White-paper

Evidens i det vi foretager os indenfor behandling af muskelo- skeletale problemstillinger er et must. Mængden af kvalitets- studier indenfor behandling af muskelo- skeletale smerter, inklusiv rygsmerter, tvinger betalere og behandlere til at genoverveje pålidelighed i de strategier, der anvendes for at hjæpe patinter. Det er overordentlig vigtigt, at den kliniske undersøgelse og behandlingsproces, der benyttes for at løse disse problemer har reliabilitets- og validitets- studier, der støtter disse. Mekanisk Diagnostik og Terapi (MDT) er den mest undersøgte konservative metode over de sidste 20 år og har vist klinikske outcomes, der yderligere understøtter empiriske data i videnskabelige undersøgelser.

Både betalere og klinikere, der har ansvar for varetagelse af muskulo-skeletale skader, bør bedre kunne forstå de foreliggende data, der viser, at der findes kliniske undersøgelser der er inter og intra-tester pålidelige. Desuden, at det er muligt med pålidelighed, at klassifikere patienter i undergrupper, der vil have gavn af konservativ behandling versus de, der ikke vil. At forebygge tilbagefald ikke er så svært, som mange tror, og at der er pålidelige måleredskaber til at holde øje med kort og langtids effekter.

Det følgende er taget fra engelsk:

The following compilation of scientific literature is the best available evidence supporting these claims and we believe reveals the first and only opportunity to attain a goal sought for years in the world That goal is controlling medical costs, reducing lost time indemnity claims and reducing recurrence while protecting the rights of the injured through best clinical practice. . The articles have been published in what most scientists and clinicians view as the most well respected peer‐review journals in regard to management, treatment and prevention of spinal injury. The data is divided into sections that reveal the natural history, incidence, cost ‐trends, reliability/validity of the assessment, treatment classification, outcome assessment tools and prophylaxis of spinal pain. The final section reveals the clinical data from a pilot program with MDT which is the first relationship between payer and clinician that assessed utilization, outcomes, recurrence and further care seeking as well as patient/member satisfaction with care.

Natural History and Incidence Studies

Von Korff M, et al., Back pain in Primary care. Outcomes at 1 year. Spine, 1993. 18(7): p. 855‐62

The goal of this study was to improve the understanding of the outcomes of back pain in primary care patients. Outcomes at 1 year were described in terms of severity of pain and total days of back pain over a 6 month period. Improvement in pain status was then related to change in depressive symptoms.

1128 patients were studied 1 year after seeking care for low back pain. Pain status and disability were assessed using the following measures of pain intensity, persistence and onset recency:At 1 year follow‐up 69% of recent onset patients (pain that began within 6 months of assessment) reported pain in the previous month compard to 82% in the prevalent patient group (patients with onset longer than 6 months prior to assessment). 46% of the prevalent group versus 36% of recent onset reported pain on more than 30 days in the previous 6 months. Nearly 35% of patients reported a fair‐poor outcome at 1 year which indicated high disability with moderate to severely limiting pain on self report scales.

Von Korff M and Saunders K, The Course of Back Pain in Primary care. Spine, 1999. 21: p. 2833‐2837.

This study was a review paper of outcome studies among primary care patients. It was designed to determine short and long term pain and functional outcomes of patients with back pain seeking treatment in primary care. Short‐term course referred to pain and function limitations in the first three months after initial visit and long term‐course referred to the pain and function loss after three months.

Results from the short –term course reveal that 66‐75% continue to experience at least mild back pain at follow‐up with some form of interference with function, 33% will continue to suffer from moderate to severe pain with substantial limitations to function. The single most important measure for back pain and associated disability is the extent of activity limitation or interference with daily activitites.

Results from the long=term course reveal that 15‐20 % with back pain continue to suffer moderate to severe restrictions of activity limitation at 1 year follow‐up and 33% continue to suffer from back pain of at least moderate intensity.

Results of the review show that back pain in primary care patients typically exhibits a recurrent pattern characterized by variation and change, rather than an acute, self‐limiting course.

Croft P, Mcfarlane G, Outcome of low back pain in general practice: a prospective study. British Medical Journal, vol. 316:1356‐9, May 1998.

This was a prospective study of adults consulting a general practice for low back pain over a 12 month period. Follow up occurred at 1 week, 3 months and 12 months post consultation.There were 490 subjects (203 men, 287 women) aged 18‐75. Main outcomes measures were patients who had ceased to consult after three months, proportion who were free of pain and back related disability at 3 and 12 months.

463 patients consulted for a new episode of low back pain with only 275 attending a single consultation and 150 attending at least a second or repeat consultation confined to the three months after initial consult. However, of those interviewed at 3 and 12 months follow up, only 21% and 25% respectively had completely recovered in terms of pain and disability.Study also revealed that those with a prior history of back pain episodes were at greatest risk of a second episode and that by age 30 almost half the population will have experienced a substantive episode of low back pain.Also quite striking was the fact that more than 90% of patients stopped consulting for care after 3 months even though they continued to experience significant pain and disability.

Roland M, Morris R, A study of the natural history of low back pain. Spine vol. 8, p. 145‐150, 1983.

The 1982 Volvo Award Winner in Clinical Science and recognized by most experts as the definitive paper regarding natural history. It is a prospective study of 230 episodes of lower back pain presenting in primary care. Aims of the study were, first, to describe the natural history of low back pain presenting in primary care; second, to identify, from a wide range of items of history and physical signs at presentation, those features which were most strongly predictive of outcome, and third, to develop and validate sensitive methods of measuring the outcome of episodes of low back pain and to compare with conventional methods of measuring outcome.

Two hundred thirty‐seven patients consulted with 252 episodes of back pain during the study year. Mean age of the sample was 40.6 years. 61% reported improvement in their disability scores during the first week with 27% reporting an increase in disability during the first week. Over the next three weeks 62% of patients reported improvement in disability scores, but 22% reported and increase. Features not related to poor outcome included age, height, weight, obesity and the primary site of pain.

In conclusion, it is not possible to make a firm diagnosis of the cause of the pain and the natural history is extremely variable. Some patients are better after a few days but many still report pain and loss of function years later. It is unlikely that any particular treatment will show a major effect when applied indiscriminately to all patients with low back pain.

Cost Trends in Occupational Management of Low back Pain

Gatchel R, Polatin P, Treatment and Cost Effectiveness of Early Intervention For Acute Low‐Back Pain Patients: A One Year Prospective Study. Journal of Occupational Rehabilitation, vol. 13, no. 1, March 2003.

Major goal of this study was to evaluate clinical effectiveness of an early intervention program with high risk patients to prevent the development of chronic disability. 700 patients with acute low back pain were screened for high risk versus low risk. The high risk group was randomized into two treatment groups: a functional restoration early intervention group(n=22) or a nonintervention group(n=48). A group of low risk subjects(n=54) who did not receive any early intervention were also evaluated. All these groups were then prospectively tracked at 3 month and 12 month follow up from their initial evaluation.

At 12 month follow up 91% of the intervention group had returned to work versus 69% of the non‐ intervention group. 87% of the low‐risk group had returned. There was an average of 38.2 disability days due to back pain in the intervention group versus 102.4 in the non‐intervention and 20.8 in the low risk group. Cost‐ comparison savings data were also quite impressive.The intervention group had an average of $12,721 per case when medical costs and indemnity were included versus the non‐intervention group with an average of$ 21,483.

The results clearly demonstrate the need for early conservative care intervention in episodes of acute low back pain.

Williams D, Feuerstein M, Health care and Indemnity Costs Across the Natural History of Disability in Occupational Low Back Pain. Spine 1998:23:2329‐2336.

The administrative database maintained by the National Council on Compensation Insurance was used to compare health care use and indemnity costs within the natural history of work related low back pain disability. 520 claims with an ICD code associated with low back pain were examined. All cases involved lost time claims and were classified as a temporary total disability. Claimants were divided into four groups based upon length of time they were receiving indemnity payments for lost time at work(<30 days, 30‐90 days, 91‐180 days and > 180 days). Health care services were then categorized into multiple service types as follows: 1) diagnostic procedures, 2) medication, 3) surgery, 4) hospital charges, 5) miscellaneous medical, 6) physical/occupational therapy, 7) mental

health, 8) chiropractic and 9) miscellaneous non medical health costs. Indemnity and health care costs at each week of disability were calculated for the entire sample and number of claimants at each week determined.

The pattern of disability was as follows: 100% had at least one day of disability, 50% remained work disabled at one month, 34% at 2 months, 25%at 3months, 20% at 4 months, 16% at 5 months and 13% at 6 months. Total healthcare and indemnity costs for this sample was $4.25 million dollars. The 50 that remained work disabled for less than 1 month only consumed 12% of the resources. Those at 2 months and 3 months consumed another 32% of the resources. Thus 80% of the individuals in the study only consumed 40% of the resources. The remaining 20%, or those disabled 4 months or more consumed the remaining 60% of healthcare resources.

The top three expenditures across the disability curve were diagnostics, surgery and physical therapy, representing 66% of the cost.

Stewart W, Ricci J, Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce. JAMA, November 12, 2003—vol. 290, no. 18, pg. 2443‐2454.

Cross sectional study using data from the American Productivity Audit which was a random sample of 28902 workers interviewed between, August 2001 and July 2002. Lost productive time due to common pain conditions(arthritis, back, headache and other musculoskeletal) expressed in hours per worker per week calculated in US dollars.

13% of the total workforce experienced a loss in productive time during a 2 week period due to a common pain condition. Headache was the most common condition pain condition (5.4%) followed by back pain (3.2%), arthritis pain (2.0%) and other musculoskeletal (2.0%). Workers who experienced lost productive time from a pain condition lost a mean of 4.6 hours/week. Workers with arthritis or back pain had an average loss of 5.2 hrs/week.The majority (76.6%) of the lost productive time was explained by reduced performance while at work and not work absence.

Wasiak R, JaeYoung K, Work Disability and Costs Caused by Recurrence of Low Back Pain: Longer and more costly than in First Episodes. Spine vol. 31, no. 2, pp. 219‐225, 2006.

Retrospective analysis of workers compensation claims data for non‐specific low back pain injuries. Study was designed to examine whether recurrence substantially contribute to total medical and indemnity costs, and total duration of work disability/ 1867 lost time claims that reported to a large WC provider in New Hampshire.

The recurrence rate for work disability was 17.2%, whereas the recurrence rate for those seeking care was 33.9%. Median total duration of work disability was 141 days for those with both types of recurrences, 52 days with only recurrence of work disability, 26 days for individuals with recurrence of care only, compared to only 10 days for those without recurrence.

Evidence‐Based Care/Mechanical Diagnosis and Therapy

1)Interexaminer Reliability of Low Back Pain Assessment Using the McKenzie Method, Kilpikoski S., Airaksinen O., Spine 2002, vol. 27, no. 8, pp. E207‐214.

A test‐retest design was used to assess interexaminer reliability of the McKenzie method for performing clinical tests and classifying patients with low back pain (LBP). For this study, 39 volunteers with LBP, mean age of 40 (range, 24‐ 55 years), with or without radiation of pain to the lower limb, were randomly drawn from a larger study at Kuopio University Hospital in Kuopio, Finland. Subjects had experienced chronic LBP for greater than 3 month’s duration and moderate functional disability which allowed them to work with occasional absences.

Before entering the study, participants were assessed medically, first by a general practitioner, and second by a physiatrist. After this, each subject was assessed by both physical therapists independently. The 2 physical therapists were highly trained in MDT (Mechanical Diagnosis & Therapy). They were diploma and credentialed in McKenzie method.

Results of the study suggest that interexaminer reliability in performing clinical tests and classifying patients with LBP into the McKenzie syndromes is high when the therapists have been trained in the McKenzie method. The reliability was best in defining the centralization phenomenon, directional preference, and relevance of a lateral shift. Reliability was good in determining main syndromes and subgroup classification. With defining the lateral component reliability was moderate.

Conclusion: Interexaminer reliability of the McKenzie lumbar spine assessment in performing clinical tests and classifying patients with low back pain into syndromes were good and statistically significantly when the examiners had been trained in the McKenzie method.

2)Centralization Phenomenom as a Prognostic Factor for Chronic Low Back Pain and Disability,Werneke M., Hart D., Spine 2001, vol. 26, no. 7, pp. 758‐765.

Two hundred twenty‐three consecutive adults with acute LBP with or without referral of leg pain were treated conservatively and followed for 1 year. The design of the study was prospective and the authors investigated whether dynamic assessment of changes in clinical measures during treatment could be used to classify patients and predict occurrence of chronic pain or disability.

Patients received a mechanical evaluation by one of five physical therapists trained in McKenzie evaluation and treatment methods. Pain location changes to mechanical evaluation/treatment were recorded at every visit. Patients were place in two groups: 1) those with pain that did not centralize and 2) those that completely centralized or demonstrated partial reduction of pain location with time. All treatments were individualized and based on McKenzie methods. Patients were contacted twelve months after discharge.

Being classified in the noncentralization group was a predictor of those who did not return to work, continued to report pain symptoms, had extended activity interference or downtime at home, and continued to use health care resources at 1 year. Conversely, those who centralized had a good outcome.This study provides evidence that mechanical evaluation based on McKenzie assessment methods and classification into categories based on this evaluation were significant in identifying patients who failed to respond to early, active rehabilitation and who developed chronic disability.

Conclusion: Dynamic assessment of change in anatomic pain location during treatment and leg pain at intake were predictors of developing chronic pain and disability.

3) Centralization: Its Prognostic Value in Patients With Referred Symptoms and Sciatica, Skytte L., May S., Spine 2005, vol. 30, no. 11, pp. E293‐299.

This prospective, comparative cohort study was designed to investigate the prognostic significance of centralization in patients with subacute sciatica and referred symptoms.

Previous studies have shown that centralization occurs commonly in the nonspecific low back population, and its occurrence is associated with a good prognosis. The phenomenon has never been evaluated in a population with sciatica and referred symptoms.

The sample pool was 104 consecutive patients referred for investigation of possible disc herniation. Of these patients, 60 were recruited into the study and underwent standardized mechanical evaluation (McKenzie method) using repeated end‐range movements, while symptom response was monitored to expose 2 groups: centralization group (CG) and noncentralization group (NCG). All patients were treated in the same way and were followed for one year. If patients did not have improvement surgery was considered.

There were 25 patients who were classified in the CG, 35 in the NCG, and other baseline characteristics were similar between groups. At 1, 2, and 3 months, the CG had significantly better outcomes than the NCG. At 2 months, the CG had more improvements in leg pain (P = 0.007), disability (P = <0.001), and Nottingham Health Profile (P = 0.001). After 1 year, disability was less in the CG (P = 0.029). In the CG, 3 patients underwent surgery, in the NCG, 16 (P = 0.01). The odds ratio for surgery in the NCG was 6.2.

Patients with centralization are 6 times less likely to require surgical intervention compare to those who do not centralize.

Conclusion: Patients with sciatica and suspected disc herniation who have centralization response to mechanical evaluation will have significantly better outcomes. Patients who do not exhibit centralization are 6 times more likely to have surgery.

4)Conservative Treatment of Acute Low Back Pain, Stankovic R., Johnell O., Spine 1995, vol. 20, no. 4, pp. 469‐472.

This prospective, randomized trial was carried out at the Department of Orthopedics, Lund University, in Malmo, Sweden. The authors wanted to compare the McKenzie method of treatment of acute low back pain with patient education in “mini back school” after 5 years; the 1‐year results have already been published.

The 5‐year results after the initial treatment are presented in this study of 89 subjects. Included in the study were 22 women and 67 men with an average age of 39.6 +/‐ 10.5 years (range 22‐66 years).

Sixty‐two subjects (70%) were interviewed by telephone, while the remaining 27 subjects (30%) were examined and interviewed personally. Information of sick leave was obtained from the Swedish National Health Insurance Office.

The results showed that subjects who received treatment according to the McKenzie method 5 years earlier had significantly less recurrences of pain and fewer were on sick leave compared with the subjects who received education in mini back school.

Conclusions: : The patients who received treatment according to the McKenzie Method 5 years earlier hadsignificantly less recurrences of pain and had significantly less sick leave.

5)Does it Matter Which Exercise?, Long, A. , Donelson, R., Fung, T. , Spine 2004, vol. 29, no. 23, pp. 2593‐2602.

This multicentered randomized controlled trial involved a total of 312 acute, subacute, and chronic patients, including LBP‐only and those with sciatica. They all underwent a standardized mechanical evaluation using the McKenzie Method. Twelve physical therapist form 5 different countries contributed to the study; they were all credentialed or diplomats in the McKenzie method.

The objective of the study was to determine if previously validated low back pain (LBP) subgroups respond differently to contrasting exercise prescriptions.

Following the mechanical evaluation subjects were classified by their pain response, specifically eliciting either a “directional preference” (DP) (i.e., an immediate, lasting improvement in pain from performing either repeated lumbar flexion, extension, or sideglide/rotation tests), or no DP. Only DP subjects were randomized to: 1) directional exercises “matching” their preferred direction (DP), 2) exercises directionally “opposite” their DP, or 3) “nondirectional” exercises.

Outcome measures included pain intensity, location, disability, medication use, degree of recovery, depression, and work interference.

A DP was elicited in 74% (230) of subjects. One third of both the opposite and non‐directionally treated subjects withdrew within 2 weeks because of no improvement or worsening (no matched subject withdrew). Significantly greater improvements occurred in matched subjects compared with both other treatment groups in every outcome (P values <0.001), including a threefold decrease in medication use.

Conclusions: Consistent with prior evidence, a standardized mechanical assessment identified a large subgroup of LBP patients with a DP. Regardless of subjects’ direction of preference, the response to contrasting exercise prescriptions was significantly different: exercises matching subjects’ DP significantly and rapidly decreased pain and medication use and improved in all other outcomes.

6)A prospective Study of Centralization of Lumbar and Referred Pain: A predictor of Symptomatic Discs and Anular Competence, Donelson, R., Aprill, C., Metcalf, R., Grant, W., Spine 1997, vol. 22, no 10, pp. 1115‐ 1122.

This study included 63 patients with chronic low back pain (LBP) with a majority experiencing pain below the knee. All were referred for discography by neurosurgeons, orthopedists and physiatrists. Sixty‐nine percent of the patients were not working as a result of their pain.

This prospective, blinded study of patients with chronic LBP sought to evaluate the existence of a relation between rapidly centralizing, peripheralizing, or abolishing low back and radiating pain, as identified during a

McKenzie mechanical lumbar assessment. This was then compared with pain provocation and anular competence findings of discography.

Centralization of referred pain has been reported as a very common occurrence during McKenzie assessment and treatment. Patients whose pain centralizes have been shown to achieve superior treatment outcomes. A dynamic internal disc model has been hypothesized as an underlying mechanism for centralization that has not been studied previously.

Patients with chronically disabling low back pain who were referred for discography underwent preliminary blinded McKenzie clinical assessment and were categorized into three groups by their pain response. Patterns, or lack thereof, of pain response were then compared with blinded discographic pain provocation and anular findings.

During the McKenzie assessment, the referred pain of 50% centralized with 74% having positive discograms, of which 91% had an intact anulus. The pain of 25% peripheralized only (would not centralize); 69% of these had positive discograms, but only 54% had an intact anulus. The distal pain of 25% did not respond at all, and only 12.5% of these had positive discograms.

This study of nonherniated discs in a chronic, out‐of‐work patient population strongly supports that a noninvasive, low‐tech, relatively inexpensive clinical assessment using repeated end‐range lumbar test movements can provide considerably more relevant information than imaging studies.

Conclusion: The McKenzie assessment process reliably differentiated discogenic from nondiscogenic pain (P < 0.001) as well as competent from an incompetent anulus (P < 0.042) in symptomatic discs and was superior to magnetic resonance imaging in distinguishing painful from nonpainful discs.

7)The Use of Lumbar Extension in the Evaluation and Treatment of Patients With Acute Herniated Nucleus Pulposus, Kopp, J., Alexander, A., Turocy, R., Levrini, M., Lichtman, D., Clinical Orthopaedics and Related Research 1986, No.202, pp. 211‐218.

This retrospective study evaluated the clinical response of patients with acute discogenic low back pain to extension therapy; if the ability to gain early extension is a reliable, early predictor of short‐term positive response to conservative care; and to delineate whether absence of this response has any correlation with surgical findings.

Many patients with acute herniated nucleus pulposus can be expected to resolve their conditions with conservative management. To date, however, no reliable sign has been described in the literature that can predict which patient will respond. This report shows that the ability to achieve normal lumbar extension represents such a sign.

Of 67 patients who met the criteria for inclusion in the study, 35 patients were treated without operation; 97% were able to achieve normal lumbar extension within three days of admission to the hospital.

Thirty‐two patients underwent laminectomy and discectomy because they failed to improve with conservative measures. Of these patients, only two (6%) were able to achieve normal lumbar extension preoperatively. Furthermore, some of these patients responded so dramatically to extension therapy that the use of extension exercises as a therapeutic modality is recommended.

In this series, patients who could achieve normal, end‐range, passive extension did not require surgery. Conversely, those who could not achieve normal, end‐range, passive extension required surgery and had a high incidence of free disc fragments or nerve root displacement at the time of surgery.

Conclusion: This report shows that the ability to achieve normal lumbar extension represents a reliable sign that patients with an acute HNP will respond to conservative treatment. Of the patients that met the criteria for the study, (67), 35 were treated without operation and 97% of those were able to achieve normal lumbar extension within three days of admission to the hospital. Some of the patients responded so dramatically to extension therapy that the use of extension exercises as a therapeutic modality is recommended.

8)Non‐operative management of Herniated Nucleus Pulposus: Patient Selection by the Extension Sign‐Long Term Follow‐up, Alexander, A., Jones, A., Rosenbaum, D., Orthopaedic Review 1992, Vol 21, No 2, pp. 181‐ 188.

In this retrospective study of 73 patients the value of end‐range, passive lumbar extension was investigated as a simple prognostic test. All patients had low back pain and pain extending below the knee, and all had at least one sign of nerve‐root irritation.

We have previously reported that the ability of patients with herniated nucleus pulposus (HNP) and radiculopathy to achieve full passive lumbar extension (negative extension sign) is a useful predictor of favorable response to conservative management. Of 154 patients with back pain and radiculopathy seen between 1979 and 1985, 73 were selected for conservative management based on this criterion.

We also reviewed results of electromyography (EMG), computed tomography (CT), myelography, straight leg raise, crossed straight leg raise, deep tendon reflex, and dermatomal‐sensory and motor deficits. Ninety‐four percent of the subjects achieved full extension within 5 days of hospital admission. Although some patients who had full extension on admission subsequently underwent chemonucleolysis or surgery, none of those who could not extend initially and who later gained full lumbar extension required surgery.Of the 33 patients who were available for long‐term follow‐up, 94% were satisfied with the results, 82% were able to resume working, 73% required no analgesics, and 9% later required chemonucleolysis or surgery. Positive findings on admission EMG (5 of 7 patients), myelography (5 of 8 patients), or CT (9 of 11) did not preclude good results with conservative management. Female patients without complaint at follow‐up (53%) outnumbered their male counterparts (25%).

Patients (19 of 33) whose extension sign was initially positive on admission and became negative within 5 days of hospitalization (average, 1.6 days) had better outcomes with 95% satisfied, 90% without job changes, 74% not requiring analgesia, and none requiring surgery.

At long‐term follow‐up, the extension sign effectively predicted a favorable response to nonoperative therapy of HNP in 91% of cases. Moreover, an extension sign that changed acutely from positive to negative strongly predicted successful non‐surgical management (100%).

Conclusion: At long term follow‐up, the extension sign effectively predicted a favorable response to nonoperative therapy of HNP in 91% of the cases. An extension sign that changed acutely from positive to negative strongly predicted successful nonsurgical management.

9)Diagnosing Painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests, Laslett, M., Young, S., Aprill, C., McDonald, B., Australian Journal of Physiotherapy 2003, Vol. 49, pp 89‐97.

Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards.

The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded con‐current criterion‐related validity design study, 48 patients with chronic lumbo‐pelvic pain referred for diagnostic spinal injection procedures were examined using the McKenzie method of spinal assessment and received diagnostic intra‐articular sacroiliac joint injections.

The centralization and peripheralization phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process.

Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97 (2.70 to 20.27) respectively.

This study provides evidence that SIJ pain provocation tests used within the context of a specific clinical reasoning process can enable the clinician to differentiate between symptomatic and asymptomatic SIJs in the majority of cases.

Conclusion: The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints.

MRI and Its Diagnostic Utility 1)Acute Low Back Pain and Radiculopathy: MR imaging Findings and Their Prognostic Role and Effect on

Outcome; Modic M, Obuchowski N., Brant‐Zawadzki M; Radiology, 2005; 237:597‐604.

PURPOSE: To prospectively determine in patients with acute low back pain (LBP) or radiculopathy, the magnetic resonance (MR) imaging findings, prognostic role of these findings, and effect of diagnostic information on outcome.

MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. This study was HIPAA compliant. A total of 246 patients with acute‐onset LBP or radiculopathy were randomized to either the early information arm of the study, with MR results provided within 48 hours, or the second arm of the study, where both patients and physicians were blinded to MR results, unless this information was critical to patient care. Patients underwent 6 weeks of conservative care. Roland function scoring, visual pain analog, Short Form 36 health status survey, self‐efficacy scoring, and a fear avoidance questionnaire were completed at presentation; at 2‐, 4‐, 6‐, and 8‐week follow‐up; and at 6‐, 12‐, and 24‐month

follow‐up. A second MR imaging examination was performed at 6‐week follow‐up. Multivariate logistic regression analysis was used to determine which imaging and nonimaging variables can be used to predict improvement in Roland function and patient satisfaction. The _2 test and repeated‐measures analysis of variance were used to compare outcome of blinded and unblinded patients.

RESULTS: Herniation was identified in 60% (n _ 147) of patients at the initial examination. The prevalence of herniations in patients with LBP (57%) (n _ 85) and those with radiculopathy (65%) (n _ 62) were similar (P _ .217), although patients with radiculopathy were more likely to have stenosis and nerve root compression (P _ .006). There was no relationship between herniation type, size, and behavior over time with outcome. An improvement of 50% or more in Roland function score at 6‐week follow‐up occurred 2.7 times as often among patients with a herniation at baseline (P _ .003). Improvement at 6‐week follow‐up was similar in unblinded (60%) (n _ 55) and blinded (67%) (n _ 57) patients (P _ .397). Self‐efficacy, fear avoidance beliefs, and the Short Form 36 subscales were similar for blinded and unblinded patients. CONCLUSION: In typical patients with LBP or radiculopathy, MR imaging does not appear to have measurable value in terms of planning conservative care. Patient knowledge of imaging findings does not alter outcome and is associated with a lesser sense of well‐being

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2)Are “Structural Abnormalities” on MRI a contraindication to the Successful Conservative Treatment of a Chronic Nonspecific Low Back Pain, Kleinstuck F, Dvorack J, Mannion A, Spine vol. 31(19), September 2006, pp. 2250‐2257.

A prospective study designed to examine the association between structural abnormalities on imaging and outcome after evidence‐based conservative treatment in patients with chronic non‐specific low back pain. Fifty‐three patients with chronic LBP underwent MRI before a 3 month program of exercise therapy. Back pain and disability scores were obtained before and after therapy and 12 months later. The improvements were examined in relation to the presence or absence of baseline MRI “abnormalities”.

Eighty‐nine percent of patients had severe disc degeneration, 74% had disc bulging, 60% had high intensity zones and 62 had endplate/bone marrow changes in at least 1 lumbar segment. Only 11% had no changes at any level. The MRI abnormalities showed only minimal association with baseline symptoms.

Conclusion. In the patient group examined, the presence of common “structural abnormalities” on MRI had no significant negative influence on the outcome after therapy.

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3)Severity of Symptoms and Signs in Relation to MRI Findings Among Sciatic Patients, Karppinen J, Malmivaara A, Tervonen O, Spine 2001, vol. 26, number 7, pp E149‐154.

A cross sectional study designed to evaluate the roles of nerve root entrapment‐‐ based on MRI‐‐ and other discogenic pain mechanisms on disability and physical signs among sciatic patients. The authors obtained MRI scans of 160 patients with unilateral sciatic pain. A clinical exam was performed on every patient and the degree of disc displacement, neural enhancement and nerve root compression were evaluated.

The degree of disc displacement in MRI did not correlate with any subjective symptoms, nor did the nerve root enhancement or nerve compression. MRI classification was associated, however, with SLR restriction.

Conclusion: The results of the study suggest that a discogenic mechanism other than nerve root entrapment generates the subjective symptoms among sciatic patients and that SLR is a good measure of nerve root entrapment.In addition, impaired walking capacity, pain on coughing, restricted SLR and analgesic use are more common in patients with extruded/sequestrated discs.

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4)The Diagnostic Accuracy of MRI, Work Perception, and Psycho‐social factors in identifying Symptomatic Disc herniations, Boos N. , Rieder R., Schade V., Spine 1995, vol. 20, no. 24, pp. 2613‐ 2625.

Prospective study of patients with symptomatic disc herniations(study group) and asymptomatic volunteers(control group).The objective of the study was to determine the prevalence of disc herniation in a matched group a asymptomatic volunteers and assess the diagnostic accuracy of MRI, work perception and psycho‐social factors in identifying symptomatic disc herniation.

Forty‐six patients with low back pain and sciatica severe enough to require discectomy were compared with forty‐six age, sex and risk factor matched asymptomatic volunteers.Both groups had a complete clinical and magnetic resonance imaging examination and completed a questionnaire to assess differences in the psycho‐social and work perception profiles. The prevalence and severity of morphologic alterations (disc herniation, disc degeneration, and neural compromise) was analyzed by two independent radiologists in a blinded fashion.

The results reveal that the asymptomatic group had a high incidence rate of disc herniation (76%) compared to the symptomatic group which had a rate of 96%. Symptomatic patients had a much higher rate of disc extrusions than asymptomatic (35% vs. 13%). There were no significant differences regarding disc degeneration between both groups (96% vs. 85%).

Conclusions reveal a substantially higher than expected prevalence of herniation in asymptomatic subjects than previously reported. Individuals with minor disc herniation are at a very high risk that their MRI findings are not a causal explanation of pain because of this high rate of findings in asymptomatics. The only highly significant difference between the study group and control group regarding morphological findings was the criteria of a nerve root compromise.

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5)MRI of the Lumbar Spine in People without Low Back Pain, Jensen M., Brant‐Zawadzki M., Obuchowski N.,NEJM, 1994, vol. 331:69‐73 .

An examination of the prevalence of abnormal findings on magnetic resonance imaging(MRI) scans of the lumbar spine in people without back pain. MRI’s were performed on 98 asymptomatic subjects. Scans were read by two neuroradiologists who did not know the clinical status of the subjects. The scans of 27 subjects with back pain were mixed into the scans of the asymptomatic subjects.

Results revealed that nearly thirty‐six percent of the 98 subjects had normal discs at all levels. 52% of subjects had a bulge in at least one level, 27% had a protrusion and 1% had an extrusion. Thirty‐eight percent had an abnormality of more than one intervertebral level. The prevalence of bulges, but not protrusions increase with age. About 8% had facet arthropathy, 7% had stenosis and 7% had spondylolisthesis.

Conclusions reveal the high prevalence of abnormality in the asymptomatic population make findings on imaging studies coincidental or meaningless if considered in isolation. Because of this peoples clinical findings must be closely correlated with the findings on the imaging studies.

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6)The Value of MRI of the Lumbar Spine to Predict Low Back Pain in Asymptomatic Subjects: A Seven Year Follow‐up Study, Borenstein D., Boden S., The Journal of Bone and Joint Surgery, 2001 Sept., vol. 83‐A, pp. 1306‐1311.

In 1989 a group of 67 asymptomatic subjects with no history of back pain underwent an MRI examination of the lumbar spine. Twenty‐one subjects (31%) had an identifiable abnormality of a disc or the spinal canal. In this study, an investigation attempted to determine whether the findings on the scan predicted the development of low back pain.

In 1996, the entire cohort of 67 asymptomatic subjects was contacted by letter. 50 subjects completed a questionnaire that asked for information concerning age, gender, episodes of low back pain since 1989, duration of pain, absence from work, sensory abnormalities in the buttocks or lower extremities, abnormality of walking, validated pain diagram, visits to healthcare providers, surgical procedures and concurrent medication. Also included was a request for a repeat MRI of the lumbar spine. Individuals who did not respond were contacted by phone. In 1996 thirty‐one individuals agreed to have a repeat MRI. These scans were randomly mixed with the original 1989 scans. These scans were then reviewed and rated in random sequence by two neuroradiologists and one orthopedic spine surgeon.

Of the 50 subjects who returned the questionnaire, 29% had no back pain. Low back pain developed in 21 subjects during the seven year study period. The 1989 scans of these individuals revealed normal findings in 12, a herniated disc in 5, stenosis in 3 and moderate degeneration in one. Eight individuals had radiating leg pain; four of them had normal findings on the original scans, two had spinal stenosis, one

7)

8) had a disc protrusion, and one had a disc extrusion. In general, repeat MRI revealed a greater frequency of disc herniation, bulging and degeneration than the original scans.

Conclusions reveal that MRI scans were not predictive of the development or duration of low back pain. Individuals with the longest duration of LBP did not have the greatest degree of anatomical abnormality on the original 1989 scans.

Risk Factors for Lumbar Disc Degeneration: A 5 Year Prospective MRI Study in Asymptomatics, Elfering A., Boos N., Zanetti M., Spine 2002, vol. 27, no. 2, pp. 125‐134.

A longitudinal MRI investigation of lumbar disc degeneration in asymptomatic individuals. In a 5 year follow‐up evaluation of 41 asymptomatic individuals, the risk factors for the development of lumbar disc degeneration and its progression were investigated.All 41 individuals had a baseline MRI scan and a follow‐up scan at 5 years using the same scanner. The scans were analyzed by two radiologists in regards to disc degeneration.

Of the 41 individuals , 17(41%) exhibited a deterioration of the disc status. In 10 individuals, the progression of disc degeneration was one grade or more. The risk of degeneration was significantly increased when a herniated disc was present on original MRI scan. Evening or night work also increased the risk of deterioration substantially. Finally, the lack of sports activities increased the risk of deterioration.

The results indicate that the extent of disc herniation, the lack of sports activities and night shift work were significant risk factors for the development of lumbar disc degeneration and its progression.

Three‐Year Incidence of Low back Pain in an initially Asymptomatic Cohort, Clinical and Imaging Risk Factors.Jarvik J., Hollingworth W., Deyo R. Spine 2005, vol. 30, pp. 1541‐1548.

Prospective cohort study of randomly selected VA outpatients without low back pain. Objective was to determine predictors of new LBP as well as the 3 year incidence of MRI findings. There was a random selection of 148 outpatients aged 35‐70 without LBP in the last 4 months. Then they compared baseline and 3 year lumbar spine MRI to develop a prediction model of back pain free survival.

At 3 years 131 subjects were contacted and 123 had a repeat MRI scan. The three year incidence of pain was 67% (88 of 131). Among baseline imaging findings, central spinal stenosis and nerve root contact had the highest though non‐significant hazard ratio. There was no association between new LBP and type 1 endplate changes, disc degeneration, annular tears or facet degeneration. The incidence of new MRI findings was low, with the most common new findings being disc signal loss.

Conclusion reveals depression is an important predictor of new LBP, with MRI findings less likely important. New imaging findings have a low incidence; disc extrusions and nerve root contact may be the most important of these findings.

9)MRI of Cervical Intervertebral Discs in Asymptomatic Subjects, Matsumoto M., Fujimura Y., Journal of Bone and Joint Surgery 1998, vol 80‐B, pp. 19‐24.

A study of the degenerative changes of the intervertebral disc of 497 asymptomatic subjects by MRI. Discs were evaluated for loss of signal intensity, posterior and anterior disc protrusion, narrowing of the disc space and foraminal stenosis. In each subject 5 disc levels from C2‐3 to C6‐7 were evaluated.

A total of 2480 discs were evaluated. Positive MRI findings increased with age. Disc degeneration being the the most frequent. Grade 1 or 2 disc degeneration was seen in 17% of discs of men and 12 % of those of women in their twenties. These numbers rose to86% and 89% respectively in subjects over the age of 60. Grade 2 disc protrusion with spinal cord compression was seen in 50 discs of 38 subjects, most of them over the age of 40.

Conclusion reveal that the findings of degenerative changes on cervical discs increases linearly with age and should be taken into account when reading the images of patients with various cervical disorders.

10)MRI Changes of the Cervical Spine in Asymptomatic and Symptomatic Young Adults, Siivola S., Levoska S.,European Spine Journal 2002, vol. 11, pp. 358‐363.

Random sample of 826 high school students examined at 17‐19 and then re‐examined again at age 24‐26. Subjects were split into two groups. Those who were symptomatic and those who had no neck pain. Thirty participants were randomly selected from the two groups for MRI study(15 from each group). Altogether 186 discs were analyzed. 25 % of discs were classified as degenerated with 20 from the symptomatic group and 26 from the asymptomatic group. 32 anular tears found with fourteen from the SG group and 18 in the NSG group. Forty‐seven disc protrusions with 18 in the SG group and 29 in the NSG group.

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11) A Prospective Study of Centralization of Lumbar and referred pain: A predictor of Symptomatic Discs and Anular Competence, Donelson R., Aprill C., Medcalf R., Spine 1997, vol. 22(10), pp. 1115‐1122.

A mechanical lumbar assessment was compared prospectively with the discographic pain provocation and anular competency. This study was undertaken to examine the relationship between the responses of centralization and peripheralization with discographic findings. Patients with chronically disabling low back pain who were referred for discography underwent preliminary blinded McKenzie assessment and

were placed into three groups by pain response. Patterns were then compared with the blinded discographic pain provocation and anular findings.

Results showed that the referred pain of 50% centralized. Centralization of pain is the movement of radicular pain from a distal site to a more proximal site in the extremity. 74% of the centralizers had a positive discogram and of these 91% had an intact nucleus. The pain of 25% peripheralized only(would not centralize or moved to a more distal location); 69% of these had positive discograms, but only 54% had an intact anulus. The distal pain of 25% did not respond at all (did not change with repeated end range movement), and only 12.5% of these had positive discograms.

Conclusions reveal that the McKenzie process reliably differentiated discogenic from non‐discogenic pain as well as a competent from an incompetent anulus in symptomatic discs and was superior to MRI in distinguishing painful from non‐painful discs.

Outcome Assessment Tools for Back/NeckPain Croft P, Roland M, Von Korff M, Waddell G, Outcomes Measures for Low Back Pain Research: A Proposal

for Standardized Use. Spine, vol. 23(18), 15 Sept. 1998, pp. 2003‐2013.

Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Those relevant outcomes are function, general well‐ being, work disability, and satisfaction with care. Conclusion of the study is that a standardized measure of outcomes would better improve clinical care. A proposed set of 6 question battery was proposed that would be practical for use in a wide variety of settings, including routine clinical care, quality improvement efforts and more formal research.

Turner J, Fulton‐Kehoe D, Comparison of Roland‐Morris Disability Questionnaire and Generic Health Status Measures: A Population‐Based Study of Workers Compensation Back Injury Claimants. Spine, vol. 28(10), 15 May 2003, pp. 1061‐67.

Objective of the study was to compare the Roland‐Morris Questionnaire with widely used generic health status measures in a sample of workers with recent work related low back injuries in terms of validity, reliability, responsiveness to change, and floor and ceiling effects.

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