Comparison of the history and physical examination for hip osteoarthritis and lumbar spinal stenosis.

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

Inciting Events Associated With Cervical Radiculopathy.

BACKGROUND: Cervical radiculopathy (CR) is a clinical diagnosis defined as a combination of neck, shoulder, and arm pain, often accompanied by sensory and motor symptoms. CR is often caused by degenerative spine pathology associated with impingement of a cervical nerve root, and this pathology can be visualized using magnetic resonance imaging (MRI) or computed tomography (CT). [Correction added September 4, 2019, after online publication: 'computer tomography' corrected to 'computed tomography'] Factors that are associated with the onset of CR have not been explored. OBJECTIVE: To investigate the types and frequencies of patient-reported inciting events associated with CR in patients with imaged-confirmed pathologies that correlate with symptoms. DESIGN: Prospective observational case series. SETTING: Two spine physiatry and three orthopedic spine surgery practices. PATIENTS: One hundred twenty-two patients with symptoms suggestive of CR were recruited. Of these, 107 patients had MRI or CT evidence of cervical disk herniation or foraminal stenosis that correlated with symptoms and matched our inclusion criteria. METHODS: We categorized patient-reported inciting events associated with onset of CR into six categories reflecting increasing severity of inciting event, and recorded the clinical characteristics, physical examination findings, pain intensity, and disability. We analyzed the characteristics of patients based on subgroups of inciting events. RESULTS: Two-thirds of patients reported that they either awoke with symptoms or symptoms began without a memorable event, and one-third of patients reported inciting physical activity or trauma associated with the onset of CR. Clinical characteristics of CR were not influenced by categories of inciting events. CONCLUSION: Most CR with correlating spine pathology was found to have onset without a specific inciting events. Furthermore, physical inciting events did not influence the severity of clinical manifestation of CR. LEVEL OF EVIDENCE: IV.

Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?: A Longitudinal Case-Crossover Feasibility Study.

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

Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria.

BACKGROUND CONTEXT: Because imaging findings of lumbar spinal stenosis (LSS) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are needed. PURPOSE: The objective of this study was to develop clinical classification criteria that identify patients with neurogenic claudication (NC) caused by LSS. STUDY DESIGN: This study is a two-stage process that includes Phase 1, the Delphi process, and Phase 2, the cross-sectional study. PATIENT SAMPLE: Outpatients were recruited from spine clinics in five countries. OUTCOME MEASURE: The outcome measure includes items from the patients' history and physical examination. METHODS: In Phase 1, a list of potential predictors of NC caused by LSS was based on the available literature and was evaluated through a Delphi process involving 17 spine specialists (surgeons and non-surgeons) from eight countries. In Phase 2, 19 different clinical spine specialists from five countries identified patients they classified as having (1) NC caused by LSS, (2) radicular pain caused by lumbar disc herniation (LDH), or (3) non-specific low back pain (NSLBP) with radiating leg pain. The patients completed survey items and the specialists documented the examination signs. Coefficients from general estimating equation models were used to select predictors, to generate a clinical classification score, and to obtain a receiver operating characteristic curve. Conduction of the Delphi process, data management, and statistical analysis were partially supported by an unrestricted grant of less than 15,000 US dollars from Merck Sharp & Dohme. No fees were allocated to participating spine specialists. RESULTS: Phase 1 generated a final list of 46 items related to LSS. In Phase 2, 209 patients with leg pain caused by LSS (n=63), LDH (n=89), or NSLBP (n=57) were included. Criteria that independently predicted NC (p<.05) were age over 60 years, positive 30-second extension test, negative straight leg test, pain in both legs, leg pain relieved by sitting, and leg pain decreased by leaning forward or flexing the spine. A classification score using a weighted set of these criteria was developed. The proposed N-CLASS score ranged from 0 to 19 and had an area under the curve of 0.92, and the cutoff (>10/19) to obtain a specificity of >90.0% resulted in a sensitivity of 82.0%. CONCLUSIONS: Clinical criteria independently associated with neurogenic claudication due to LSS were identified. The use of these symptom and physical variables as a classification score for clinical research could improve homogeneity among enrolled patients.

Comparison of Symptoms From C6 and C7 Radiculopathy.

STUDY DESIGN: Case series. OBJECTIVE: This study compared the locations of arm pain, sensory symptoms, and subjective complaints of arm weakness in patients with cervical radiculopathy from MRI confirmed C6 and C7 nerve root compression. SUMMARY OF BACKGROUND DATA: Cervical radiculopathy is defined as arm pain, sensory and motor symptoms caused by irritation of a cervical nerve root. The C6 and C7 roots are most commonly involved, and differentiating symptoms associated with each root has proven difficult. Cervical MRI allows accurate identification of nerve root compression and therefore makes it possible to explore symptom patterns that may differentiate C6 from C7 radiculopathy. METHODS: A total of 122 patients with symptoms suggestive of cervical radiculopathy were recruited. Of these, 30 patients had MRI confirmed C6 and 39 patients C7 nerve root compression. By completing a study questionnaire, patients reported specific arm weakness, and marked the location of arm pain and tingling/numbness on graphic representations of the arm. Marked areas were interpreted by superimposing a grid that divided the arm into 54 distinct areas. The frequencies of reported symptoms with C6 and C7 were totaled and then compared with likelihood rations. Power analysis calculated that 27 patients would be needed in each group based on the assumption that a 30 percentage point difference in frequency of specific symptom would be clinically useful for differentiating C6 from C7 radiculopathy. RESULTS: Arm pain and sensory symptoms were diffuse, and were not distinctly different for C6 or C7 radiculopathy. Some weakness was reported by 41 percent of patients, with specific descriptions of weakness having limited value for differentiating between radiculopathies. CONCLUSION: The location of pain and sensory symptoms, and specific weakness complaints associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting root involvement based on symptoms. LEVEL OF EVIDENCE: 3.

Clinical classification criteria for radicular pain caused by lumbar disc herniation: the radicular pain caused by disc herniation (RAPIDH) criteria.

BACKGROUND CONTEXT: Classification criteria are recommended for diseases that lack specific biomarkers to improve homogeneity in clinical research studies. Because imaging evidence of lumbar disc herniations (LDHs) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are required. PURPOSE: This study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH. STUDY DESIGN: The study design was a two-stage process. Phase 1 included a Delphi process and Phase 2 included a cohort study. PATIENT SAMPLE: The patient sample included outpatients recruited from spine clinics in five countries. OUTCOME MEASURES: The outcome measures were items from history and physical examination. MATERIALS AND METHODS: In Phase 1, 17 spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2, 19 different clinical experts identified patients they confidently classified as presenting with (1) radicular pain caused by LDH, (2) neurogenic claudication (NC) caused by lumbar spinal stenosis, or (3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than US$15,000 was received from MSD: It was used to support the conception of the Delphi, data management, and statistical analysis. No fees were allocated to participating spine specialists. RESULTS: Phase 1 generated a final list of 74 potential symptoms and signs. In Phase 2, 209 patients with pain caused by LDH (89), NC (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p<.05) were monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test <60° (or femoral stretch test), unilateral motor weakness, and asymmetric ankle reflex. The score had an AUC of 0.91. An easy-to-use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%). CONCLUSIONS: Classification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies.

Exploration of sensory impairments associated with C6 and C7 radiculopathies.

BACKGROUND CONTEXT: Cervical radiculopathy is a common disorder caused by compression of the cervical nerve roots and is characterized by arm pain and altered sensory-motor function. Incongruity in the locations of C6 and C7 dermatomes in competing versions of historical dermatome maps has plagued interpretation of impaired sensation associated with C6 and C7 radiculopathies. Magnetic resonance imaging (MRI) allows accurate identification of the C6 or C7 nerve root compression and therefore makes it possible to explore sensory findings that are associated with compression of specific nerve root. PURPOSE: This study compared the locations of impaired sensation in subjects with cervical radiculopathy from MRI-confirmed C6 and C7 nerve root compression. STUDY DESIGN: Case series was used for this study. PATIENT SAMPLE: A total of 122 subjects with symptoms suggestive of cervical radiculopathy were recruited by 11 spine specialist from 5 practice locations. Of these, 30 subjects had MRI-confirmed C6 and 40 subjects C7 radiculopathy. OUTCOME MEASURES: Standardized pinprick sensory examination of the forearm and hand of every subject was performed, and the locations of sensory impairments were recorded. METHODS: Sensory examination was performed before reviewing MRI results or performing motor or reflex examination. Areas of impaired sensation were recorded on drawings of the palmar and dorsal forearm and hand, and translated using a grid into 36 specific areas for analysis. Chi-square was used to compare frequencies of findings for each grid area for C6 and C7 radiculopathies. Power analysis suggested that a minimum of 27 subjects in each group were needed to detect a 30 percentage point difference in frequency of sensory impairments. Significance was set at ≤.05. RESULTS: Approximately 80% of subjects had impaired sensation in at least 1 grid area, most often in the distal forearm and hand, and many had findings in multiple areas. There was nearly complete overlap for locations of impaired sensation for C6 and C7 radiculopathy, and the frequencies of impaired sensation differed only in the dorsal aspect of the distal radial forearm where it was twice as common in C6 radiculopathy (p=.02). CONCLUSIONS: The location of sensory impairments associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting compression of either the C6 or C7 nerve roots based on locations of impaired sensation. Impaired sensation in the radial aspect of the distal forearm is more common in C6 radiculopathies.

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain.

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

Report of the NIH Task Force on research standards for chronic low back pain.

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

Physical activity and associations with computed tomography-detected lumbar zygapophyseal joint osteoarthritis.

BACKGROUND CONTEXT: There are no previous epidemiologic studies examining associations between physical activity and imaging-detected lumbar zygapophyseal joint osteoarthritis (ZJO) in a community-based sample. PURPOSE: To determine whether physical activity is associated with prevalent lumbar ZJO on computed tomography (CT). STUDY DESIGN/SETTING: A community-based cross-sectional study. PATIENT SAMPLE: Four hundred twenty-four older adults from the Framingham Heart Study. OUTCOME MEASURES: Participants received standardized CT assessments of lumbar ZJO at the L2-S1 levels. Severe lumbar ZJO was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intra-articular vacuum phenomenon. This definition of lumbar ZJO was based entirely on CT imaging findings and did not include any clinical criteria such as low back pain. METHODS: Physical activity was measured using the Physical Activity Index, which estimate hours per day typically spent in these activity categories: sleeping, sitting, slight activity, moderate activity, and heavy activity. Participants reported on usual frequency of walking, running, swimming, and weightlifting. We used multivariable logistic regression to examine associations between self-reported activity and severe lumbar ZJO, while adjusting for key covariates including age, sex, height, and weight. RESULTS: In multivariable analyses, ordinal categories of heavy physical activity duration per day were significantly associated with severe lumbar ZJO (p for trend=.04), with the greatest risk observed for the category 3 or more hours per day, odds ratio 2.13 (95% confidence interval [CI] 0.97-4.67). When heavy activity was modeled as a continuous independent variable, each hour was independently associated with 1.19 times the odds of severe lumbar ZJO (95% CI 1.03-1.38, p=.02). Less vigorous types of physical activity and the type of exercise were not associated with severe lumbar ZJO. Older age, lesser height, and greater weight were independently and significantly associated with severe lumbar ZJO. In multivariable models predicting lumbar ZJO, neither model discrimination nor reclassification improved with the addition of physical activity variables, compared with a multivariable model including age, sex, height, and weight. CONCLUSIONS: Our findings demonstrate a statistically significant cross-sectional association between heavy physical activity and CT-detected severe lumbar ZJO. However, the additional discriminatory capability of heavy physical activity above and beyond that contributed by other factors was negligible.

Nonoperative treatment for lumbosacral radiculopathy: what factors predict treatment failure?

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

Focus article: report of the NIH Task Force on Research Standards for Chronic Low Back Pain.

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

Report of the NIH Task Force on research standards for chronic low back pain.

OBJECTIVE: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. DESIGN: Expert panel and preliminary evaluation of key recommendations. METHODS: The NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting. RESULTS: The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. CONCLUSION: The RTF believes these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document, and undergo continual improvement. PERSPECTIVE: A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Report of the National Institutes of Health task force on research standards for chronic low back pain.

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

Focus article report of the NIH task force on research standards for chronic low back pain.

BACKGROUND: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. METHODS: The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting. RESULTS: The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. CONCLUSIONS: The RTF believes these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain.

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

Report of the NIH task force on research standards for chronic low back pain.

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

Report of the NIH Task Force on research standards for chronic low back pain.

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

Comparison of radicular symptoms caused by lumbar disc herniation and lumbar spinal stenosis in the elderly.

STUDY DESIGN: Comparative study using combined data from 2 prospective cohort studies. OBJECTIVE: To expose the differences between the clinical characteristics of neurogenic claudication from magnetic resonance image-documented lumbar spinal stenosis (LSS) and lumbosacral radicular syndrome from acute, magnetic resonance image-documented, lumbar disc herniation (LDH). SUMMARY OF BACKGROUND DATA: LSS and LDH are the common lumbar disorders that produce lower extremity pain. Though known factors such as pain induced by walking for LSS and the rapid onset of symptoms for LDH are useful for differentiating these disorders, exploration of differences in other factors has received limited study. METHODS: This study included participants aged 60 yr or older from 2 previous studies. One examined walking limitations caused by LSS and the second the natural history of LDH in elderly adults. The clinical features of both groups were compared by calculating means, medians, and standard deviations for continuous variables, and frequencies for categorical variables. χ test was used to explore differences between LSS and LDH for categorical variables, and Student t test or Mann-Whitney test for continuous variables. RESULTS: Participants with LSS had more medical comorbidity, less intense leg pain, and less disability than those with LDH. Leg pain was more common in the anterior thigh, anterior knee and shin in LDH, and in the posterior knee in LSS. Trunk flexion was more impaired in LDH. Positive straight leg raising and femoral stretch signs were common in LDH, and rare in LSS. Abnormal Achilles reflexes were noted more frequently in LSS. CONCLUSION: In addition to established factors, greater leg pain intensity, greater disability, and pain in the anterior leg are more common in the elderly with LDH than in the elderly with LSS. Normal trunk flexion, absence of nerve root tension signs and abnormal Achilles reflexes are more common in LSS. LEVEL OF EVIDENCE: 3.