Acupuncture and dry-needling for low back pain.

BACKGROUND: Although low-back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for its treatment. OBJECTIVES: To assess the effects of acupuncture for the treatment of non-specific low-back pain and dry-needling for myofascial pain syndrome in the low-back region. 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 trials of acupuncture (that involves needling) for adults with non-specific (sub)acute or chronic low-back pain, or dry-needling for myofascial pain syndrome in the low-back region. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analyses methods or levels of evidence when the data reported did not allow statistical pooling. MAIN RESULTS: Thirty-five RCTs were included; 20 were published in English, seven in Japanese, five in Chinese and one each in Norwegian, Polish and German. There were only three trials of acupuncture for acute low-back pain. They did not justify firm conclusions, because of small sample sizes and low methodological quality of the studies. 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 at short-term follow-up. There is evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, 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. AUTHORS' CONCLUSIONS: The data do not allow firm conclusions about 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 methodological quality, there certainly is a further need for higher quality trials in this area.

Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects.

STUDY DESIGN: A subanalysis of data derived from a randomized clinical trial was performed. OBJECTIVE: To evaluate the association of a patient's expectation for benefit from a specific treatment with improved functional outcome. SUMMARY OF BACKGROUND DATA: Psychosocial factors, ambiguous diagnoses, and lack of a clearly superior treatment have complicated the management of patients with chronic low back pain. The authors hypothesized that patient expectation for benefit from a specific treatment is associated with improved functional outcomes when that treatment is administered. METHODS: In a randomized trial, 135 patients with chronic low back pain who received acupuncture or massage were studied. Before randomization, study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. The primary outcome was level of function at 10 weeks as measured by the modified Roland Disability scale. RESULTS: After adjustment for baseline characteristics, improved function was observed for 86% of the participants with higher expectations for the treatment they received, as compared with 68% of those with lower expectations (P = 0.01). Furthermore, patients who expected greater benefit from massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa (P = 0.03). CONCLUSIONS: The results of this study suggest that patient expectations may influence clinical outcome independently of the treatment itself. In contrast, general optimism about treatment, divorced from a specific treatment, is not strongly associated with outcome. These results may have important implications for clinical trial design and recruitment, and may help to explain the apparent success of some conventional and alternative therapies in trials that do not control for patient expectations. The findings also may be important for therapy choices made in the clinical setting.

Acupuncture for chronic low back pain: diagnosis and treatment patterns among acupuncturists evaluating the same patient.

BACKGROUND: There is increasing need to examine the effectiveness of acupuncture and other alternative therapies for common conditions. However, little attention has focused on the variability in acupuncturists' assessment, diagnosis, and treatment patterns. METHODS: Seven office-based acupuncturists practicing Traditional Chinese Medicine evaluated the same patient with chronic low back pain and provided data regarding principal assessment techniques, diagnoses, and therapeutic recommendations. RESULTS: A high diagnostic agreement existed among 5 of 7 acupuncturists. However, recommended treatments included varying numbers and locations of acupuncture points. Recommendations varied between 5 and 14 points requiring 7 to 26 needles, since many points were intended for bilateral application. Of 28 acupuncture points selected, only 4 (14%) were prescribed by two or more acupuncturists. Most recommended various forms of adjuvant heat. CONCLUSIONS: Seven acupuncturists agreed considerably in the diagnoses for the same patient with chronic low back pain, but treatment recommendations varied substantially. Clinicians and researchers must recognize treatment recommendation variations and the challenges they present for study design and interpretation.

Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain.

BACKGROUND: Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain. METHODS: We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects. RESULTS: Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P =.01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P =.002; dysfunction scale: 6.29 vs 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care. CONCLUSIONS: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.

Helping patients decide about back surgery: a randomized trial of an interactive video program.

STUDY DESIGN: A randomized trial of 100 patients with low back pain who were potential surgical candidates. OBJECTIVES: To determine whether an interactive videodisc with a booklet is superior to a booklet alone for informing patients about back surgery. SUMMARY OF BACKGROUND DATA: Substantial geographic variation has been observed in lumbar spine surgery. Informed patient preferences should play an important role in decisions about surgery. However, little is known about optimal strategies for informing patients. METHODS: Subjects were randomized to receive an interactive videodisc (with a booklet) or a booklet alone. A knowledge test administered at baseline and follow-up was used to measure improvement in knowledge about treatment options for lumbar spine problems. Patients' reactions to the videodisc and booklet and preferences for treatment were also assessed. RESULTS: The patients' knowledge improved after exposure to either intervention. Multivariate analyses adjusted for baseline score, age, education, gender, and diagnosis showed a significant advantage for the videodisc with booklet over the booklet alone. The videodisc-booklet group showed significantly greater gains in knowledge among subjects with the worst baseline knowledge scores. A larger proportion of subjects in the videodisc-booklet group rated the materials easy to understand (93% vs.- 72%,P = 0.04), containing the right amount of information (93% vs.- 80%,P = 0.3), and adequate to assist in choice of treatment (75% vs.- 51%,P = 0.2). Those who viewed the videodisc expressed a somewhat lower preference for surgery than those who received the booklet alone (23% vs.- 42%,P = 0.4). CONCLUSIONS: Both the booklet alone and the combination of videodisc and booklet improved knowledge. The combination produced greater knowledge gains than the booklet alone for the subgroup with the least knowledge at baseline. Patients preferred the combination and had a slightly lower preference for surgery if they had viewed the video presentation. For some patients, the video may enhance involvement in clinical decisions.

How traditional Chinese medicine acupuncturists would diagnose and treat chronic low back pain: results of a survey of licensed acupuncturists in Washington State.

OBJECTIVES: This survey was undertaken to learn how Traditional Chinese Medicine acupuncturists' diagnose and treat patients with chronic low back pain in order to develop a standardized treatment for a clinical trial of that condition. DESIGN: We surveyed a randomly selected group of 56 acupuncturists in Washington State, USA about styles of acupuncture they used for treating chronic low back pain, diagnoses made, and key features of treatment for this condition. RESULTS: While substantial variability existed among practitioners, there was agreement on several broad features of treatment including: the use of local and distal acupuncture points (86% of practitioners), the use of acupuncture points on the meridians traversing the back (especially the UB meridian, 90%) the use of acupoints determined by palpation (82%), the importance of eliciting de qi (60%), and of providing up to eight treatments for achieving therapeutic results (79%). CONCLUSION: The use of practitioner surveys can enhance the systematic development of acupuncture treatment protocols and should be part of this process in future clinical trials of common conditions.

Variation in diagnosis and treatment of chronic low back pain by traditional Chinese medicine acupuncturists.

OBJECTIVES: To assess interrater reliability of Traditional Chinese Medicine (TCM) diagnosis and treatment of chronic low back pain. DESIGN: Under a Latin square design, six TCM acupuncturists evaluated the same six patients on the same day. SETTING: Northwest Institute of Acupuncture and Oriental Medicine, Seattle, Washington. INTERVENTIONS: Assessment only. OUTCOME MEASURES: TCM diagnosis, acupoint prescriptions, auxiliary treatment recommendations. RESULTS: Twenty diagnoses and 65 acupoints were used at least once. The diagnosis of Qi/Blood Stagnation with Kidney Deficiency and the acupoint UB23 were used for every patient by most acupuncturists. However, consistency across acupuncturists regarding diagnostic details and other acupoints was poor. No diagnoses, and only one acupoint, were used preferentially for a subgroup of patients. Some diagnoses and treatment recommendations were dependent more on the practitioner than on the patient. Fine-grained diagnoses and most acupoints were unrelated to either patient or practitioner. CONCLUSIONS: TCM diagnoses and treatment recommendations for specific patients with chronic low back pain vary widely across practitioners. Acupuncture clinical trials using an individualized treatment arm may be difficult to replicate or evaluate because of low concordance among acupuncturists. Comparison of individualized treatment with a thoughtfully developed standardized approach is warranted to determine which, if either, is superior.

The diagnosis and treatment of patients with chronic low-back pain by traditional Chinese medical acupuncturists.

The selection of appropriate treatments in clinical trials of acupuncture requires understanding how acupuncturists diagnose and treat specific conditions. We examined the Traditional Chinese Medical (TCM) diagnoses and treatments for patients with chronic low-back pain using two separate sets of treatment records. Information from more than 150 initial visits was available for analysis. A diagnosis of Qi and Blood Stagnation or Qi Stagnation was made for 85% of patients. A diagnosis of kidney deficiency (or one of its three subtypes) was made for 33%-51% of patients. Other specific diagnoses were made for less than 20% of the patients. An average of 12-13 needles was used in each treatment. Although more than 85 different acupoints were used in each data set, only 5 or 6 acupoints were used in more than 20 of the treatments in each data set. Only two of those acupoints (UB23, UB40) were the same for both sources of data. More than half of the patients received adjunctive treatments, including heat (36%-67%), and cupping (16%-21%). There was substantial variability in treatments among providers. Such diversity will make it challenging to select a single treatment that has wide applicability. We recommend that researchers attempt to develop a treatment that is considered credible by expert acupuncturists and has broad features characteristic of patterns of common clinical practice.

Involving patients in clinical decisions: impact of an interactive video program on use of back surgery.

BACKGROUND: Back surgery rates are rapidly rising in the United States. This surgery is usually elective, so patient preferences are important in the treatment decision. OBJECTIVES: The objective of this study was to determine the impact on outcomes and surgical choices of an interactive, diagnosis-specific videodisk program for informing patients about treatment choices. RESEARCH DESIGN: This was a randomized, controlled trial at 2 sites comparing the interactive video plus a booklet with the booklet alone. SUBJECTS: Elective surgery candidates (n = 393) included 171 patients with herniated disks, 110 with spinal stenosis, and 112 with other diagnoses. MEASURES: Mailed questionnaires were used to assess outcomes and satisfaction; surgery rates were determined by questionnaires and automated records. RESULTS: Symptom and functional outcomes at 3 months and 1 year were similar between study groups. The overall surgery rate was 22% lower in the videodisk group (26% versus 33%, P = 0.08). Among patients with herniated disks, those in the video group underwent significantly less surgery (32% versus 47%, P = 0.05 by Kaplan-Meier test). Among patients with spinal stenosis, surgery rates in the video group were higher (39% for the video group, 29% for the booklet group; P = 0.4). There was little effect on patient satisfaction, but patients in the video group felt better informed. CONCLUSIONS: The program appears to facilitate decision making and may help to ensure informed consent. For patients with herniated disks, it reduced the surgery rate without diminishing patient outcomes. Its impact on costs of care depends on the proportion of patients with various diagnoses and on local surgery rates.

Acupuncture for low back pain.

BACKGROUND: Although low back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for the treatment of low back pain. OBJECTIVES: The objective of this review was to assess the effects of acupuncture for the treatment of non-specific low back pain. SEARCH STRATEGY: We searched the Cochrane Complementary Medicine Field trials register, the Cochrane Controlled Trials Register (1997, issue 1), Medline (1966 - 1996), Embase (1988 - 1996), Science Citation Index and reference lists of articles. SELECTION CRITERIA: Randomised trials of all types of acupuncture treatment that involves needling for subjects with non-specific low back pain. DATA COLLECTION AND ANALYSIS: Two reviewers blinded with respect to authors, institution and journal independently assessed trial quality and extracted data. MAIN RESULTS: Eleven trials were included. The methodological quality was low. Only two trials were of high quality. Three trials compared acupuncture to no treatment, which were of low methodological quality and provide conflicting evidence. There was moderate evidence from two trials that acupuncture is not more effective than trigger point injection or transcutaneous electrical nerve stimulation (TENS). There was limited evidence from eight trials that acupuncture is not more effective than placebo or sham acupuncture for the treatment of chronic low back pain. REVIEWER'S CONCLUSIONS: The evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.

The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group.

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To evaluate the efficacy and effectiveness of acupuncture for the management of nonspecific low back pain. SUMMARY OF BACKGROUND DATA: Acupuncture is one of the oldest forms of therapy, but little is known about the effectiveness of acupuncture for low back pain. METHODS: Randomized controlled trials were done to assess the effectiveness of all types of acupuncture treatment, which involves needling for subjects with nonspecific low back pain. Two reviewers blinded with respect to authors, institution, and journal independently assessed the methodologic quality of the studies. Because data were statistically and clinically too heterogeneous, a qualitative review was performed. The evidence was classified into four levels: strong, moderate, limited, or no evidence. RESULTS: Eleven randomized controlled trials were included. Overall, the methodologic quality was low. Only two studies met the preset "high quality" level for this review. No study clearly evaluated acupuncture for acute low back pain. The results indicate that there was no evidence showing acupuncture to be more effective than no treatment. There was moderate evidence indicating that acupuncture is not more effective than trigger-point injection or transcutaneous electrical nerve stimulation, and there was limited evidence that acupuncture is not more effective than placebo or sham acupuncture for the management of chronic low back pain. CONCLUSIONS: Because this systematic review did not clearly indicate that acupuncture is effective in the management of back pain, the authors would not recommend acupuncture as a regular treatment for patients with low back pain. There clearly is a need for more high-quality randomized controlled trials.

A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care.

STUDY DESIGN: Randomized, controlled trial. OBJECTIVE: To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. BACKGROUND DATA: Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. METHODS: Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. RESULTS: Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. CONCLUSIONS: Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.

A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities.

STUDY DESIGN: Consensus process. OBJECTIVES: Reexamining and redirecting the research agenda for low back pain in primary care. SUMMARY OF BACKGROUND DATA: Most research, publications, and funding have traditionally been directed toward specialty and biologically oriented investigations of "spinal disorders" from biomedical and biomechanical perspectives. Beginning in the mid-1980s, primary care researchers began to investigate this field in earnest, focusing on lower back pain as a pain syndrome within an individual, family, and community context. Unfortunately, more progress has been made on what should not be done in diagnosing and treating lower back pain than on what should be done. METHODS: This was a modified group process designed to reach consensus among an international group of primary care lower back pain researchers. RESULTS: Nearly all of the research priorities from the initial 1995 forum are still thought to be important, although only modest progress has been made on most of them. The priorities perceived to be the most feasible to investigate and the ones in which the greatest strides have been achieved are in methodologic rather than substantive areas. Identifying subgroups of people with lower back pain is still given top ranking in 1997, but the priorities have changed dramatically. Greater emphasis is given to finding predictors and risk factors for lower back pain chronicity, improving self-care strategies, and stimulating self-reliance. New items now make up 50% of the top 10 priorities. In general, the additions reflect a greater emphasis on expanding methodologic avenues of inquiry. CONCLUSIONS: Methodologic advances, the enlistment of new techniques and disciplines, and redirected research efforts may facilitate progress in the diagnosis and treatment of lower back pain.

Primary care research on low back pain. The state of the science.

The past few years have witnessed an explosion of primary care-relevant research on low back pain. The descriptive studies have helped elucidate the diagnostic and therapeutic interventions that are in current use. The literature syntheses have clarified what is known about the usefulness of these interventions. The randomized trials have pushed the frontiers of knowledge in several important areas. The quality of research in this field is mixed but has improved significantly in recent years. If research is to lead to substantial improvements in primary care for low back pain, however, the focus must be broadened to embrace an existing but neglected paradigm, the biopsychosocial model. It must be understood how the physician can become a more effective healer and counselor for the patient with back pain. This will require that greater attention be paid to literature outside of the field and that communication and collaboration with researchers in other disciplines increase. Modern distractions such as technology, litigation, and disability compensation have interfered with the ability of physicians to meet their patients' needs. If physicians are to become more effective managers of such common problems as low back pain, they must rediscover their ability to help their patients cope with illness and suffering.

A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain.

BACKGROUND AND METHODS: There are few data on the relative effectiveness and costs of treatments for low back pain. We randomly assigned 321 adults with low back pain that persisted for seven days after a primary care visit to the McKenzie method of physical therapy, chiropractic manipulation, or a minimal intervention (provision of an educational booklet). Patients with sciatica were excluded. Physical therapy or chiropractic manipulation was provided for one month (the number of visits was determined by the practitioner but was limited to a maximum of nine); patients were followed for a total of two years. The bothersomeness of symptoms was measured on an 11-point scale, and the level of dysfunction was measured on the 24-point Roland Disability Scale. RESULTS: After adjustment for base-line differences, the chiropractic group had less severe symptoms than the booklet group at four weeks (P=0.02), and there was a trend toward less severe symptoms in the physical therapy group (P=0.06). However, these differences were small and not significant after transformations of the data to adjust for their non-normal distribution. Differences in the extent of dysfunction among the groups were small and approached significance only at one year, with greater dysfunction in the booklet group than in the other two groups (P=0.05). For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were $437 for the physical-therapy group, $429 for the chiropractic group, and $153 for the booklet group. CONCLUSIONS: For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.

Reasons for repeated medical visits among patients with chronic back pain.

OBJECTIVE: This study identifies the key motivations of patients repeatedly seeking medical care for chronic back problems. DESIGN: We conducted one-on-one, in-depth interviews with patients to discuss their experiences with low back pain and its care. To validate our interpretation of the qualitative data, participants were mailed questionnaires listing the themes identified in the interviews and asked to rate the importance to them of each of the themes. SETTING: Managed health care plans in Atlanta, Dallas, and Seattle. PARTICIPANTS: Fifty-four patients (37% male, 63% female) who were 25 to 65 years of age and had three or more medically attended episodes of low back pain during the 3 years preceding the study. MAIN RESULTS: In describing their motivations for seeking medical care for back pain, nearly all participants cited difficulty in performing normal activities and the desire to discover the cause of the pain. Other motivations for seeking medical care for back pain included increased pain and the desire for a diagnostic test or a new treatment. Many of the verbalized reasons for repeated medical visits among patients with chronic back pain are probably best understood as seeking validation of their suffering. CONCLUSIONS: Patients with chronic back pain report many unmet needs and expectations. Overall satisfaction might be improved if clinicians elicit patients' views of underlying causes and their expectations from office visits.

Employer-sponsored health insurance for chiropractic services.

The use of chiropractors has increased substantially in recent years, and there is growing scientific evidence on the effectiveness of chiropractic treatment for common low back ailments. Despite the increased acceptance of chiropractic care, little is known about the prevalence of chiropractic coverage in employer health plans and the nature of such benefits when they are provided. This article reports on the extent and composition of chiropractic insurance among workers with employer-sponsored health insurance in 1993. The prevalence of the benefits in employer plans was examined, as was the extent to which plans are in compliance with state mandated benefits in this area. The authors also examined what the actual benefits consist of and how they compare with those for physician office visits and physical therapy.

Medication use for low back pain in primary care.

STUDY DESIGN: A longitudinal observational study of primary care patients with low back pain. OBJECTIVES: 1) To describe medications prescribed for back pain, 2) to identify patient characteristics associated with type of drug therapy, 3) to determine if the prescription of certain drugs is associated with better outcomes, and 4) to compare physician prescribing behavior with national guidelines. SUMMARY OF BACKGROUND DATA: Few previous studies have focused on medication prescribing patterns for back pain in primary care. METHODS: Two-hundred nineteen patients aged 20-69 years who were making a first visit for an episode of back pain were studied. After the visit, patients completed questionnaires regarding sociodemographic characteristics, health status, back pain experience, and use of medications. Symptom severity and dysfunction were assessed by telephone 1 week after the visit. RESULTS: Sixty-nine percent of patients were prescribed nonsteroidal anti-inflammatory drugs, 35% muscle relaxants, 12% narcotics, and 4% acetaminophen. Twenty percent received no medications. Patients were more likely to receive medications if they had a desire for medication, pain below the knee, less than 3 weeks of pain before visit, more severe symptoms, or greater dysfunction. Patients with more severe symptoms were more likely to receive narcotics or muscle relaxants. Patients with greater dysfunction were also more likely to receive narcotics. Type of drug therapy predicted symptom severity but not dysfunction after 1 week. Controlling for other factors, those receiving medications had less severe symptoms after 1 week than patients who received no medication. Patients receiving both muscle relaxants and nonsteroidal anti-inflammatory drugs had the best outcomes. Medication use for back pain in this health maintenance organization was generally concordant with national guidelines. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs, often augmented by muscle relaxants, are a standard medical treatment for back pain in primary care. In this observational study, patients prescribed medications, particularly muscle relaxants, reported less severe symptoms after 1 week than those receiving no medications. However, randomized trials are needed to determine which medication or combinations of medications are most effective.

An agenda for primary care research on low back pain.

In October 1995, an International Forum for Primary Care Research on Low Back Pain was held in Seattle, Washington. The Forum focused on the broad range of decisions that patients and their primary care providers make concerning how to best manage low back pain. In addition to providing a venue for summarizing the current state of knowledge about these issues, a major goal of the Forum was to draft an agenda for future primary care research on low back pain. Previous efforts to delineate priority areas for research in this field have emphasized the concerns of basic scientists, pain specialists, and surgeons while ignoring the major concerns of patients and providers in the primary care setting, where the majority of patients with back pain are seen. This article describes the group consensus process used to draft an agenda, presents the items included, and contrasts this primary care agenda with agendas for back pain research developed primarily by specialists. This agenda identifies for the first time the clinical and methodologic issues that primary care experts on back pain consider to be of highest priority. Hopefully, it will help focus future primary care research and encourage funding agencies to give priority to the issues identified.

Predicting poor outcomes for back pain seen in primary care using patients' own criteria.

STUDY DESIGN: A prospective cohort study of patients seen in primary care for low back pain. OBJECTIVES: A new measure of back pain outcomes is used to describe the status of back problems at various intervals after visits to primary care physicians and to identify subsets of patients with worse prognoses. SUMMARY OF BACKGROUND DATA: Most previous studies of the prognosis of back pain in primary care have failed to provide clinically useful information. METHODS: Baseline data were collected from 219 patients making an initial visit for an episode of low back pain to a primary care clinic. A measure of how patients reported they would feel if they had their current back symptoms for the rest of their lives ("Symptom Satisfaction") was used to distinguish good from poor outcomes. Patient outcomes were assessed 1, 3, 7, and 52 weeks after the index visit. RESULTS: Only 67% of patients reported good outcomes after 7 weeks, and only 71% were satisfied with their condition 1 year later. After controlling for the effects of other variables measured during the initial physician visit, only younger age, depression, and pain below the knee were significant predictors of poor outcome at 7 weeks, and only pain below the knee and depression were significant predictors at 1 year. CONCLUSIONS: The proportion of primary care patients with back pain who have poor outcomes appears to be higher than generally recognized. Ways of improving how primary care responds to patients with persisting pain should be investigated.