Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Risk factors for a recurrence of low back pain. Are first-time episodes of serious LBP associated with new MRI findings? Self reported health status and magnetic resonance imaging findings in patients with low back pain Natural History of Individuals With Asymptomatic Disc Abnormalities in Magnetic Resonance Imaging: Predictors of Low Back Pain–Related Medical Consultation and Work Incapacity A Prospective Study of Incidence and Risk Factors for the Onset and Persistence of Low Back Pain in Thai University Students Spinal mechanical load: a predictor of persistent low back pain? A prospective cohort study A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Diagnosis of Symptomatic Disc by Magnetic Resonance Imaging: T2-Weighted and Gadolinium-DTPA-Enhanced T1-Weighted Magnetic Resonance Imaging Non-specific low back pain in primary care in the Spanish National Health Service: a prospective study on clinical outcomes and determinants of management Low back pain incident episodes: a community-based study. It's time for change with the management of non-specific chronic low back pain The natural course of low back pain: a systematic critical literature review Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Magnetic resonance imaging of the lumbar spine in people without back pain. Pain response classification does not predict long-term outcome in patients with low back pain who are sick-listed. Cumulative Low Back Load at Work as a Risk Factor of Low Back Pain: A Prospective Cohort Study
BACKGROUND CONTEXT A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain ( LBP ) illness . Although the relative contributions of structural and psychosocial variables are intensely debated , the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects . These factors dictate the requirement for large sample sizes , extensive structural imaging and extended longitudinal study . Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline . PURPOSE To establish , using a strict patient sample design , the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness . STUDY DESIGN / SETTING A prospect i ve , longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics . PATIENT SAMPLE One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic ( non-lumbar ) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease , to undergo baseline examination , testing and 5-year follow-up . OUTCOME MEASURES Observations were made at 6-month intervals over 4 to 6 years ( mean , 5.3 ) for the after primary outcomes measures : episodes of serious back pain ( visual analogue scale [ VAS ] > or = 6 ) , episodes of occupational disability less than 1 week , episodes of occupational disability for 1 week , remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment . METHODS Lumbar magnetic resonance imaging ( MRI ) , lumbar provocative discography ( in psychometrically normal subjects ) , physical examinations , medical and work histories and psychometric testing were performed at baseline . Imaging and psychometric testing were grade d by blinded examiners . A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data . The interview covered interval medical , occupational and accident or injury histories . RESULTS Psychosocial variables strongly predicted both long- and short-term disability events , duration and health-care visits for LBP problems ( p<0.0001 - 0.004 ) . The likelihood of a sustained remission from the baseline persistent ( sub clinical ) LBP appeared to be linked to occupation factors ( leaving a heavy labor occupation ; p=0.0001 ) , neurophysiologic variables ( chronic nonlumbar pain ; p=0.0002 ) and psychometric profiles at baseline ( DRAM and FABQ-PA ; p=0.003 - 0.002 ) . Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome . A positive provocative discogram at baseline did not predict any future adverse event . CONCLUSION The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables . Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care BACKGROUND CONTEXT The clinical importance of lumbar pathology identified on magnetic resonance imaging ( MRI ) remains unclear . It is plausible that pathology seen on MRI is a risk factor for a recurrence of low back pain ( LBP ) ;  however , to our knowledge , this has not been investigated by previous studies . PURPOSE The aim was to investigate whether lumbar pathology , identifiable on MRI , increases the risk of a recurrence of LBP . STUDY DESIGN This was a prospect i ve inception cohort study with 1-year follow-up . PATIENT SAMPLE Seventy-six people who had recovered from an episode of LBP within the previous 3 months were included . OUTCOME MEASURES The primary outcome was time to recurrence of LBP , which was determined by contacting participants at 2-month intervals for 12 months . METHODS All participants underwent a baseline assessment including MRI scan and completion of a question naire , which assessed a range of potential risk factors for recurrence . Magnetic resonance imaging scans were reported for the presence of a range of MRI findings . The primary analysis investigated the predictive value of two clinical features ( age and number of previous episodes ) and six MRI findings ( disc degeneration , high intensity zone , Modic changes , disc herniation , facet joint arthrosis , and spondylolisthesis ) in a multivariate Cox regression model . We decided a priori that dichotomous predictors with hazard ratios ( HRs ) of greater than 1.5 or less than 0.67 would be considered potentially clinical ly important and justify further investigation . RESULTS Of the eight predictors entered into the primary multivariate model , three ( disc degeneration , high intensity zone , and number of previous episodes ) met our a priori threshold for potential importance . Participants with disc degeneration score greater than or equal to 3 ( Pfirrmann scale ) had a HR of 1.89 ( 95 % confidence interval [ CI ] 0.42 - 8.53 ) compared with those without . Patients with high intensity zone had an HR of 1.84 ( 95 % CI 0.94 - 3.59 ) compared with those without . For every additional previous episode , participants had an HR of 1.04 ( 95 % CI 1.02 - 1.07 ) . CONCLUSIONS We identified promising risk factors for a recurrence of LBP , which should be further investigated in larger trials . The findings suggest that pathology seen on MRI plays a potentially important role in recurrence of LBP BACKGROUND 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 prospect i ve study has established a baseline MR status of the lumbar spine in subjects without significant LBP problems and prospect ively 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 . PURPOSE To determine if new and serious episodes of LBP are associated with new and relevant findings on MRI . STUDY DESIGN Prospect i ve observational study with baseline and post-LBP MRI monitoring of 200 subjects over 5 years . OUTCOME MEASURES 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 . METHODS 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 ( LBP > or=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 . RESULTS During the 5-year observation period of 200 subjects , 51 ( 25 % ) subjects were evaluated with a lumbar MRI for clinical ly 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 cl aims ( OR=2.35 ; 95 % CI 0.97 - 5.69 ) . Subjects involved in current compensation cl aims 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 . CONCLUSION 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 Abstract The authors present a prospect i ve study of quality of life ( SF-36 ) and MRI findings in patients with low back pain ( LBP ) . Disc herniation and nerve root compression contribute to LBP and poor quality of life . However , significant proportions of asymptomatic subjects have disc herniation and neural compromise . Little is known about the influence of disc abnormalities and neural compression on quality of life in symptomatic patients . The purpose of this study was to assess the relationship between the extent of disc abnormality , neural impingement and quality of life . A total of 317 consecutive patients with LBP referred for MRI completed an SF-36 health status question naire immediately before imaging and again 6 months later . Patients were grouped according to the most extensive disc abnormality and any neural compromise reported at MRI . The relationship between symptoms , radiological signs and SF-36 scores was assessed . Eighty percent ( 255/317 ) and 65 % ( 205/317 ) of patients completed the initial and 6-month SF-36 , respectively . Thirty-six percent of patients ( 115/317 ) had one or more herniated discs and 44 % ( 140/317 ) had neural impingement . There was little relationship between the extent of disc abnormality and quality of life . Patients with radiological evidence of neural impingement reported better general health ( P < 0.01 ) . SF-36 scores improved at 6 months in four dimensions , but general health deteriorated ( P < 0.01 ) . Patients with neural impingement had improved pain scores at 6 months ( P < 0.05 ) . The study results showed that the pain and dysfunction caused by disc herniation and neural compromise are not sufficiently distinct from other causes of back pain to be distinguished by the SF-36 . Whilst neural compromise may be the best radiological feature distinguishing patients who may benefit from intervention , it can not predict quality of life deficits in the diffuse group of patients with LBP Study Design . Prospect i ve study on individuals with asymptomatic lumbar disc abnormalities detected in magnetic resonance imaging .  Objectives . To determine the natural history of asymptomatic disc abnormalities in magnetic resonance imaging and to identify predictors of future low back pain – related medical consultation and work incapacity . Summary of Background Data . The natural history of individuals with asymptomatic disc herniations has not been well established , but the high rate of lumbar disc alterations recently detected in asymptomatic individuals by magnetic resonance imaging dem and s reconsideration of a pathomorphology-based explanation of low back pain and sciatica . Methods . Forty-six asymptomatic individuals who had a high rate of disc herniations ( 73 % ) were observed for an average of 5 years ( range , 54–72 months ) . Four classes of variables ( medical data including magnetic resonance imaging – identified disc abnormalities , general psychological factors , physical job characteristics , and psychosocial aspects of work ) were assessed at baseline and follow-up . Results . Disc herniations and neural compromise did not significantly worsen at follow-up , whereas disc degeneration progressed in 17 individuals ( 41.5 % ) . Minor episodes of low back pain occurred in 19 individuals ( 41.3 % ) , 6 of whom had to seek medical treatment and 5 of whom had to stop work temporarily . The requirement for low back pain – related medical consultation was predicted with high accuracy by listlessness , job satisfaction , and working in shifts ( P < 0.001 ) . Work incapacity was best predicted by physical job characteristics , job disaffection , and working in shifts ( P < 0.01 ) . Conclusion . Physical job characteristics and psychological aspects of work were more powerful than magnetic resonance imaging – identified disc abnormalities in predicting the need for low back pain – related medical consultation and the result ant work incapacity . However , the conclusions are still preliminary , and replication of the findings in larger and more representative study sample s is needed This study aim ed to examine the 12-month incidence and risk factors for the onset and persistence of low back pain ( LBP ) in undergraduate students . A 1-year prospect i ve study was carried out among 684 healthy students in a large public university in Thail and . Data were collected using a self-administered question naire and a physical examination . Follow-up data were collected every 3 months . A total of 524 ( 77 % ) students were followed for 1 year . A total of 31 % reported a new onset of LBP , of whom 31 % reported persistent LBP . Having no low back support during computer work was a significant predictor for the onset and persistence of LBP . The onset of LBP was also associated with quadriceps muscle tightness . LBP is common among undergraduate students , and many of them may have persistent symptoms . Physical risk factor plays a significant role for the onset and persistence of LBP among the study population Prospect i ve inception cohort . To assess the prognostic value of spinal mechanical load , assessed with the 24-hour schedule ( 24HS ) , in subjects with acute non-specific low back pain ( ALBP ) and to examine the influence of spinal mechanical load on the course of ALBP . In view of the characteristics of the natural course of ALBP , this should be viewed as a persistent condition in many patients rather that a benign self-limiting disease . Therefore , secondary prevention could be beneficial . Spinal mechanical load is a risk factor for ALBP and possibly a ( modifiable ) prognostic factor for persistent ( i.e. recurrent and /or chronic ) LBP . One hundred patients from primary care with ALBP were eligible for inclusion . At 6 months , 88 subjects completed the follow-up . For the follow-up assessment a research assistant , unaware of our interest in the prognostic factors , contacted the subjects by telephone . Question naires were completed focusing on changes in demographic data and on the course and current status of ALBP . Persistent LBP occurred in 60 % subjects . After multivariate regression analysis smoking ( harmful ) and advanced age ( protective ) were associated with persistent LBP . Differences in 24HS scores at baseline and follow-up were univariate-related to persistent LBP . Spinal mechanical load , quantified with the 24HS , is not a prognostic factor for persistent LBP . Modification of spinal mechanical load in terms of 24HS scores could be beneficial for secondary prevention in patients with acute LBP Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing Although radial tear of the annulus fibrosus can be detected on T2-weighted and Gd-DTPA-enhanced magnetic resonance ( MR ) images , the association between the annular tear on MR images and the symptomatic discs is unclear . The purpose of this study was to investigate the relationship between T2-weighted , gadolinium-DTPA-enhanced MR images and pain response through discography in patients with chronic low back pain . A total of 56 lumbar discs from 23 patients with chronic low back pain ( 13 to 47 years old ) underwent MR imaging ( T2-weighted , gadolinium-DTPA-enhanced MR images ) followed by provocative discography . The sensitivity , specificity , positive predictive value , and negative predictive value of T2-weighted and gadolinium-DTPA-enhanced MR images in detecting the symptomatic discs were calculated . The sensitivity , specificity , positive predictive value , and negative predictive value of T2-weighted images in detecting the symptomatic disc were 94 % , 71 % , 59 % , and 97 % , respectively . The sensitivity , specificity , positive predictive value , and negative predictive value of gadolinium-DTPA-enhanced images were 71 % , 75 % , 56 % , and 86 % , respectively . The high sensitivity and the high negative predictive value of T2-weighted MR imaging in detecting the symptomatic disc indicated that MR imaging can be a useful screening tool in avoiding unnecessary discography in patients with chronic low back pain Background The Spanish National Health Service is a universal and free health care system . Non-specific low back pain ( LBP ) is a prevalent disorder , generating large health and social costs . The objectives of this study were to describe its management in primary care , to assess patient characteristics that influence physicians ' decisions , and to describe clinical outcome at 2 months . Methods A cross-sectional sample of 648 patients with non-specific low back pain was recruited by 75 physicians ( out of 361 – 20.8 % ) working in 40 primary care centers in 10 of the 17 administrative regions in Spain , covering 693,026 out of the 40,499,792 inhabitants . Patients were assessed on the day they were recruited , and prospect ively followed-up 14 and 60 days later . The principal patient characteristics that were analyzed were : sex , duration of the episode , history of LBP , working status , severity of LBP , leg pain and disability , and results of straight leg raising test . Descriptors of management were : performance of the straight leg raising test , ordering of diagnostic procedures , prescription of drug treatment , referral to physical therapy , rehabilitation or surgery , and granting of sick leave . Regression analysis was used to analyze the relationship between patients ' baseline characteristics and physicians ' management decisions . Only workers were included in the models on sick leave . Results Mean age ( SD ) of included patients was 46.5 ( 15.5 ) years , 367 ( 56.6 % ) were workers , and 338 ( 52.5 % ) were females . Median ( 25th–75th interquartile range ) duration of pain when entering the study was 4 ( 2–10 ) days and only 28 patients ( 4.3 % ) had chronic low back pain . Diagnostic studies included plain radiographs in 43.1 % of patients and CT or MRI scans in 18.8 % . Drug medication was prescribed to 91.7 % of patients , 19.1 % were sent to physical therapy or rehabilitation , and 9.6 % were referred to surgery . The main determinants of the clinical management were duration of the episode and , to a lesser extent , the intensity of the pain ( especially leg pain ) , a positive straight leg raising test , and degree of disability . The main determinant of sick leave was the degree of disability , followed by the characteristics of the labor contract and the intensity of leg pain ( but not low back pain ) . After at least 2 months of treatment , 37 % of patients were still in pain and approximately 10 % of patients had not improved or had worsened . Conclusion Although the use of X-Rays is high , determinants of physicians ' management of LBP in primary care made clinical sense and were consistent with patterns suggested by evidence -based recommendations . However , after 2 months of treatment more than one third of patients continued to have back pain and about 10 % had worsened BACKGROUND CONTEXT The available evidence regarding low back pain ( LBP ) incident episodes is not consistent . Such knowledge can add information for the potential contribution of preventive programs . PURPOSE a ) To evaluate annual incident episodes of LBP among the general population . b ) To evaluate the contribution of demographic , lifestyle , and back pain history to LBP incident episodes . STUDY DESIGN A community-based longitudinal study . PATIENT SAMPLE A r and omized sample of individuals , free of LBP at a previous cross-sectional survey . OUTCOME MEASURES Low back pain during the past year . METHODS Subjects were followed up after 1 year . Baseline data included back pain history , perception of general health , physical activity , smoking , work satisfaction , and demographic characteristics . RESULTS Annual incident episodes of LBP were 18.4 % . Those who experienced LBP during the past year had a lower baseline perception of general health and were less involved in sporting activities than those free of pain . Those without history of LBP were more likely to be free of back pain after 1 year . CONCLUSIONS The annual incident episodes of LBP are relatively high and relate indirectly to baseline perception of general health and to level of sporting activities . Those without history of LBP are more likely to be free of back pain after 1 year . These results raise the potential of LBP preventive programs for adult population Low back pain ( LBP ) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health re sources spent on LBP disorders , the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies , opiod medications , spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach , and evidence that only 8–15 % of patients with LBP have an identified patho-anatomical diagnosis , result ing in the majority being diagnosed as having non-specific LBP.3 Of this population , a small but significant group becomes chronic and disabled , labelled non-specific chronic low back pain ( NSCLBP ) , consuming a disproportionate amount of healthcare re sources .4 1 . Over the past decade , the traditional biomedical view of LBP has been greatly challenged . This is a result of : the failure of simplistic single-dimensional therapies to show large effects in patients with NSCLBP5–8 ; 2 . the results of clinical trials testing commonly prescribed interventions demonstrating that no management approaches are clearly superior5–7 9 ; 3 . the stories of NSCLBP patients relating their own ongoing pain experiences of multiple failed treatments , conflicting diagnoses , lost hope and ongoing suffering10 ; 4 . the indisputable evidence supporting the multidimensional nature of NSCLBP as a disorder , where disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones11 12 ; 5 . positive outcomes in r and omised controlled trials ( RCTs ) are best predicted by changes in psychological distress , fear avoidance beliefs , self-efficacy in Background Most patients in the secondary care sector consulting for low back pain ( LBP ) seem to have a more or less constant course of pain during the ensuing year . Fewer patients with LBP in the primary care sector report continual pain over a one-year period . However , not much is known about the long-term course of LBP in the general population . A systematic critical literature review was undertaken in order to study the natural course of LBP over time in the general population . Methods A search of articles was performed in Pubmed , Cinahl and Psychinfo using the search terms ‘ epidemiology ’ ; ‘ low back pain ’ or ‘ back pain ’ ; ‘ prospect i ve study ’ or ‘ longitudinal study ’ ; ‘ follow-up ’ , ‘ natural course ’ , ‘ course ’ or ‘ natural history ’ ; ‘ general population ’ or ‘ working population ’ . Inclusion criteria were that one of the objectives was to study the course of (L)BP in the adult population , that the period of follow-up was at least 3 months , and that there were three points of observation or more . The review was undertaken by two independent review ers using three checklists relating to description of studies , quality and outcomes . The course of LBP was established in relation to those who , at baseline , were reported not to have LBP or to have LBP . Would this course be stable , fluctuating , worsening , or improving over time ? A synthesis of results in relation to common patterns was presented in a table and interpreted in a narrative form . Results Eight articles were included . Articles were different on time span , the number of surveys , and the definition of LBP . In six of the seven relevant studies , for those with no LBP at baseline , relatively substantial stable subgroups of people who continued to be LBP free were identified . In six of the seven relevant studies , definite stable subgroups of continued LBP were noted and improvement ( becoming pain free ) was never reported to be a common finding . Conclusion The status of LBP in individuals of the general population appears to be relatively stable over time , perhaps particularly so for those without LBP at baseline OBJECTIVE To determine the onset of low back pain ( LBP ) in schoolchildren and to investigate the role of mechanical and psychosocial factors as risk factors for its onset . METHODS A prospect i ve population -based cohort study was conducted of 1046 schoolchildren , aged 11 to 14 years at baseline , identified as being free of LBP , from 39 secondary schools in Northwest Engl and .  New onset of LBP at 1-year follow-up was measured . RESULTS Children who reported high levels of psychosocial difficulties were more likely to develop LBP than their peers ( relative risk : 1.6 ; 95 % confidence interval : 1.1 - 2.3 ) . An excess risk was , in particular , associated with conduct problems ( 2.5 ; 1.7 - 3.7 ) . Similarly , children who reported high numbers of somatic symptoms at baseline were at greater risk of developing LBP : abdominal pain ( 1.8 ; 1.1 - 3.0 ) , headaches ( 1.6 ; 0.97 - 2.8 ) , and sore throats ( 1.5 ; 0.8 - 2.6 ) . In contrast , we have been unable to demonstrate a strong association between daily mechanical load ( schoolbag weight ) and the short-term risk of new-onset LBP ( highest versus lowest quintile : 1.2 ; 0.7 - 2.1 ) . CONCLUSIONS In children who were initially free of LBP , adverse psychosocial factors and the presence of other preexisting somatic pain symptoms were predictive of future LBP , reflecting findings in adults . In contrast , there was little evidence of an increase in short-term risk associated with mechanical load across the range of weights commonly carried by children to school BACKGROUND The relation between abnormalities in the lumbar spine and low back pain is controversial . We examined the prevalence of abnormal findings on magnetic resonance imaging ( MRI ) scans of the lumbar spine in people without back pain . METHODS We performed MRI examinations on 98 asymptomatic people . The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects . To reduce the possibility of bias in interpreting the studies , abnormal  MRI scans from 27 people with back pain were mixed r and omly with the scans from the asymptomatic people . We used the following st and ardized terms to classify the five intervertebral disks in the lumbosacral spine : normal , bulge ( circumferential symmetric extension of the disk beyond the interspace ) , protrusion ( focal or asymmetric extension of the disk beyond the interspace ) , and extrusion ( more extreme extension of the disk beyond the interspace ) . Nonintervertebral disk abnormalities , such as facet arthropathy , were also documented . RESULTS Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels . With the results of the two readings averaged , 52 percent of the subjects had a bulge at at least one level , 27 percent had a protrusion , and 1 percent had an extrusion . Thirty-eight percent had an abnormality of more than one intervertebral disk . The prevalence of bulges , but not of protrusions , increased with age . The most common nonintervertebral disk abnormalities were Schmorl 's nodes ( herniation of the disk into the vertebral-body end plate ) , found in 19 percent of the subjects ; annular defects ( disruption of the outer fibrous ring of the disk ) , in 14 percent ; and facet arthropathy ( degenerative disease of the posterior articular processes of the vertebrae ) , in 8 percent . The findings were similar in men and women . CONCLUSIONS On MRI examination of the lumbar spine , many people without back pain have disk bulges or protrusions but not extrusions . Given the high prevalence of these findings and of back pain , the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental STUDY DESIGN Prospect i ve cohort study nested in a r and omized clinical trial . OBJECTIVE To investigate the prognostic value of pain response classification at initial physiotherapy examination in patients with low back pain ( LBP ) who are sick-listed . BACKGROUND Recurrent and chronic LBP accounts for a substantial proportion of all absence from work . In predicting outcome in patients with LBP , psychosocial factors are thought to play an important role , while findings from clinical examination seem to be of more limited value . Mechanical evaluation , using repeated end range spinal movements that result in specific pain responses , has been shown to be of some value . METHODS The study included 351 patients sick-listed because of LBP with or without sciatica . Prior to clinical examination , the patients completed a comprehensive question naire including questions on pain , function , and psychosocial factors . The physiotherapy examination included a st and ardized mechanical evaluation . Patients were classified into 3 groups according to their pain response : central ization , peripheralization , or no response . Outcomes were obtained by national register data , medical records , and a postal question naire at 1 year . RESULTS At 1-year follow-up , 65 % of the patients had returned to work . All pain response groups showed significant and clinical ly important improvements in both pain and disability . No significant differences were found between pain response groups in any outcome measure . Results remained unchanged after adjustment for potential confounders . CONCLUSION The prognostic value of pain response classification seems limited in patients sick-listed from work because of LBP Purpose Much research has been performed on physical exposures during work ( e.g. lifting , trunk flexion or body vibrations ) as risk factors for  low back pain ( LBP ) , however results are inconsistent . Information on the effect of doses ( e.g. spinal force or low back moments ) on LBP may be more reliable but is lacking yet . The aim of the present study was to investigate the prospect i ve relationship of cumulative low back loads ( CLBL ) with LBP and to compare the association of this mechanical load measure to exposure measures used previously . Methods The current study was part of the Study on Musculoskeletal disorders , Absenteeism and Health ( SMASH ) study in which 1,745 workers completed question naires .  Physical load at the workplace was assessed by video-observations and force measurements . These measures were used to calculate CLBL . Furthermore , a 3-year follow-up was conducted to assess the occurrence of LBP . Logistic regressions were performed to assess associations of CLBL and physical risk factors established earlier ( i.e. lifting and working in a flexed posture ) with LBP . Furthermore , CLBL and the risk factors combined were assessed as predictors in logistic regression analyses to assess the association with LBP . Results Results showed that CLBL is a significant risk factor for LBP ( OR : 2.06 ( 1.32–3.20 ) ) . Furthermore , CLBL had a more consistent association with LBP than two of the three risk factors reported earlier . Conclusions From these results it can be concluded that CLBL is a risk factor for the occurrence of LBP , having a more consistent association with LBP compared to most risk factors reported earlier
MRI findings of disc protrusion , nerve root displacement or compression , disc degeneration , and high intensity zone are all associated with LBP , but individually , none of these abnormalities provides a strong indication that LBP is attributable to underlying pathology .
This limits their value in refining epidemiological case definitions for LBP
OBJECTIVE to assess how confidently  low back pain ( LBP ) can be attributed to abnormalities on magnetic resonance imaging ( MRI ) , and thereby explore the potential value of MRI abnormalities in refining case definition for mechanical LBP in epidemiological research .
SUMMARY OF BACKGROUND DATA most epidemiological studies of mechanical LBP have defined cases only by reported symptoms , but it is possible that the potency of causes differs depending on whether there is demonstrable underlying spinal pathology .