Do national health priorities align with Global Burden of Disease estimates on disease burden? An analysis of national health plans and official governmental websites.

OBJECTIVE: To investigate the alignment of national health priorities with a country's burden of disease as measured by disability-adjusted life years (DALYs). METHODS: We identified priorities in national health plans and the 20 most burdensome conditions measured by DALYs from the 2017 Global Burden of Disease Study. We computed point-biserial correlations (rpb) between DALYs and being nominated as a health priority and the pooled proportion (95% confidence intervals [CIs]) of the 20 most burdensome conditions nominated as a priority across countries. RESULTS: We identified national health plans and official governmental websites in 145 countries. There was little to no correlation (rpb = 0.06, 95% CI: 0.02 to 0.09) between national DALY data and whether a condition was nominated as a health priority. The pooled proportion of the 20 most burdensome conditions nominated as priorities across countries was 46%. HIV/AIDS had the greatest number of nominations as a national health priority (62 countries) as well as the greatest match with the burden of disease (among the top 20 most burdensome conditions in 51 [82%] countries). Low back pain, headache disorders and congenital birth defects had the lowest proportion of nominations as health priorities in countries where they were in the top 20 most burdensome conditions (6%, 6% and 11%, respectively). CONCLUSION: Globally, there were low correlations between national health priorities and GBD estimates on disease burden. Failing to prioritise health priorities according to burden may mean that insufficient resources have been directed to improve health outcomes for people with those health conditions.

What proportion of patients with chronic noncancer pain are prescribed an opioid medicine? Systematic review and meta-regression of observational studies.

Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority (n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0-21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95% CI 7.2-9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) (P = 0.014) and not geographic region (P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.

Predicting Return to Work in a Heterogeneous Sample of Recently Injured Workers Using the Brief ÖMPSQ-SF.

Purpose (1) to examine the ability of the Örebro Musculoskeletal Pain Screening Questionnaire-short version (ÖMPSQ-SF) to predict time to return to pre-injury work duties (PID) following a work-related soft tissue injury (regardless of body location); and (2) to examine the appropriateness of 50/100 as a suitable cut-off score for case identification. Methods Injured workers (IW) from six public hospitals in Sydney, Australia, who had taken medically-sanctioned time off work due to their injury, were recruited by insurance case managers within 5-15 days of their injury. Eligible participants (N = 213 in total) were administered the ÖMPSQ-SF over the telephone by the case manager. For objective (1) Cox proportional hazards regression analysis was used to predict days to return to PID using the ÖMPSQ-SF. For objective (2) receiver operator characteristic (ROC) analysis was used to determine the ÖMPSQ-SF total score that optimises sensitivity and specificity in detecting whether or not participants had returned to PID within 2-7 weeks. Results The total ÖMPSQ-SF score significantly predicted number of days to return to PID, such that for every 1-point increase in the total ÖMPSQ-SF score the predicted chance of returning to work reduced by 4% (i.e., hazard ratio = 0.96), p < 0.001. Sensitivity and specificity for the ROC analysis comparing ÖMPSQ-SF total score to return to PID within 2-7 weeks suggested 48 as the optimal cut off (sensitivity = 0.65, specificity = 0.79). Conclusion The results provide strong support for the use of the ÖMPSQ-SF in an applied setting for identifying those IW likely to have delayed RTW when administered within 15 days of the injury. While a score of 48/100 was the optimal cut point for sensitivity and specificity, pragmatically, 50/100 should be acceptable as a cut-off in future studies of this type.

Discontinuation of the PACE Plus trial: problems in patient recruitment in general practice.

BACKGROUND: The PACE Plus trial was a multi-center, double-blinded, superiority randomized controlled trial (RCT) conducted in patients from Dutch general practice to investigate the efficacy of paracetamol and NSAIDs in acute non-specific low back pain (LBP). Because insufficient numbers of patients could be recruited (only four out of the required 800 patients could be recruited over a period of 6 months), the trial was prematurely terminated in February 2017, 6 months after the start of recruitment. This article aims to transparently communicate the discontinuation of PACE Plus and to make recommendations for future studies. METHODS: General Practitioners (GPs) from 36 participating practices received a one-question survey in which they were asked to give the three most important factors that in their opinion contributed to failure of patient recruitment. RESULTS: GPs of 33 out of 36 (92%) participating practices sent a response. A total of 81 factors were reported. These have been categorized into patient factors (26 out of 81 comments, 32%), GP factors (39 out of 81 comments, 48%) and research factors (16 out of 81 comments, 20%). DISCUSSION: Patient recruitment in the PACE Plus trial may have failed due to inefficient medication distribution, recruitment of incident rather than prevalent cases, a design that was too complicated, adequate self-management of LBP, patient expectations different from the trial's scope and lack of time of participating GPs. Substantial differences in design may explain why the preceding PACE trial did manage to successfully complete patient recruitment. CONCLUSION: Although the PACE Plus trial was terminated as a result of insufficient patient inclusion, the research questions addressed in this trial remain relevant but unanswered. We hope that lessons learned from the discontinuation of PACE Plus and corresponding recommendations may be helpful in the design of upcoming research projects in LBP in general practice. TRIAL REGISTRATION: Dutch Trial Registration NTR6089, registered September 14th 2016.

Efficacy of paracetamol, diclofenac and advice for acute low back pain in general practice: design of a randomized controlled trial (PACE Plus).

BACKGROUND: Low back pain is common and associated with a considerable burden to patients and society. There is uncertainty regarding the relative benefit of paracetamol and diclofenac and regarding the additional effect of pain medication compared with advice only in patients with acute low back pain. This trial will assess the effectiveness of paracetamol, diclofenac and placebo for acute low back pain over a period of 4 weeks. Furthermore, this trial will assess the additional effectiveness of paracetamol, diclofenac and placebo compared with advice only for acute low back pain over a period of 4 weeks. METHODS: The PACE Plus trial is a multi-center, placebo-blinded, superiority randomized controlled trial in primary care, with a follow-up of 12 weeks. Patients with acute low back pain aged 18-60 years presenting in general practice will be included. Patients are randomized into four groups: 1) Advice only (usual care conforming with the clinical guideline of the Dutch College of General Practitioners); 2) Advice and paracetamol; 3) Advice and diclofenac; 4) Advice and placebo. The primary outcome is low back pain intensity measured with a numerical rating scale (0-10). Secondary outcomes include compliance to treatment, disability, perceived recovery, costs, adverse reactions, satisfaction, sleep quality, co-interventions and adequacy of blinding. Between group differences for low back pain intensity will be evaluated using a repeated measurements analysis with linear effects models. An economic evaluation will be performed using a cost-effectiveness analysis with low back pain intensity and a cost-utility analysis with quality of life. Explorative analyses will be performed to assess effect modification by predefined variables. Ethical approval has been granted. Trial results will be released to an appropriate peer-viewed journal. DISCUSSION: This paper presents the design of the PACE Plus trial: a multi-center, placebo-blinded, superiority randomized controlled trial in primary care that will assess the effectiveness of advice only, paracetamol, diclofenac and placebo for acute low back pain. TRIAL REGISTRATION: Dutch Trial Registration NTR6089 , registered September 14th, 2016. PROTOCOL: Version 4, June 2016.

The association between symptom severity and physical activity participation in people seeking care for acute low back pain.

PURPOSE: To investigate the association between symptom severity and physical activity participation in people with acute non-specific low back pain (LBP). METHODS: The sample included a total of 999 patients who presented to primary care with an acute episode of low back pain. Symptom severity, in terms of activity limitation and severity of pain; and physical activity participation before (habitual) and after pain onset were assessed using self-report questionnaires. All participants were interviewed within 14 days of pain onset. RESULTS: At interview most of the participants (87.5 %) reported having moderate to extreme activity limitation due to back pain. There was a significant decrease in physical activity participation after pain onset (mean difference: -176 min, 95 % CI 327-400; p < 0.0001) but no association between habitual or change in physical activity participation and symptom severity was observed (p > 0.21). CONCLUSION: Pain onset causes a significant and immediate decrease in physical activity participation, but this change does not seem to be associated with symptom severity.

Characteristics and Effectiveness of Interventions That Target the Reporting, Communication, or Clinical Interpretation of Lumbar Imaging Findings: A Systematic Review.

BACKGROUND: Patients and clinicians may misinterpret the clinical importance of imaging findings in patients with low back pain, leading to potential harm related to overdiagnosis. PURPOSE: Our aims were to qualitatively summarize the characteristics of tested interventions that target the reporting, communication, or clinical interpretation of lumbar imaging findings and determine whether interventions are effective in improving low back pain-related health outcomes, health care use, or health care costs. DATA SOURCES: PubMed, MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library were searched from inception to October 20, 2021. STUDY SELECTION: The search retrieved 4394 articles, nine articles (seven studies) met the inclusion criteria to summarize intervention characteristics. Five of these studies had an adequate design for evaluating intervention effectiveness. DATA ANALYSES: Intervention characteristics were summarized using the Template for Intervention Description and Replication checklist. Effectiveness data were extracted from short, intermediate, and long-term follow-up points. Studies were assessed for risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology was used to determine the certainty of the evidence. DATA SYNTHESIS: Four studies investigated the insertion of prevalence information into imaging reports. Single studies investigated withholding diagnostic information, education, and reassurance. Moderate-quality evidence (from 1 study) suggests that inserting prevalence information into imaging reports probably does not change the overall health care use in the long-term but may reduce opioid prescribing. LIMITATIONS: The available evidence is limited, and a meta-analysis was not possible. CONCLUSIONS: Further work is required to develop and test interventions that target the reporting, communication, and clinical interpretation of lumbar imaging findings that may reduce overdiagnosis and improve the management of low back pain.

Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain.

OBJECTIVES: Although motor control exercises have been shown to be effective in the management of low back pain (LBP) the mechanism of action is unclear. The current study investigated the relationship between the ability to recruit transversus abdominis and clinical outcomes of participants in a clinical trial. METHODS: Ultrasonography was used to assess the ability to recruit transversus abdominis in a nested design: a sample of 34 participants with chronic LBP was recruited from participants in a randomised controlled trial comparing the efficacy of motor control exercise, general exercise and spinal manipulative therapy. Perceived recovery, function, disability and pain were also assessed. RESULTS: Participants with chronic LBP receiving motor control exercise had a greater improvement in recruitment of transversus abdominis (7.8%) than participants receiving general exercise (4.9% reduction) or spinal manipulative therapy (3.7% reduction). The effect of motor control exercise on pain reduction was greater in participants who had a poor ability to recruit transversus abdominis at baseline. There was a significant, moderate correlation between improved recruitment of transversus abdominis and a reduction in disability (r = -0.35; 95% CI 0.02 to 0.62). CONCLUSION: These data provide some support for the hypothesised mechanism of action of motor control exercise and suggest that the treatment may be more effective in those with a poor ability to recruit transversus abdominis.

Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials.

OBJECTIVE: Estimates of treatment effects reported in placebo-controlled randomized trials are less subject to bias than those estimates provided by other study designs. The objective of this meta-analysis was to estimate the analgesic effects of treatments for non-specific low back pain reported in placebo-controlled randomized trials. METHODS: Medline, Embase, Cinahl, PsychInfo and Cochrane Central Register of Controlled Trials databases were searched for eligible trials from earliest records to November 2006. Continuous pain outcomes were converted to a common 0-100 scale and pooled using a random effects model. RESULTS: A total of 76 trials reporting on 34 treatments were included. Fifty percent of the investigated treatments had statistically significant effects, but for most the effects were small or moderate: 47% had point estimates of effects of <10 points on the 100-point scale, 38% had point estimates from 10 to 20 points and 15% had point estimates of >20 points. Treatments reported to have large effects (>20 points) had been investigated only in a single trial. CONCLUSIONS: This meta-analysis revealed that the analgesic effects of many treatments for non-specific low back pain are small and that they do not differ in populations with acute or chronic symptoms.

Imperfect placebos are common in low back pain trials: a systematic review of the literature.

The placebo is an important tool to blind patients to treatment allocation and therefore minimise some sources of bias in clinical trials. However, placebos that are improperly designed or implemented may introduce bias into trials. The purpose of this systematic review was to evaluate the adequacy of placebo interventions used in low back pain trials. Electronic databases were searched systematically for randomised placebo-controlled trials of conservative interventions for low back pain. Trial selection and data extraction were performed by two reviewers independently. A total of 126 trials using over 25 different placebo interventions were included. The strategy most commonly used to enhance blinding was the provision of structurally equivalent placebos. Adequacy of blinding was assessed in only 13% of trials. In 20% of trials the placebo intervention was a potentially genuine treatment. Most trials that assessed patients' expectations showed that the placebo generated lower expectations than the experimental intervention. Taken together, these results demonstrate that imperfect placebos are common in low back pain trials; a result suggesting that many trials provide potentially biased estimates of treatment efficacy. This finding has implications for the interpretation of published trials and the design of future trials. Implementation of strategies to facilitate blinding and balance expectations in randomised groups need a higher priority in low back pain research.

Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis.

Muscle relaxants are commonly prescribed for low back pain (LBP); however, there is limited evidence of their clinical efficacy and tolerability. This review evaluated the efficacy and tolerability of muscle relaxants in people with LBP. We searched online databases including Medline, EMBASE, CENTRAL and PsycINFO (inception to end October 2015) and performed citation tracking for eligible randomized controlled trials (RCTs). Two authors independently extracted data and assessed risk of bias of randomized controlled trials of muscle relaxants. Pain outcomes were converted to a common 0-100 scale. Data were pooled using a random effects model with strength of evidence assessed using GRADE. Fifteen trials (3362 participants) were evaluated in this review. A total of five trials (496 participants) provide high quality evidence that muscle relaxants provide clinically significant pain relief in the short term for acute LBP; MD -21.3, [-29.0, -13.5]. There was no information on long-term outcomes. The median adverse event rate in clinical trials for muscle relaxants was similar to placebo 14.1% IQR (7.0-28.7%) and 16.0% (4.1-31.2%); p = 0.5, respectively. There is no evidence for the efficacy of benzodiazepines in LBP. For people with acute LBP, muscle relaxants provide clinically significant short-term pain relief. For chronic LBP, the efficacy of muscle relaxants is largely unknown. There was no eligible RCT evidence to support the efficacy of benzodiazepines in LBP. Prolonged use of these medicines in LBP cannot be guided by trial evidence. WHAT DOES THIS REVIEW ADD?: Muscle relaxants provide clinically significant pain relief for acute low back pain. Caution must be taken with the interpretation of the findings as the evidence comes from specific muscle relaxant medicines.

Prospective Comparison of Changes in Lumbar Spine MRI Findings over Time between Individuals with Acute Low Back Pain and Controls: An Exploratory Study.

BACKGROUND AND PURPOSE: The clinical importance of lumbar MR imaging findings is unclear. This study was an exploratory investigation of whether lumbar spine MR imaging findings change more commonly during a 12-week period in individuals with acute low back pain compared with pain-free controls. MATERIALS AND METHODS: Twenty individuals with recent-onset low back pain and 10 pain-free controls were recruited into an exploratory prospective cohort study. All participants had a lumbar spine MR imaging at baseline and repeat MR imaging scans at 1, 2, 6, and 12 weeks. The proportion of individuals who had MR imaging findings that changed during the 12-week period was compared with the same proportion in the controls. RESULTS: In 85% of subjects, we identified a change in at least 1 MR imaging finding during the 12 weeks; however, the proportion was similar in the controls (80%). A change in disc herniation, annular fissure, and nerve root compromise was reported more than twice as commonly in the subjects as in controls (65% versus 30%, 25% versus 10%, and 15% versus 0%, respectively). Caution is required in interpreting these findings due to wide confidence intervals, including no statistical difference. For all other MR imaging findings, the proportions of subjects and controls in whom MR imaging findings were reported to change during 12 weeks were similar. CONCLUSIONS: Changes in MR imaging findings were observed in a similar proportion of the low back pain and control groups, except for herniations, annular fissures, and nerve root compromise, which were twice as common in subjects with low back pain.

Is this back pain killing me? All-cause and cardiovascular-specific mortality in older Danish twins with spinal pain.

BACKGROUND: Few studies have examined the potentially reduced life expectancy associated with spinal pain (i.e. low back and neck pain) in an ageing population, particularly after controlling for familial factors, including genetics. METHODS: We investigated whether spinal pain increased the rate of all-cause and disease-specific cardiovascular mortality in older Danish twins aged ≥70 years. Data from 4391 participants collected at baseline were linked with the Danish Cause of Death Registry with the study ending on 31 December 2014. Two crude and adjusted Cox proportional hazards regression analyses determined the rate of all-cause and disease-specific cardiovascular mortality by baseline spinal pain exposure; unpaired (total sample analysis) and twin pair (intra-pair analysis). Analyses were also adjusted for confounders; baseline physical functional ability and depressive symptoms. Competing risk regression models determined the rate of cardiovascular mortality, adjusting for similar confounders and using the total sample only. RESULTS: Spinal pain was associated with an increased rate of all-cause mortality, hazard ratio (HR): 1.13 [95% confidence interval (CI): 1.06-1.21]. There was no association between spinal pain and cardiovascular disease mortality, sub-distribution hazard ratio (SHR): 1.08 [95% CI 0.96-1.21]. After adjusting for confounders (physical functional ability and depressive symptoms), the association became non-significant. All intra-pair analyses were statistically non-significant, although greater in magnitude for monozygotic twins. CONCLUSIONS: Older people reporting spinal pain have 13% increased risk of mortality per years lived but the connection is not causal. We found no association between spinal pain and cardiovascular-specific mortality. The influence of shared familial factors is unlikely. SIGNIFICANCE: Older people reporting spinal pain have 13% increased risk of mortality per year lived. However, this association is not likely to be causal, with the relevant confounders contributing to this relationship. Thus, pain in the spine may be part of a pattern of poor health, which increases mortality risk in the older population.

Low back pain investigations and prognosis: a review.

Low back pain is reviewed in terms of when investigations are useful and its clinical course. Despite the extensive evaluation of the accuracy of investigations such as radiography, magnetic resonance imaging, and myelography, there is a surprising dearth of research to inform their use in primary care. There is no clear evidence on which to base judgments for selection of appropriate tests to confirm or exclude low back pain pathology. It appears that investigations are rarely necessary for low back pain. Specific investigations should be ordered to identify a particular pathology but should not be ordered routinely for general screening. In the absence of pathology, low back pain and its associated disability improve rapidly in the first weeks after onset, but, in contradiction to all guidelines, both commonly persist and the best evidence suggests that recurrences are common.

Understanding patient beliefs regarding the use of imaging in the management of low back pain.

BACKGROUND: Imaging for low back pain (LBP) remains common despite guidelines recommending against routine imaging. Patient beliefs about imaging may contribute to the problem. This study aimed to quantitatively investigate patient beliefs regarding the need for imaging in managing LBP and to investigate whether personal characteristics, pain characteristics or back pain beliefs are associated with imaging beliefs. METHODS: A survey was performed of consecutive patients presenting to general medical practitioners in Sydney, Australia. Nine medical clinics were selected across varied socioeconomic regions. Survey questions assessed beliefs about the importance of imaging for LBP, collected demographic information, LBP history and general beliefs about back pain. Descriptive statistics and multivariate logistic regression were used to analyse findings. RESULTS: Three hundred completed surveys were collected with a 79.6% response rate. The mean age was 44 years and 60.7% of respondents were women. Exactly, 54.3% (95% CI: 48.7-58.9%) believed that imaging was necessary for the best medical care for LBP. Exactly, 48.0% (95% CI: 42.4-53.6%) believed that everyone with LBP should obtain imaging. Increased age, lower education level, non-European or non-Anglo-saxon cultural background, history of previous imaging and Back Beliefs Questionnaire scores were associated with beliefs that imaging was necessary. CONCLUSION: Approximately, half of all patients presenting to a medical doctor consider low back imaging to be necessary. This may have important implications for overutilization of low back imaging investigations. Knowledge of the factors associated with the patient's belief that imaging is necessary may be helpful in designing appropriate interventions to reduce unnecessary imaging for LBP.

Patients with sciatica still experience pain and disability 5 years after surgery: A systematic review with meta-analysis of cohort studies.

BACKGROUND AND OBJECTIVE: The clinical course of patients with sciatica is believed to be favourable, but there is conflicting evidence on the postoperative course of this condition. We aimed to investigate the clinical course of sciatica following surgery. DATABASES AND DATA TREATMENT: An electronic search was conducted on MEDLINE, EMBASE and CINAHL from inception to April 2015. We screened for prospective cohort studies investigating pain or disability outcomes for patients with sciatica treated surgically. Fractional polynomial regression analysis was used to generate pooled means and 95% confidence intervals (CI) of pain and disability up to 5 years after surgery. Estimates of pain and disability (converted to a 0-100 scale) were plotted over time, from inception to last available follow-up time. RESULTS: Forty records (39 cohort studies) were included with a total of 13,883 patients with sciatica. Before surgery, the pooled mean leg pain score was 75.2 (95% CI 68.1-82.4) which reduced to 15.3 (95% CI 8.5-22.1) at 3 months. Patients were never fully recovered in the long-term and pain increased to 21.0 (95% CI 12.5-29.5) at 5 years. The pooled mean disability score before surgery was 55.1 (95% CI 52.3-58.0) and this decreased to 15.5 (95% CI 13.3-17.6) at 3 months, and further reduced to 13.1 (95% CI 10.6-15.5) at 5 years. CONCLUSIONS: Although surgery is followed by a rapid decrease in pain and disability by 3 months, patients still experience mild to moderate pain and disability 5 years after surgery. WHAT DOES THIS REVIEW ADD?: This review provides a quantitative summary of the postoperative course of patients with sciatica. Patients with sciatica experienced a rapid reduction in pain and disability in the first 3 months, but still had mild to moderate symptoms 5 years after surgery. Although no significant differences were found, microdiscectomy showed larger improvements compared to other surgical techniques.

Effect of applying different "levels of evidence" criteria on conclusions of Cochrane reviews of interventions for low back pain.

The objective of this study was to examine the consistency of conclusions of Cochrane systematic reviews when different criteria are used to determine levels of evidence. We reanalyzed the data in six Cochrane reviews of conservative treatment of low back pain by applying three additional sets of "levels of evidence" criteria. Overall agreement between the conclusions attained with the different levels of evidence criteria was only "fair" (multirater kappa coefficient 0.33; 95% CI 0.28 to 0.38). For example, the four sets of levels of evidence criteria produced four conclusions on the efficacy of back school: "strong evidence that back schools are effective," "weak evidence," "limited evidence," and "no evidence." Pairwise agreement between the four pooling systems ranged from slight to substantial (kappas ranging from 0.10 to 0.80). Different rules for determining levels of evidence in systematic reviews produce markedly different conclusions on treatment efficacy. Crown

Randomized controlled trial of neural mobilization after spinal surgery.

STUDY DESIGN: Randomized controlled trial with 12-month follow-up. OBJECTIVES: To determine whether the addition of neural mobilization to standard postoperative care improved the outcome of lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: It has been suggested that neural mobilization should be performed after spinal surgery to prevent nerve root adhesions and improve outcome. However, to date, there is no convincing evidence of the value of neural mobilization. METHODS: Eighty-one patients undergoing lumbar discectomy, fusion, or laminectomy at a private hospital in Sydney were randomly allocated to standard postoperative care or standard care plus neural mobilization. Neural mobilization included passive movements and active exercises designed to mobilize the lumbosacral nerve roots and sciatic tract. Primary outcome measures were global perceived effect measured on a 7-point scale, pain measured using visual analogue scales and the McGill Pain Questionnaire, and disability measured with the Quebec Disability Scale. RESULTS: All patients received the treatment as allocated with 12-month follow-up data available for 76 patients (94% of those randomized). There were no statistically significant or clinically significant benefits provided by the neural mobilization treatment for any outcome. CONCLUSIONS: The neural mobilization protocol evaluated in this study did not provide an additional benefit to standard postoperative care for patients undergoing spinal surgery. The authors advocate that this protocol not be used in clinical practice.

The reliability and validity of the Biering-Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain.

STUDY DESIGN: A reliability study and case-control study were conducted. OBJECTIVES: To determine the reliability and discriminative validity of the Biering-Sorensen test. SUMMARY OF BACKGROUND DATA: A low Biering-Sorensen score has been found to predict who will have nonspecific low back pain. However, the reliability of the test remains controversial, implying that some studies may have produced results that underestimated the magnitude of the predictive validity of this test. METHODS: Two raters measured the time holding a specific position (holding time) of 63 subjects (23 currently experiencing nonspecific low back pain, 20 who had had an episode, and 20 who were asymptomatic) while they performed the Biering-Sorensen test twice, 15 minutes apart. A standardized protocol was followed. Test-retest reliability was evaluated by calculating intra-class correlation coefficients (ICC 1,1), 95% confidence intervals (CI), and standard errors of the measurement (SEM) for the total group and for the subgroups. A three-way analysis of variance was used to determine whether test order, subject gender, or symptom status affected holding time. RESULTS: High reliability indices were obtained for the Biering-Sorensen test in subjects with current nonspecific low back pain (ICC [1,1], 0.88; 95% CI, 0.73-0.95; SEM, 11.6 seconds), in subjects who had had nonspecific low back pain (ICC [1,1], 0.77; 95% CI, 0.52-0.90; SEM, 17.5 seconds), and in asymptomatic subjects (ICC [1,1], 0.83; 95% CI, 0.62-0.93; SEM, 17.4 seconds). Results of an analysis of variance showed that subjects asymptomatic for low back pain had a significantly longer holding time than the other two groups (P < 0.05). CONCLUSIONS: The Biering-Sorensen test provides reliable measures of position-holding time and can discriminate between subjects with and without nonspecific low back pain.

Therapists' conceptualization and characterization of the clinical concept of spinal stiffness.

BACKGROUND AND PURPOSE: The clinical concept of spinal stiffness provides one basis for applying spinal manipulation. Because the terms used to describe the perceptual results of manual spinal stiffness testing are poorly defined, the nature and number of attributes contained in the concept remain unclear. This study attempted to clarify the concept of spinal stiffness by examining the relationships among 31 published spinal stiffness descriptors using cluster analysis. SUBJECTS AND METHODS: Each stiffness descriptor was printed on a magnetized rubber strip. Physical therapists in Houston (Tex) and Sydney (New South Wales, Australia) judged the similarity of the stiffness descriptors by arranging them on a board. The squared Euclidean distance between words was calculated, and cluster analysis was performed using Ward's method. RESULTS: Cluster analysis reduced the 31 stiffness descriptors to three superclusters (limited mobility, increased mobility, and viscoelasticity) in both the Houston and Sydney data. CONCLUSION AND DISCUSSION: In a step toward improving the reliability of spinal stiffness judgments, this study has identified the fundamental characteristics of the clinical concept of spinal stiffness. Research is now needed to clearly define these characteristics and then develop protocols that will allow physical therapists to reliably rate these attributes.