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Background: Leg pain associated with walking is sometimes incorrectly attributed to hip osteoarthritis (OA) or lumbar spinal stenosis (LSS).Purpose: This study compared physicians' values of signs and symptoms for diagnosing and differentiating hip OA and LSS to their clinical utility.Study Design/setting: Musculoskeletal physicians were surveyed with online questionnaires. Patients were recruited from hip and spine specialty practices.Patient Sample: Seventy-seven hip OA and 79 LSS patients.Outcome Measures: Signs and symptoms of hip OA and LSS.Methods: Fifty-one of 66 invited musculoskeletal physicians completed online surveys about the values of 83 signs and symptoms for diagnosing hip OA and LSS. Of these, the most valued 32 symptoms and 13 physical examination items were applied to patients with symptomatic hip OA or LSS. Positive likelihood ratios (+LR) were calculated for each items' ability to differentiate hip OA from LSS, with a +LR>2 set as indicating usefulness for favoring either diagnosis. Positive LRs were compared with surveyed physicians' values for each test.Results: All symptoms were reported by some patients with each diagnosis. Only 11 of 32 physician-valued symptoms were useful for discriminating hip OA from LSS. Eight symptoms favored hip OA over LSS: groin pain (+LR=4.9); knee pain (+LR=2.2); pain that decreased with continued walking (+LR=3.9); pain that occurs immediately with walking (+LR=2.4); pain that occurs immediately with standing (+LR=2.1); pain getting in/out of a car (+LR=3.3); pain with dressing the symptomatic leg (+LR=3.1); and difficulty reaching the foot of the symptomatic leg while dressing (+LR=2.3). Three symptoms favored LSS over hip OA: pain below the knee (+LR=2.3); leg tingling and/or numbness (+LR=2.7); and some pain in both legs (+LR=2.5). Notable symptoms that did not discriminate hip OA from LSS included: pain is less while pushing a shopping cart (+LR=1.0); back pain (+LR=1.1); weakness and/or heaviness of leg (+LR=1.1); buttocks pain (+LR=1.2); poor balance or unsteadiness (+LR=1.2); pain that increased with weight-bearing on the painful leg (+LR=1.3), and step to gait on stairs (+LR=1.7). Consistent with physicians' expectations, 7 of 13 physical examination items strongly favored hip OA over LSS: limited weight-bearing on painful leg when standing (+LR=10); observed limp (+LR=9); and painful and restricted range-of-motion with any of five hip maneuvers (+LR range 21-99). Four of five tested neurological deficits (+LR range 3-8) favored the diagnosis of LSS over hip OA.Conclusions: There is substantial crossover of symptoms between hip OA and LSS, with some physician-valued symptoms useful for differentiating these disorders whereas others were not. Physicians recognize the value of the examination of gait, the hip, and lower extremity neurological function for differentiating hip OA from LSS. These tests should be routinely performed on all patients for which either diagnosis is considered. Awareness of these findings might reduce diagnostic errors. [ABSTRACT FROM AUTHOR]

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]

Objectives: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The purpose of this article is to disseminate the report of the National Institutes of Health (NIH) task force on research standards for cLBP. Methods: The NIH Pain Consortium charged a research task force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting. Results: The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved these recommendations, which investigators should incorporate into NIH grant proposals. Conclusions: The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of cLBP. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document and undergo continual improvement. [ABSTRACT FROM AUTHOR]

: Background contextPain anticipated before and induced by physical activities has been shown to influence the physical performance of patients with chronic back pain. Limited data exist as to the influence of treatment on this component of pain.: PurposeThis study attempted to determine if pain anticipated before and induced by physical activities was altered during an exercise-oriented physical therapy program for chronic back pain.: Study design/settingSubjects were recruited from three physical therapy sites with similar spine rehabilitation programs that used intense exercise delivered in a group format. During the recruitment period, 70 subjects with chronic low back pain and disability agreed to participate and complied with recommended treatments. The primary outcome measures were anticipated and induced pain as assessed by visual analog scales (VAS) during six tests of back flexibility and strength. Additional outcome measures included the performance levels of these six tests (trunk flexion, extension, straight leg raising, back strength, lifting from floor to waist and waist to shoulder height), global back and leg VAS and Oswestry Low Back Pain Disability Questionnaire scores.: MethodsAt evaluation for the spine rehabilitation programs, we recorded the anticipated and induced pain levels associated with the six tests of back function, the performance levels on each test and global pain and disability scores. Subjects then participated in the spine rehabilitation program that consisted of intense exercise delivered up to three times per week, for 2 hours over a period of 6 weeks. All outcome measures were reassessed at discharge. Pre- and posttreatment outcome scores were statistically compared using paired sample t tests and chi-squared test. Spearman correlation coefficients were used to compare anticipated and induced pain results with global back and leg pain VAS scores, Oswestry scores and physical performance levels for each physical test.: ResultsMost measures of anticipated and induced pain improved between evaluation and discharge. Improvements were noted for global back pain (p<.001), leg pain (p = .001), disability (p<.001) and performance on each physical testing (p<.001) after treatment. Performances on all physical testing correlated with anticipated and induced pain for all tests at evaluation but only for measures of flexibility at discharge. Improvements in global pain and disability correlated with improvements in anticipated and induced pain with physical testing.: ConclusionAnticipated and induced pain with physical activities was lessened after physical therapy using exercise. Anticipated and induced pain with physical activities related to physical performance levels, global pain and disability ratings. These findings may help explain how exercise exerts a positive influence on chronic back pain and disability. [Copyright &y& Elsevier]

: Background contextExercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work.: PurposeThe goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain.: Study design/settingA computerized literature search of MEDLINE was conducted using “exercise,” “fitness,” “back pain,” “backache” and “rehabilitation” as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article.: ResultsFor people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain–related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research.: ConclusionsExercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes. [Copyright &y& Elsevier]

The author discusses the aspects of low back pain and the effect of the Back Book on back pain related disability. He mentions that self-education has been used effectively through experiences, study and exposure to media such as the availabilioty of in formation from the world wide web. He is critical that cognition plays a vital role in back-pain-related disability and the efforts undertaken to influence cognition that might alter people's choices and improve disability.

Objective: Chronic back pain is common in the elderly population and can be treated with exercise. Long-term adherence to exercise recommendations has been documented in adults of <65 yrs of age but not for elderly adults. This study explored exercise behaviors of elderly adults with a history of chronic back pain before and 2 yrs after treatment in an exercise-oriented rehabilitation program. Design: This study utilized a case series design to survey 126 subjects >65 yrs old who underwent physical therapy during the year 2000 for complaints of chronic low back pain. Of these, 89 (70%) responded to the 2-yr questionnaire. Outcome measures included visual analog scale for pain, Oswestry disability questionnaires, back flexibility and strength, and a questionnaire exploring exercise behaviors. All subjects underwent a 6-wk physical therapy program that consisted of exercise coupled with advice to remain active. Results: Improvements in flexibility and strength occurred during treatment. Mean Oswestry disability scores (0-100 scale) improved from 32 to 20, and pain scores (0-10 scale) from 5.0 to 3.0 during treatment (P < 0.001) and were maintained at the 2-yr follow-up, regardless of exercise adherence. The percentage of patients who performed at least some exercise increased from 49% before treatment to 72% at the 2-yr follow-up. The changes in disability or pain observed during treatment did not influence exercise compliance. The most frequently stated reasons for non-adherence was that exercise did not help or aggravated pain (33%). For those who exercised regularly, 80% did so because of the health benefits from exercise. Conclusions: The exercise behaviors of many elderly adults with chronic low back pain can increase after an exercise-oriented spine physical therapy program. [ABSTRACT FROM AUTHOR]

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a research task force to draft standards for research on cLBP The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum data set to describe research participants (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The research task force believes that these recommendations will advance the field, help resolve controversies. and facilitate future research addressing the genomic, neurological, and other mechanistic substrates of cLBP We expect that the research task force recommendations will become a dynamic document and undergo continual improvement. Perspective: A task force was convened by the NIH Pain Consortium with the goal of developing research standards for cLBP. The results included recommendations for definitions, a minimum data set, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. [ABSTRACT FROM AUTHOR]