Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

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Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

Osteoarthritis is the most common form of arthritis, affecting millions of people in the United States. It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of systemic factors (such as genetics, dietary intake, estrogen use, and bone density) and of local biomechanical factors (such as muscle weakness, obesity, and joint laxity). These risk factors are particularly important in weightbearing joints, and modifying them may present opportunities for prevention of osteoarthritis-related pain and disability. Major advances in management to reduce pain and disability are yielding a panoply of available treatments ranging from nutriceuticals to chondrocyte transplantation, new oral anti-inflammatory medications, and health education. This article is part 1 of a two-part summary of a National Institutes of Health conference. The conference brought together experts on osteoarthritis from diverse backgrounds and provided a multidisciplinary and comprehensive summary of recent advances in the prevention of osteoarthritis onset, progression, and disability. Part 1 focuses on a new understanding of what osteoarthritis is and on risk factors that predispose to disease occurrence. It concludes with a discussion of the impact of osteoarthritis on disability. Ann Intern Med. 2000;133:635-646. www.annals.org For author affiliations and current addresses, see end of text.

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Osteoarthritis: New Insights Part 1: The Disease and Its Risk Factors

This guideline from the ACP provides clinical recommendations about noninvasive pharmacologic and nonpharmacologic treatment of low back pain.

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians

Socioeconomic factors are important risk factors for lumbar pain and disability. The total costs of low-back pain in the United States exceed $100 billion per year. Two-thirds of these costs are indirect, due to lost wages and reduced productivity. Each year, the fewer than 5% of the patients who have an episode of low-back pain account for 75% of the total costs. Because indirect costs rely heavily on changes in work status, total costs are difficult to calculate for many women and students as well as elderly and disabled patients. These methodologic challenges notwithstanding, the toll of lumbar disc disorders is enormous, underscoring the critical importance of identifying strategies to prevent these disorders and their consequences.

Lumbar Disc Disorders and Low-Back Pain: Socioeconomic Factors and Consequences

PURPOSE: To study how adding oxaliplatin (l-OHP) to chronomodulated fluorouracil (5-FU)–leucovorin (LV) affected the objective response rate, as first-line treatment of metastatic colorectal cancer. PATIENTS AND METHODS: Two hundred patients from 15 institutions in four countries were randomly assigned to receive a 5-day course of chronomodulated 5-FU and LV (700 and 300 mg/m2/d, respectively; peak delivery rate at 0400 hours) with or without l-OHP on the first day of each course (125 mg/m2, as a 6-hour infusion). Each course was repeated every 21 days. Response was assessed by extramural review of computed tomography scans. RESULTS: Grade 3 to 4 toxicity from 5-FU–LV occurred in ≤ 5% of the patients (≤ 1% of the courses). Grade 3 to 4 diarrhea occurred in 43% of the patients given l-OHP (10% of the courses), and less than 2% of the patients had severe hematotoxicity. Thirteen percent of the patients had moderate functional impairment from peripheral sensory neuropathy. Sixteen percent of the patients rec...

Phase III Multicenter Randomized Trial of Oxaliplatin Added to Chronomodulated Fluorouracil–Leucovorin as First-Line Treatment of Metastatic Colorectal Cancer

One hundred seventy-nine patients with advanced measurable colorectal cancer not previously treated with chemotherapy were entered into a prospective randomized clinical trial by the Mid-Atlantic Oncology Program (MAOP) to compare two schedules of delivery for single-agent fluorouracil (5-FU). The "standard" treatment was a schedule commonly employed in clinical practice, namely, a daily bolus dose administered intravenously (IV) for five consecutive days and repeated at 5-week intervals. The investigational treatment was a continuous infusion of 5-FU administered 24 hours a day for a protracted time (10 weeks or more). Both treatments were continued until the development of disease progression or unless interrupted for toxicity. Using stringent objective criteria requiring independent confirmation of x-ray or scan-documented response, the tumor response rate reached 7% (six of 87) for the bolus arm and 30% (26 of 87) for the infusion arms (P less than .001). Toxicity was substantially different for the two arms with major leukopenia observed only on the bolus arm, 22% developing grade 3 (severe) or grade 4 (life-threatening) leukopenia with four sepsis-related deaths. Hand-foot syndrome was observed only in the infusional arm, requiring treatment interruptions and dose reductions in 24% of patients, but with little impact on quality of life. In spite of the major difference in objective response rate, overall survival for the two groups was comparable. Administration of 5-FU as a continuous infusion for protracted periods clearly improves the therapeutic index for this agent in patients with advanced colon cancer with respect to response rate and reduced toxicity. This schedule appears workable in the community setting and yields response rates similar to those reported for 5-FU with high-dose leucovorin, but without the gastroin testinal toxicity profile of the latter combination.

A prospective randomized comparison of continuous infusion fluorouracil with a conventional bolus schedule in metastatic colorectal carcinoma: a Mid-Atlantic Oncology Program Study.

Background Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. Methods Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. Results The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study...

https://www.nejm.org/doi/pdf/10.1056/NEJM199510053331406

The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

Study design Telephone interviews were conducted with a random sample of adults in 4437 North Carolina households The response rate was 79% Objective The prevalence of low back pain and the correlates of care-seeking in a defined population were examined Summary of background data Previous research on low back pain has used varying definitions of the illness of low back pain, and has admixed patients with acute and chronic low back pain Acute low back pain was examined in this study as a distinct phenomenon separate from chronic low back pain Methods Respondents completed a detailed interview regarding the occurrence of and care sought for back pain in 1991 Acute back pain was defined as functionally limiting pain lasting less than 3 months Results From this sample, 485 individuals had at least one occurrence of acute severe low back pain in 1991, representing 76% of the adult population Symptoms were reported less commonly in individuals older than age 60 years (5% vs 85%) and in nonwhites compared with whites (5% vs 85%) Thirty-nine percent of those with back pain sought medical care; 24% sought care initially from an allopathic physician, 13% from a chiropractor, and 2% from other providers More prolonged pain, more severe pain, and sciatica were associated with care-seeking Gender, income, age, rural residence, and health insurance status did not correlate with the decision to seek medical care Younger age, male gender, and nonjob-related pain did correlate with the decision to seek care from a chiropractor Conclusions Acute back pain is common Care is often sought regardless of income and insurance status Seeing a health care provider for acute back pain may not be discretionary from the perspective of the patient

Acute severe low back pain : a population-based study of prevalence and care-seeking

Study Design. This was a stratified, random telephone survey of adults in North Carolina. Objective To determine the prevalance of chronic low back pain and the extent to which treatment is sought for this condition. Summary of Background Data Chronic low back pain is a major problem. Previous studies often have comb ined acute and chronic back pain. Methods Telephone interviews regarding back pain were conducted with 4437 North Caroliona adults during 1992. Results Chronic back pain affects 3.9% of the North Carolina population. Thirty-four percent considered themselves permanently disabled and 52% assessed their overall health as fair or poor. The median number of bed-disability days per year was three. Seventy-three percent saw a health care provider Of those who sought care, 91% saw a medical doctore, 29% saw a physical therapist, and 25% saw a chiropractor, Use of technology was extensive: 37% received a computed tomography scan, 25% received a magnetic resonance imaging scan, and 10.4% underwent surgery. Conclusions Chronic back pain is common, and the level of care-seeking and costs of care among those afflicted are extremely high.

Care-seeking among individuals with chronic low back pain.

Objective. Rural residents may experience more arthritis and disability than urban dwellers. This paper reviews data on arthritis in rural areas and describes a new study, the Johnston County Osteoarthritis Project, a population-based study of osteoarthritis (OA) of the knee and hip in rural North Carolina.

Methods. Published reports of urban and rural comparisons of arthritis were reviewed. Data from the first 1,432 African-American and Caucasian participants in the Johnston County Osteoarthritis Project were analyzed. Radiographic knee and hip OA were defined as a Kellgren-Lawrence grade ≥2. Functional ability was assessed by the Health Assessment Questionnaire, timed chair stands, and 8-foot walk time. Unweighted prevalences of knee and hip OA were calculated for age, sex, and racial groups. Associations between hip and knee OA, and hip and knee pain and functional ability were examined.

Results Hip OA was present in 27.9% and knee OA in 38.4% of participants. Both were strongly related to age (P < 0.0001), but only knee OA to female sex (odds ratio = 1.33, 95% confidence interval 1.05, 1.68). Neither hip OA nor knee OA was related to race. Hip OA, hip pain, knee OA, and knee pain was each associated with self-reported and observed functional ability.

Conclusion. Residents in rural areas may experience more arthritis and disability than previously expected. Contrary to other studies, African-American and Caucasian residents of rural Johnston County, North Carolina, have similar high rates of knee and hip OA. Further study is needed to address urban/rural differences in arthritis and its impact, with adequate control of confounders, standard definitions of rural/urban and of disease, and assessment of multiple arthritis outcomes.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1790080407

John G. Fryer

Papers

A prospective randomized comparison of continuous infusion fluorouracil with a conventional bolus schedule in metastatic colorectal carcinoma: a Mid-Atlantic Oncology Program Study.

The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

Acute severe low back pain : a population-based study of prevalence and care-seeking

Care-seeking among individuals with chronic low back pain.

The impact of arthritis in rural populations.