five subjects with diagnostic imaging evidence of either C6 (n = 25) or C7 (n = 30) cervical root compression and clinical symptoms consistent with cervical radiculopathy were recruited for this study. These subjects underwent manual muscle testing of forearm pronation, wrist extension, elbow flexion, and elbow extension. The frequency of impaired strength was recorded and compared for C6 and C7 radiculopathies. A second examiner evaluated each subject, with his or her findings compared with the first examiner only for the determination of interrater reliability., Results: In C6 radiculopathy subjects, forearm pronation weakness was present in 72%, was twice as common as wrist extension weakness, was present in all cases where elbow flexion or wrist extension weakness was noted, and was found in all but 2 subjects where elbow extension weakness was present. In C7 radiculopathy subjects, forearm pronation weakness accompanies elbow extension weakness in 23% of subjects and was the only weakness in 10% of subjects. Manual muscle testing demonstrated adequate interrater reliability., Conclusions: Forearm pronation weakness is the most frequent motor finding in C6 radiculopathies and may be noted is some cases of C7 nerve root compression.

Study Design: Literature review., Objectives: To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area., Summary of Background Data: While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients' general health, employment, and financial well-being., Methods: Medical literature search., Results: Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients' desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients' requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians., Conclusions: Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.

Study Design: This prospective cohort study evaluated four office tests of quadriceps strength in symptomatic adults with radiographic evidence of L3 or L4 nerve root compression., Objective: The study observed the performance of each test for its ability to detect quadriceps weakness when compared to the asymptomatic side. To determine the potential influence of radicular pain on the performance of the four tests, a control group of patients over the age of 40 with clinical and radiographic L5 or S1 radiculopathies underwent identical testing of quadriceps strength., Summary of Background Data: The L3 and L4 nerve roots innervate the quadriceps; therefore, quadriceps weakness may be a consequence of L3 or L4 radiculopathies. There are no standardized or validated methods to evaluate quadriceps strength in the clinical office setting. This may lead to inconsistent detection by clinicians of quadriceps weakness in cases of L3 or L4 radiculopathy., Methods: Thirty-three consecutive patients with L3 or L4 radiculopathies and 19 with L5 or S1 radiculopathies were studied. The four tests of quadriceps strength included: 1) single leg sit-to-stand test; 2) step-up test; 3) knee-flexed manual muscle testing; and 4) knee-extended manual muscle testing. Results from a second examiner repeating the four tests were used to calculate interrater reliability., Results: In L3 and L4 radiculopathies, unilateral quadriceps weakness was detected by the single leg sit-to-stand test in 61%, by knee-flexed manual muscle testing in 42%, by step-up test in 27% and by knee-extended manual muscle testing in 9% of patients. The sit-to-stand test detected weakness in all but one case when weakness was detected by another test. All patients with L5 or S1 radiculopathies could perform the sit-to-stand test. Kappa coefficient was high for sit-to-stand test (0.85), step-up (0.83), and knee-flexed manual muscle testing (0.66), and low for knee-extended manual muscle testing (0.08)., Conclusion: In L3 and L4 radiculopathies, unilateral quadriceps weakness was best detected by a single leg sit-to-stand test. Patients of similar age with radicular pain caused by L5 or S1 radiculopathies could perform this test. As the interrater reliability of the single leg sit-to-stand test is high, clinicians should consider utilizing this test for assessing quadriceps strength in cases of L3 and L4 radiculopathies.