Back Pain: van Tulder M

van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A, Anonymous00002. · No affiliation provided · Eur Spine J. · Pubmed #16550447 No free full text.

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van Tulder M. · No affiliation provided · BMJ. · Pubmed #18713810 No free full text.

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Bronfort G, Haas M, Moher D, Bouter L, van Tulder M, Triano J, Assendelft WJ, Evans R, Dagenais S, Rosner A. · No affiliation provided · Chiropr Osteopat. · Pubmed #16887028 links to  free full text

Abstract: In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a review of the most recent systematic reviews on the effectiveness of spinal manipulation for any condition. The authors concluded that, except for back pain, spinal manipulation is not an effective intervention for any condition and, because of potential side effects, cannot be recommended for use at all in clinical practice. Based on a critical appraisal of their review, the authors of this commentary seriously challenge the conclusions by Ernst and Canter, who did not adhere to standard systematic review methodology, thus threatening the validity of their conclusions. There was no systematic assessment of the literature pertaining to the hazards of manipulation, including comparison to other therapies. Hence, their claim that the risks of manipulation outweigh the benefits, and thus spinal manipulation cannot be recommended as treatment for any condition, was not supported by the data analyzed. Their conclusions are misleading and not based on evidence that allow discrediting of a large body of professionals using spinal manipulation.

Rubinstein SM, van Tulder M. · EMGO Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. · Best Pract Res Clin Rheumatol. · Pubmed #18519100 No free full text.

Abstract: This chapter aims to present an overview of the best available evidence on diagnostic procedures for neck and low-back pain. Relatively little is known about the accuracy of such procedures. Although most spinal conditions are benign and self-limiting, the real challenge to the clinician is to distinguish serious spinal pathology or nerve-root pain from non-specific neck and low-back pain. The use of valid procedures can assist the clinician in this aim. A search was conducted in PubMed to identify relevant systematic reviews and primary studies on diagnostic procedures for the neck and low back. A systematic review was included if at least two independent reviewers were used; a systematic procedure was followed for identifying the literature; and a methodological assessment was conducted. In the absence of systematic reviews, primary studies are reported. Systematic reviews were identified which evaluated evidence for diagnostic procedures in the following categories: history, physical examination, and special studies, including diagnostic imaging, diagnostic blocks, and facet and sacroiliac joint injections. In general, there is much more evidence on diagnostic procedures for the low back than there is for the neck. With regard to the history, a number of factors can be identified which can assist the clinician in identifying sciatica due to disc herniation or serious pathology. With regard to the physical examination, the straight-leg raise is the only sign consistently reported to be sensitive for sciatica due to disc herniation, but is limited by its low specificity. The diagnostic accuracy of other neurological signs and tests is unclear. Orthopaedic tests of the neck, such as Spurling's or the upper-limb tension test, are useful to rule a radiculopathy in or rule out, respectively. In patients 50 years of age or older, plain spinal radiography together with standard laboratory tests are highly accurate in identifying underlying systemic disease; however, plain spinal radiography is not a valuable tool for non-specific neck or low-back pain. There is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, and moderate evidence for transforaminal epidural injections, as well as sacroiliac joint injections for diagnostic purposes. In conclusion, during the history, the clinician can accurately identify sciatica due to disc herniation, as well as serious pathology. There is sufficient evidence regarding the accuracy of specific tests for identifying sciatica or radiculopathy (such as the straight-leg raise) or certain orthopaedic tests of the neck. Plain spinal radiography in combination with standard laboratory tests is useful for identifying pathology, but is not advisable for non-specific neck or low-back pain.

Ammendolia C, Furlan AD, Imamura M, Irvin E, van Tulder M. · University Health Network, Rehabilitation Solutions, Toronto Western Hospital, Fell Pavillion 4-132, 399 Bathurst Street, Toronto, Ontario, Canada MST 258. · Spine J. · Pubmed #18164464 No free full text.

Abstract: The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue to The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

van der Velde G, van Tulder M, Côté P, Hogg-Johnson S, Aker P, Cassidy JD, Anonymous00046, Carragee E, Carroll L, Guzman J, Haldeman S, Holm L, Hurwitz E, Nordin M, Peloso P. · Institute for Work and Health, Toronto, Ontario, Canada. · Spine (Phila Pa 1976). · Pubmed #17414916 No free full text.

Abstract: STUDY DESIGN: Systematic review. OBJECTIVE: To determine whether results and conclusions on the effectiveness of exercise for workers with neck pain vary with the Cochrane Back Review Group Guidelines and best-evidence synthesis review methods. To identify methodologic weaknesses associated with these review methods that may impact on the validity of their results. SUMMARY OF BACKGROUND DATA: The Cochrane Back Review Group Guidelines and best-evidence synthesis have different approaches to appraising trial quality and incorporating quality into data synthesis. The impact of different review methods on the reproducibility and validity of review results is unknown. METHODS AND RESULTS: Systematic search of Medline, Embase, CINAHL, and Cochrane databases, without language restrictions. Twelve trials were selected. Two review methods were used to appraise trial quality and to incorporate quality into data synthesis. As recommended by the Cochrane Back Review Group Guidelines, trials were assigned quality scores using a scale. Results of all 12 trials were stratified into levels of evidence according to their scores. Based on these results, no treatment recommendation could be formulated. Best-evidence synthesis critically appraised methodology; trials were accepted on the strength of their scientific merit or rejected due to risk of bias. According to the 4 trials accepted for best-evidence synthesis, workers should be activated with exercise given its beneficial effect on patient-perceived recovery. Both the Cochrane Back Review Group Guidelines and best-evidence synthesis reviews were found to have weaknesses associated with their methods. CONCLUSIONS: Review results and conclusions are sensitive to methods for appraising trial quality and incorporating quality into data synthesis when the evidence consists largely of low-quality trials. Both the Cochrane Back Review Group Guidelines and best-evidence synthesis methods were found to have strengths and methodologic weaknesses that healthcare decision-makers should be aware of when interpreting systematic reviews.

Krismer M, van Tulder M, Anonymous00875. · Department of Orthopaedic Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria. · Best Pract Res Clin Rheumatol. · Pubmed #17350545 No free full text.

Abstract: Low back pain (LBP) is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain. Most cases are non-specific, but in about 10% of cases a specific cause is identified. Red flags are typical signs or symptoms that are frequently associated with specific LBP. Yellow flags are prognostic factors associated with a more unfavourable and often chronic disabling course of the disease. LBP has a lifetime prevalence of 60-85%. At any one time, about 15% of adults have LBP. LBP poses an economic burden to society, mainly in terms of the large number of work days lost (indirect costs) and less so by direct treatment costs. A substantial proportion of individuals with chronic LBP has been found to have chronic widespread pain. LBP is often associated with other pain manifestations such as headache, abdominal pain and pain in different locations of the extremities. Widespread pain is associated with a worse prognosis compared to localised LBP. Treatment targets are reduction of pain and better activity/participation, including prevention of disability as well as maintainance of work capacity. The evidence from selected and appraised guidelines, systematic reviews and major clinical studies was classified into four levels, level Ia being the best level with evidence from meta-analysis of randomised controlled trials. Key recommendations (level Ia): fitness programmes and advice to stay active can reduce pain, improve function and can prevent LBP becoming chronic. Simple analgesics, NSAIDs and muscle relaxants can reduce pain and can improve and maintain function. Maintaining physical activity, avoiding rest and manual therapy can reduce pain and maintain and restore function in acute LBP. Behavioural treatment can prevent LBP becoming chronic. Aerobic fitness and endurance training, behavioural treatment and multi-disciplinary treatment programmes can reduce pain and can improve/maintain function in chronic LBP.

van Tulder M, Koes B. · VU University Medical Centre, Amsterdam, The Netherlands. · Am Fam Physician. · Pubmed #17111899 links to  free full text

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van Tulder M, Koes B. · Institute for Research in Extramural Medicine, VU University Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #16973063 No free full text.

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Koes B, van Tulder M. · Department of General Practice, Erasmus University, Rotterdam, The Netherlands. · Clin Evid. · Pubmed #16973062 No free full text.

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Clarke J, van Tulder M, Blomberg S, de Vet H, van der Heijden G, Bronfort G. · Institute for Work & Health, Toronto, Ontario, Canada. · Spine (Phila Pa 1976). · Pubmed #16778694 No free full text.

Abstract: STUDY DESIGN: Systematic review. OBJECTIVE: To determine if traction is more effective than reference treatments, placebo/sham traction, or no treatment for low back pain (LBP). SUMMARY OF BACKGROUND DATA: Various types of traction are used in the treatment of LBP, often in conjunction with other treatments. METHODS: We searched MEDLINE, EMBASE, and CINAHL to November 2004, and screened the latest issue of the Cochrane Library (2004, issue 4) and references in relevant reviews and our personal files. We selected randomized controlled trials (RCTs) involving any type of traction for the treatment of acute (less than 4 weeks duration), subacute (4-12 weeks), or chronic (more than 12 weeks) nonspecific LBP with or without sciatica. Sets of 2 reviewers independently performed study selection, methodological quality assessment, and data extraction. Because available studies did not provide sufficient data for statistical pooling, we performed a qualitative "levels of evidence" analysis, systematically estimating the strength of the cumulative evidence on the difference/lack of difference observed in trial outcomes. RESULTS: A total of 24 RCTs (2177 patients) were included. There were 5 trials considered high quality. For mixed groups of patients with LBP with and without sciatica, we found: (1) strong evidence that there is no statistically significant difference in short or long-term outcomes between traction as a single treatment, (continuous or intermittent) and placebo, sham, or no treatment; (2) moderate evidence that traction as a single treatment is no more effective than other treatments; and (3) limited evidence that adding traction to a standard physiotherapy program does not result in significantly different outcomes. For LBP with sciatica, we found conflicting evidence in several of the comparisons: autotraction compared to placebo, sham, or no treatment; other forms of traction compared to other treatments; and different forms of traction. In the remaining comparisons, there were no statistically significant differences; level of evidence is moderate regarding continuous or intermittent traction compared to placebo, sham, or no treatment, and is limited regarding different forms of traction. CONCLUSION: Based on the current evidence, intermittent or continuous traction as a single treatment for LBP cannot be recommended for mixed groups of patients with LBP with and without sciatica. Neither can traction be recommended for patients with sciatica because of inconsistent results and methodological problems in most of the studies involved. However, because high-quality studies within the field are scarce, because many are underpowered, and because traction often is supplied in combination with other treatment modalities, the literature allows no firm negative conclusion that traction, in a generalized sense, is not an effective treatment for patients with LBP.

Gagnier JJ, van Tulder M, Berman B, Bombardier C. · Provincal Medical Centre, 5955 Ontario St., Unit 307, Windsor, Ontario, Canada, N8S1W6. · Cochrane Database Syst Rev. · Pubmed #16625605 No free full text.

Abstract: BACKGROUND: Low-back pain is a common condition and a substantial economic burden in industrialized societies. A large proportion of patients with chronic low-back pain use complementary and alternative medicine (CAM), visit CAM practitioners, or both. Several herbal medicines have been purported for use in low-back pain. OBJECTIVES: To determine the effectiveness of herbal medicine for non-specific low-back pain. SEARCH STRATEGY: We searched the following electronic databases: Cochrane Complementary Medicine Field Trials Register (Issue 3, 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005); checked reference lists in review articles, guidelines and retrieved trials; and personally contacted individuals with expertise in this very specialized area. SELECTION CRITERIA: We included randomized controlled trials, examining adults (over 18 years of age) suffering from acute, sub-acute or chronic non-specific low-back pain. The interventions were herbal medicines, defined as plants that are used for medicinal purposes in any form. Primary outcome measures were pain and function. DATA COLLECTION AND ANALYSIS: Two authors (JJG & MVT) conducted the database searches. One author contacted content experts and acquired relevant citations. Full references and abstracts of the identified studies were downloaded. A hard copy was retrieved for final inclusion decisions. Methodological quality and clinical relevance were assessed separately by two individuals. Disagreements were resolved by consensus. MAIN RESULTS: Ten trials were included in this review. Two high quality trials examining the effects of Harpagophytum Procumbens (Devil's Claw) found strong evidence that daily doses standardized to 50 mg or 100 mg harpagoside were better than placebo for short-term improvements in pain and rescue medication. Another high quality trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib (Vioxx). Two trials examining the effects of Salix Alba (White Willow Bark) found moderate evidence that daily doses standardized to 120 mg or 240 mg salicin were better than placebo for short-term improvements in pain and rescue medication. An additional trial demonstrated relative equivalence to 12.5 mg per day of rofecoxib. Three low quality trials on Capsicum Frutescens (Cayenne), examining various topical preparations, found moderate evidence that Capsicum Frutescens produced more favourable results than placebo and one trial found equivalence to a homeopathic ointment. AUTHORS' CONCLUSIONS: Harpagophytum Procumbens, Salix Alba and Capsicum Frutescens seem to reduce pain more than placebo. Additional trials testing these herbal medicines against standard treatments are needed. The quality of reporting in these trials was generally poor. Trialists should refer to the CONSORT statement extension for reporting trials of herbal medicine interventions.

Wessels T, van Tulder M, Sigl T, Ewert T, Limm H, Stucki G. · Department of Physical Medicine and Rehabilitation, Ludwig-Maximilans University, Marchioninistr. 15, 81377, Munich, Germany. · Eur Spine J. · Pubmed #16575598 No free full text.

Abstract: Systematic reviews have shown that as non-operative treatments exercise, behavioural and multimodal treatment programs are effective for chronic low back pain. There is, however, a lack of knowledge concerning the association between changes in treatment process variables and changes in outcome for the three treatment forms. The objective of this systematic review was to evaluate which changes in treatment process variables predict outcome of exercise, behavioural and multimodal treatment of chronic low back pain. Medline, Embase and PsychInfo were systematically searched. A descriptive analysis was used to summarize the results regarding the outcomes pain, disability and return to work (RTW). 13 studies were identified. The results showed that functional coping mechanisms and pain reduction were associated with a decrease in disability and increase in RTW, and physical performance factors were not. Related to pain reduction decreases in disability, functional coping mechanisms as well as physical performance factors were associated. Strong conclusions cannot be drawn from this review, because of the heterogeneity and the limited number of studies. The results of this review raise the question if changes in behavioural variables and reductions of disability which facilitate an improvement in function, may be more important than physical performance factors for successful treatment of chronic low back pain. This is relevant for the refinement of future treatment programs.

van Tulder M, Koes B. · VU University Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #15865740 No free full text.

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van Tulder M, Koes B. · Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #15865739 No free full text.

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Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. · Institute for Work & Health, Toronto, Ontario, Canada. · Spine (Phila Pa 1976). · Pubmed #15834340 No free full text.

Abstract: OBJECTIVES: To assess the effects of acupuncture and dry-needling for the treatment of nonspecific low back pain. BACKGROUND: Low back pain is usually a self-limiting condition that tends to improve spontaneously over time. However, for many people, back pain becomes a chronic or recurrent problem for which a large variety of therapeutic interventions are employed. SEARCH STRATEGY: We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. SELECTION CRITERIA: Randomized controlled trials of acupuncture (that involved needling) or dry-needling for adults with nonspecific acute/subacute or chronic low back pain. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodologic quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analysis methods or levels of evidence when the data reported did not allow statistical pooling. RESULTS: Thirty-five randomized clinical trials were included: 20 were published in English, 7 in Japanese, 5 in Chinese, and 1 each in Norwegian, Polish, and German. There were only 3 trials of acupuncture for acute low back pain. These studies did not justify firm conclusions because of their small sample sizes and low methodologic quality. For chronic low back pain, there is evidence of pain relief and functional improvement for acupuncture compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and in short-term follow-up. There is also evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, the effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low back pain. No clear recommendations could be made about the most effective acupuncture technique. CONCLUSIONS: The data do not allow firm conclusions regarding the effectiveness of acupuncture for acute low back pain. For chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and "alternative" treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain. Because most of the studies were of lower methodologic quality, there is a clear need for higher quality trials in this area.

van Tulder M, Koes B. · Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #15555152 No free full text.

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van Tulder M, Koes B. · Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #15555151 No free full text.

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van Tulder M, Koes B. · Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #15366180 No free full text.

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van Tulder M, Koes B. · Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #15366178 No free full text.

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Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. · Occupational Medicine, Finnish Institute of Occupational Health, Topeliuksenkatu 41 aA, Helsinki, Finland. · Cochrane Database Syst Rev. · Pubmed #12804427 No free full text.

Abstract: BACKGROUND: Multidisciplinary biopsychosocial rehabilitation programs are widely applied for chronic low back pain patients. The biopsychosocial approach can also prevent chronicity, by providing rehabilitation for patients who still have pain past the initial acute phase. Nevertheless, multidisciplinary treatment programmes are often laborious and long processes and require good collaboration between the patient, the rehabilitation team and the work place. By using workplace visits and developing close relationships with occupational health care providers, one might expect patients' working ability to improve. OBJECTIVES: The objective of this systematic review was to determine the effectiveness of multidisciplinary rehabilitation for subacute low back pain among working age adults. SEARCH STRATEGY: The reviewed studies for this review were electronically identified from MEDLINE, EMBASE, PsycLIT, CENTRAL, Medic, the Science Citation Index, reference checking and consulting experts in the rehabilitation field. The original search was planned and performed for the broader area of musculoskeletal disorders. Trials on subacute low back pain were separated afterwards. The literature search was last updated in November 2002 in EMBASE and MEDLINE. SELECTION CRITERIA: From all references identified in our original search, we selected randomised controlled trials (RCTs) and non-randomised controlled clinical trials (CCTs). Trials had to assess the effectiveness of multidisciplinary rehabilitation for working age patients suffering from subacute low back pain (more than four weeks but less than three months). The rehabilitation program was required to be multidisciplinary, i.e., it had to consist of a physician's consultation plus either a psychological, social or vocational intervention, or a combination of these. DATA COLLECTION AND ANALYSIS: Four reviewers blinded to journal and author selected trials that met the specified inclusion criteria. Two experts in the field of rehabilitation evaluated the clinical relevance and applicability of the findings of the selected studies for actual clinical use. Two other reviewers blinded to journal and author extracted the data and assessed the main results and the methodological quality of the studies, using standardized forms. Finally, a qualitative analysis was performed to evaluate the level of scientific evidence for the effectiveness of multidisciplinary rehabilitation. MAIN RESULTS: After screening 1808 abstracts, and the references of 65 reviews, we found only two relevant studies that satisfied our criteria on subacute low back pain. No more studies were found during the updates. Both studies were considered to be methodologically low quality RCTs. The clinical relevance of included studies was sufficient. There was moderate scientific evidence showing that multidisciplinary rehabilitation, which includes a workplace visit or more comprehensive occupational health care intervention, helps patients to return to work faster, results in fewer sick leaves and alleviates subjective disability. REVIEWER'S CONCLUSIONS: We conclude that there is moderate evidence of positive effectiveness of multidisciplinary rehabilitation for subacute low back pain and that a workplace visit increases the effectiveness. But because this evidence is based on trials that had some methodological shortcomings, and several expensive multidisciplinary rehabilitation programmes are commonly used for uncomplicated/non-specific subacute low back problems, there is an obvious need for high quality trials in this field.

Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M. · Department of Epidemiology, Maastricht University, The Netherlands. · Spine (Phila Pa 1976). · Pubmed #12567020 No free full text.

Abstract: STUDY DESIGN: A systematic review of randomized controlled trials. BACKGROUND: Although several rehabilitation programs, physical fitness programs, or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy of these treatments, and there are still persistent fears of causing reinjury, reherniation, or instability. OBJECTIVES: The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery. METHODS: The authors searched the MEDLINE, Embase, and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, issue 3. Both randomized and nonrandomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included. Two independent reviewers performed the inclusion of studies, and two other reviewers independently performed the methodologic quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results. RESULTS: Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately postsurgery, mainly because of the lack of good quality studies. For treatments that start 4 to 6 weeks postsurgery, there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs, and there is strong evidence (level 1) that on long-term follow-up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs, there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There is also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months postsurgery, are more effective in improving low-back functional status as compared to physical agents, joint manipulations, or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately postsurgery or later. None of the investigated treatments seem harmful with regard to reherniation or reoperation. CONCLUSIONS: There is no evidence that patients need to have their activities restricted after first-time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks postoperative) and no evidence they increase the reoperation rate. It is unclear what the exact content of postsurgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately postsurgery or possibly 4 to 6 weeks later.

van Tulder M, Koes B, Bombardier C. · Institute for Work and Health, 481 University Avenue, Suite 800, Toronto, ON, M5G 2E9, Canada. · Best Pract Res Clin Rheumatol. · Pubmed #12473272 No free full text.

Abstract: Low back pain is a major burden to society. Many people will experience an episode of low back pain during their life. Some people develop chronic low back pain, which can be very disabling. Low back pain is associated with high direct and indirect costs. Recent epidemiological data suggest that there is a need to revise our views regarding the course of low back pain. Low back pain is not simply either acute or chronic but fluctuates over time with frequent recurrences or exacerbations. Also, low back pain may frequently be part of a widespread pain problem instead of being isolated, regional pain. Although epidemiological studies have identified many individual, psychosocial and occupational risk factors for the onset of low back pain, their independent prognostic value is usually low. Similarly, a number of factors have now been identified that may increase the risk of chronic disability but no single factor seems to have a strong impact. Consequently, it is still unclear what the most efficient strategy is for primary and secondary prevention. In general, multi-modal preventative approaches seem better able to reflect the clinical reality than single-modal interventions.

van Tulder M, Koes B. · Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #12230725 No free full text.

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van Tulder M, Koes B. · Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. · Clin Evid. · Pubmed #12230724 No free full text.

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