Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Musculoskeletal disorders and occupational exposures: How should we judge the evidence concerning the causal association? Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews Low pressure pain thresholds are associated with, but does not predispose for, low back pain Dose-response relations between occupational exposures to physical and psychosocial factors and the risk of low back pain Associations between daily chronic pain intensity, daily anger expression, and trait anger expressiveness: An ecological momentary assessment study Exploring Factors Influencing Low Back Pain in People With Nondysvascular Lower Limb Amputation: A National Survey. Identification of Modifiable Personal Factors That Predict New-onset Low Back Pain: A Prospective Study of Female Nursing Students Cumulative Low Back Load at Work as a Risk Factor of Low Back Pain: A Prospective Cohort Study Body Mass Index as a Risk Factor for Developing Chronic Low Back Pain: A Follow-up in the Nord-Trøndelag Health Study Low Back Pain Among Nurses: A Follow-up Beginning at Entry to the Nursing School The natural course of low back pain: a systematic critical literature review Sociocultural factors and back pain. A population-based study in Belgian adults. A 35-Year Trend Analysis for Back Pain in Austria: The Role of Obesity Is there a relationship between pain intensity and postural sway in patients with non-specific low back pain? painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain Effectiveness of a lumbopelvic monitor and feedback device to change postural behaviour: a protocol for the ELF cluster randomised controlled trial Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study Work factors as predictors of intense or disabling low back pain; a prospective study of nurses’ aides Reduction of chronic non-specific low back pain: A randomised controlled clinical trial on acupuncture and baclofen A randomized trial of behavioral physical therapy interventions for acute and sub-acute low back pain (NCT00373867) Do psychological factors predict outcome in both low-back pain and shoulder pain? Delivering an Optimised Behavioural Intervention (OBI) to people with low back pain with high psychological risk; results and lessons learnt from a feasibility randomised controlled trial of Contextual Cognitive Behavioural Therapy (CCBT) vs. Physiotherapy Manual handling activities and risk of low back pain in nurses. Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the Dutch Transition Project. Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol The prevalence, incidence and severity of low back pain among international-level rowers A methodological survey of the analysis, reporting and interpretation of Absolute Risk ReductiOn in systematic revieWs (ARROW): a study protocol A study of work stress, patient handling activities and the risk of low back pain among nurses in Hong Kong. One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Abstract Purpose To evaluate the effectiveness of non-steroidal anti-inflammatory drugs ( NSAIDs ) for the management of neck pain and associated disorders ( NAD ) , whiplash-associated disorders , and non-specific low back pain ( LBP ) with or without radiculopathy . Methods We systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s had a low risk of bias . For recent-onset NAD , evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy . For NAD ( duration not specified ) , oral NSAIDs may be more effective than placebo . For recent-onset LBP , evidence suggests that : ( 1 ) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant ; and ( 2 ) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest . For persistent LBP , evidence suggests that : ( 1 ) oral NSAIDs are more effective than placebo ; and ( 2 ) oral NSAIDs may be more effective than acetaminophen . For recent-onset LBP with radiculopathy , there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo . Finally , different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy . Conclusions For NAD , oral NSAIDs may be more effective than placebo . Oral NSAIDs are more effective than placebo for persistent LBP , but not for recent-onset LBP . Different oral NSAIDs lead to similar outcomes for neck pain and LBP Musculoskeletal disorders ( MSDs ) affecting the back , upper and lower extremities are widespread in the general population , implying a variety of causal factors . Multiple causes are not mutually exclusive , and a high background rate does not preclude associations with specific factors that are uncommon in the general population . MSDs have well-documented associations with occupational ergonomic stressors such as repetitive motion , heavy lifting , non-neutral postures , and vibration . Organizational features of the work environment , such as time pressure and low decision latitude , may also play a role , at least by potentiating the effects of physical loading . Numerous systematic review s have mostly concurred with these overall findings . Nevertheless , some continue to debate whether MSDs are sometimes work-related , even for those performing jobs with repetitive and routinized tasks , heavy lifting , and /or pronounced postural strain . This article discusses ( 1 ) some epidemiologic features of MSDs that underlie that debate ; and ( 2 ) the question of what should appropriately be considered a gold st and ard for scientific evidence on an etiological question such as the health effects of a non-voluntary exposure , such as an occupational or environmental agent . In particular , r and omized clinical trials have little relevance for determining the health effects of non-therapeutic risk factors BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies Chronic pain is often associated with hyperalgesia in cross-sectional studies . In the present study , a r and om cohort of 40-year-old individuals ( n = 264 ) from the general population was assessed for low back pain ( LBP ) status and pressure pain threshold ( PPT )  , with follow-up assessment 4 and 8 years later . Low PPT at baseline as a potential risk factor for the development of LBP was investigated longitudinally and the association between LBP and hyperalgesia was studied cross-sectionally at baseline and 8-year follow-up . Generalized ( p < 0.03 ) and localized pressure hyperalgesia ( p < 0.02 ) was found in participants with long-lasting LBP , but not with recent LBP ( p > 0.08 ) . Of the participants without recent or long-lasting LBP , those with a low PPT at baseline ( lower 10 % percentile ) had no increased risk of developing LBP ( p > 0.05 ) . The findings indicate that PPT decreases as a consequence of long-lasting pain , whereas a low PPT seems not to constitute a separate risk factor for the development of LBP Aims : To assess dose-response relations between occupational exposures to physical and psychosocial factors and the risk of  low back pain .  Methods : A cohort of 523 subjects , working in nursing homes and homes for the elderly , was followed prospect ively for one year . Physical load for different occupations was assessed by quantitative observations at the workplace . Information on low back pain and other factors was gathered with question naires administered at baseline and at one year . Two outcome measures of low back pain incidence were used : any new episode of pain lasting for at least a few hours during follow up ( LBP ) ; and any new episode of disabling pain that interfered with daily activities during follow up ( LBP/D ) . Hierarchical regression analysis with a spline function was used to estimate dose-response relations . Results : The risk of LBP was not associated with physical factors , controlling for confounders ; but this outcome was inversely associated with age and weakly , though imprecisely , associated with two psychosocial factors — low decision authority and high work dem and s. In contrast , the risk of LBP/D was positively associated with age and not associated with the psychosocial factors . Trunk flexion over 45 degrees was monotonically associated with the risk of LBP/D ; the estimated relative risk was 3.18 ( 95 % CI 1.13 to 9.00 ) for 1 hour and 45 minutes of bending per week ( 90th centile ) , relative to 30 minutes per week . The hierarchical estimates of effect were more stable than were the maximum likelihood estimates . Conclusion : Occupational exposure to trunk flexion over 45 degrees appears to be a risk factor for low back pain with disability among persons employed in nursing homes and homes for the elderly in the Netherl and Summary Within‐day associations between behavioral anger expression and momentary chronic pain intensity show significant lagged effects , with elevated behavioral anger expression linked to greater subsequent pain intensity . ABSTRACT Links between elevated trait anger expressiveness ( anger‐out ) and greater chronic pain intensity are well documented , but pain‐related effects of expressive behaviors actually used to regulate anger when it is experienced have been little explored . This study used ecological momentary assessment methods to explore prospect i ve associations between daily behavioral anger expression and daily chronic pain intensity .  Forty‐eight chronic low back pain ( LBP ) patients and 36 healthy controls completed electronic diary ratings of momentary pain and behavioral anger expression in response to r and om prompts 4 times daily for 7 days . Across groups , greater trait anger‐out was associated with greater daily behavioral anger expression ( P < 0.001 ) . LBP participants showed higher levels of daily anger expression than controls ( P < 0.001 ) . Generalized estimating equation analyses in the LBP group revealed a lagged main effect of greater behavioral anger expression on increased chronic pain intensity in the subsequent assessment period ( P < 0.05 ) . Examination of a trait × situation model for anger‐out revealed prospect i ve associations between elevated chronic pain intensity and later increases in behavioral anger expression that were restricted largely to individuals low in trait anger‐out ( P < 0.001 ) . Trait × situation interactions for trait anger suppression ( anger‐in ) indicated similar influences of pain intensity on subsequent behavioral anger expression occurring among low anger‐in persons ( P < 0.001 ) . Overlap with trait and state negative affect did not account for study findings . This study for the first time documents lagged within‐day influences of behavioral anger expression on subsequent chronic pain intensity . Trait anger regulation style may moderate associations between behavioral anger expression and chronic pain intensity BACKGROUND Chronic low back pain ( LBP ) is a common musculoskeletal impairment in people with lower limb amputation . Given the multifactorial nature of LBP , exploring the factors influencing the presence and intensity of LBP is warranted . OBJECTIVE To investigate which physical , personal , and amputee-specific factors predicted the presence and intensity of LBP in persons with nondysvascular transfemoral amputation ( TFA ) and transtibial amputation ( TTA ) . DESIGN A retrospective cross-sectional survey . SETTING A national r and om sample of people with nondysvascular TFA and TTA . PARTICIPANTS Participants ( N = 526 ) with unilateral TFA and TTA due to nondysvascular etiology ( ie , trauma , tumors , and congenital causes ) and a minimum prosthesis use of 1 year since amputation were invited to participate in the survey . The data from 208 participants ( 43.4 % response rate ) were used for multivariate regression analysis . METHODS ( INDEPENDENT VARIABLES ) Personal ( ie , age , body mass , gender , work status , and presence of comorbid conditions ) , amputee-specific ( ie , level of amputation , years of prosthesis use , presence of phantom-limb pain , residual-limb problems , and nonamputated limb pain ) , and physical factors ( ie , pain-provoking postures including st and ing , bending , lifting , walking , sitting , sit-to-st and , and climbing stairs ) . MAIN OUTCOME MEASURES ( DEPENDENT VARIABLES ) LBP presence and intensity . RESULTS A multivariate logistic regression model showed that the presence of 2 or more comorbid conditions ( prevalence odds ratio [ POR ] = 4.34 , P = .01 ) , residual-limb problems ( POR = 3.76 , P < .01 ) , and phantom-limb pain ( POR = 2.46 , P = .01 ) influenced the presence of LBP . Given the high LBP prevalence ( 63 % ) in the study , there is a tendency for overestimation of POR , and the results must be interpreted with caution . In those with LBP , the presence of residual-limb problems ( β = 0.21 , P = .01 ) and experiencing LBP symptoms during sit-to-st and task ( β = 0.22 , P = .03 ) were positively associated with LBP intensity , whereas being employed demonstrated a negative association ( β = -0.18 , P = .03 ) in the multivariate linear regression model . CONCLUSIONS Rehabilitation professionals should be cognizant of the influence that comorbid conditions , residual-limb problems , and phantom pain have on the presence of LBP in people with nondysvascular lower limb amputation .  Further prospect i ve studies could investigate the underlying causal mechanisms of LBP . LEVEL OF EVIDENCE II Objectives Prevention of occupational low back pain ( LBP ) in nurses is a research priority . Recent research suggests intervening before commencing nursing employment is ideal ; however , identification of modifiable risk factors is required . The objective of this study was to investigate modifiable personal characteristics that predicted new-onset LBP in nursing students . Methods This prospect i ve study was conducted on female nursing students ( n=117 ) without LBP at baseline to predict new-onset LBP ( an episode of significant LBP during the follow-up period ) . At the 12-month follow-up , participants with ( n=31 ) and without new-onset LBP ( n=76 ) were compared across baseline social or lifestyle , psychologic ( distress , back pain beliefs , coping strategies , and catastrophising ) , and physical ( spinal postures and spinal kinematics in functional tasks , leg and back muscle endurance , spinal repositioning error , and cardiovascular fitness ) characteristics . Results Participants response rate at follow-up was excellent ( 91 % ) . After controlling for earlier LBP , age , and BMI , regression analysis showed that modifiable social or lifestyle , psychologic and physical characteristics ( namely , smoking , increased physical activity , higher stress , reduced back muscle endurance , greater posterior pelvic rotation in slump sitting , and more accurate spinal repositioning in sitting ) were significant and independent predictors of new-onset LBP at follow-up . Inclusion of these factors in multivariate logistic regression analysis , with significant new-onset LBP as the outcome , result ed in a substantial model R2 of 0.45 . Discussion Modifiable personal characteristics across multiple domains are associated with new-onset LBP in female nursing students . These findings may have implication s for the development of prevention and management interventions for LBP in nurses Purpose Much research has been performed on physical exposures during work ( e.g. lifting , trunk flexion or body vibrations ) as risk factors for  low back pain ( LBP ) , however results are inconsistent . Information on the effect of doses ( e.g. spinal force or low back moments ) on LBP may be more reliable but is lacking yet . The aim of the present study was to investigate the prospect i ve relationship of cumulative low back loads ( CLBL ) with LBP and to compare the association of this mechanical load measure to exposure measures used previously . Methods The current study was part of the Study on Musculoskeletal disorders , Absenteeism and Health ( SMASH ) study in which 1,745 workers completed question naires .  Physical load at the workplace was assessed by video-observations and force measurements . These measures were used to calculate CLBL . Furthermore , a 3-year follow-up was conducted to assess the occurrence of LBP . Logistic regressions were performed to assess associations of CLBL and physical risk factors established earlier ( i.e. lifting and working in a flexed posture ) with LBP . Furthermore , CLBL and the risk factors combined were assessed as predictors in logistic regression analyses to assess the association with LBP . Results Results showed that CLBL is a significant risk factor for LBP ( OR : 2.06 ( 1.32–3.20 ) ) . Furthermore , CLBL had a more consistent association with LBP than two of the three risk factors reported earlier . Conclusions From these results it can be concluded that CLBL is a risk factor for the occurrence of LBP , having a more consistent association with LBP compared to most risk factors reported earlier Study Design . A population -based , prospect i ve cohort study . Objective . To determine whether overweight , obesity , or more generally an elevated body mass index ( BMI ) increase the probability of experiencing  chronic low back pain ( LBP ) after an 11-year period , both among participants with and without LBP at baseline . Summary of Background Data . Chronic LBP is a common disabling disorder in modern society . Cross-sectional studies suggest an association between an elevated BMI and LBP , but it is not clear whether this is a causal relationship . Methods . Data were obtained from the community-based HUNT 2 ( 1995–1997 ) and HUNT 3 ( 2006–2008 ) studies of an entire Norwegian county . Participants were 8733 men and 10,149 women , aged 30 to 69 years , who did not have chronic LBP at baseline , and 2669 men and 3899 women with LBP at baseline . After 11 years , both groups indicated whether they currently had chronic LBP , defined as pain persisting for at least 3 months continuously during the last year . Results . A significant positive association was found between BMI and risk of LBP among persons without LBP at baseline . The odds ratio for BMI 30 or more versus BMI less than 25 was 1.34 ( 95 % confidence interval [ CI ] , 1.08–1.67 ) for men and 1.22 ( 95 % CI , 1.03–1.46 ) for women , in analyses adjusted for age , education , work status , physical activity at work and in leisure time , smoking , blood pressure , and serum lipid levels . A significant positive association was also established between BMI and recurrence of LBP among women . LBP status at baseline had negligible influence on subsequent change in BMI . Conclusion . High values of BMI may predispose to chronic LBP 11 years later , both in individuals with and without LBP . The association between BMI and LBP is not explained by an effect of LBP on later change in BMI Study Design . A prospect i ve cohort . Objectives . To investigate the prevalence of back pain from entering the nursing school through 5 years in nursing and the determinants and modifiers of back pain and disability . Summary of Background Data . Physical loading , psychologic characteristics , and several other factors have been associated with back pain at work in earlier studies . Because of the lack of the prework entry morbidity data , the nature of the associations between these exposures and the symptoms is unclear . That previous back pain is a predictor of later pain underlines the importance to have pre-employment data in investigations of the role of exposures at work . Methods . Female nursing students ( n = 174 ) were followed for 7.5 years . Data on constitutional and behavioral  factors , occupational exposures  , and  back-related symptoms and disability  were collected . Back pain was grouped into “ sciatic , ” “ sudden , ” or “ other ” and related disability . Results . The lifetime cumulative prevalence of back pain increased from 31 % at entry to nursing school to 72 % at the end of the school and further to 82 % after 5 years as a nurse . The 1-year prevalence of any back pain was 54 % for the first year in nursing school , 57 % for the first year as a nurse , and 64 % for the fifth year as a nurse . In multivariate analyses , other back pain and related disability as a nurse were associated with back pain history at the entry to nursing school ( odds ratio , 7.1 ; 95 % confidence interval , 1.5–34 ; and 3.6 ; 1.2–11 , respectively ) , and working in twisted/bent positions ( odds ratio , 6.2 ; 95 % confidence interval , 1.7–23 ; and 7.5 ; 2.9–20 , respectively ) . Sudden back pain was not associated with any of the studied risk factors . Sciatic back pain was associated only with working positions ( odds ratio , 6.9 ; 95 % confidence interval , 2.1–23 ) . Conclusions . Lifetime prevalence of back pain increased sharply during nursing school but slowly after that . Back pain at entering the nursing school wasa predictor for back-related pain and disability . Self- reported occupational physical work load was associated with back pain and related disability . The nature of the association is unclear , but it is likely that back pain is exacerbated during nursing Background Most patients in the secondary care sector consulting for low back pain ( LBP ) seem to have a more or less constant course of pain during the ensuing year . Fewer patients with LBP in the primary care sector report continual pain over a one-year period . However , not much is known about the long-term course of LBP in the general population . A systematic critical literature review was undertaken in order to study the natural course of LBP over time in the general population . Methods A search of articles was performed in Pubmed , Cinahl and Psychinfo using the search terms ‘ epidemiology ’ ; ‘ low back pain ’ or ‘ back pain ’ ; ‘ prospect i ve study ’ or ‘ longitudinal study ’ ; ‘ follow-up ’ , ‘ natural course ’ , ‘ course ’ or ‘ natural history ’ ; ‘ general population ’ or ‘ working population ’ . Inclusion criteria were that one of the objectives was to study the course of (L)BP in the adult population , that the period of follow-up was at least 3 months , and that there were three points of observation or more . The review was undertaken by two independent review ers using three checklists relating to description of studies , quality and outcomes . The course of LBP was established in relation to those who , at baseline , were reported not to have LBP or to have LBP . Would this course be stable , fluctuating , worsening , or improving over time ? A synthesis of results in relation to common patterns was presented in a table and interpreted in a narrative form . Results Eight articles were included . Articles were different on time span , the number of surveys , and the definition of LBP . In six of the seven relevant studies , for those with no LBP at baseline , relatively substantial stable subgroups of people who continued to be LBP free were identified . In six of the seven relevant studies , definite stable subgroups of continued LBP were noted and improvement ( becoming pain free ) was never reported to be a common finding . Conclusion The status of LBP in individuals of the general population appears to be relatively stable over time , perhaps particularly so for those without LBP at baseline A  population -based survey of approximately 4000 adults in Belgium , a bi-cultural country with a uniform health care system , explored the relationships of socio-cultural and employment factors to the reported experience of  low back pain ( LBP ) .  Predictors of 1 ) history of LBP , 2 ) first LBP , and 3 ) daily LBP were examined by multiple logistic regression analysis . Thirty-three percent of the population had current LBP , including 5 % experiencing their first episode ; 26 % had past but not current LBP , and 41 % had never had LBP . Increasing age ( OR > 2.0 , P = .000 ) and female gender ( OR 2.16 , P = .000 ) were associated with history of LBP ; only gender ( OR 1.40 , P = .02 ) was associated with first episode ; neither was associated with daily LBP . Language was associated with history ( OR 1.80 , P = .000 ) and first occurrence ( OR 1.77 , P = .000 ) but not daily LBP . Among those employed , work dissatisfaction was associated with history of LBP ( OR > 2.4 , P = .02 ) and daily LBP ( OR 3.85 , P = .02 ) , but not with first episode . The results suggest that sociocultural factors influence the expression of LBP , but not the risk of chronicity once LBP is reported , and that work satisfaction may not be causally related to LBP , but may intervene along with type of occupation in the possibility of continuing employment once LBP is present . Prospect i ve studies are needed to confirm these results and eluci date causal relationships Background The prevalence of back pain is constantly increasing and a public health problem of high priority . In Austria there is a lack of empirical evidence for the development of back pain and its related factors . The present study aims to investigate trends in the prevalence of back pain across different sub population s ( sex , age , obesity ) . Methods A secondary data analysis based on five nationally representative cross-sectional health surveys ( 1973–2007 ) was carried out . Face-to-face interviews were conducted in private homes in Austria . Subjects aged 20 years and older were included in the study sample ( n = 178,818 ) . Obesity was defined as BMI ≥30 kg/m2 and adjusted for self-report bias . Back pain was measured as the self-reported presence of the disorder . Results The age-st and ardized prevalence of back pain was 32.9 % in 2007 ; it was higher among women than men ( p<0.001 ) , higher in older than younger subjects ( p<0.001 ) and higher in obese than non-obese individuals ( p<0.001 ) . During the investigation period the absolute change in the prevalence of back pain was + 19.4 % . Among all sub population s the prevalence steadily increased . Obese men showed the highest increase of and the greatest risk for back pain . Conclusion These results help to underst and the development of back pain  in Austria and can be used to plan controlled promotion programs . Further monitoring is recommended in order to control risk groups and plan target group-specific prevention strategies . In Austria particular emphasis should be on obese individuals . We recommend conducting prospect i ve studies to confirm our results and investigate causal relationships Background Increased center of pressure excursions are well documented in patients suffering from non-specific low back pain , whereby the altered postural sway includes both higher mean sway velocities and larger sway area . No investigation has been conducted to evaluate a relationship between pain intensity and postural sway in adults ( aged 50 or less ) with non-specific low back pain . Methods Seventy-seven patients with non-specific low back pain and a matching number of healthy controls were enrolled .  Center of pressure parameters were measured by three static bipedal st and ing tasks of 90 sec duration with eyes closed in narrow stance on a firm surface . The perceived pain intensity was assessed by a numeric rating scale ( NRS-11 ) , an equal number of patients ( n = 11 ) was enrolled per pain score . Results Generally , our results confirmed increased postural instability in pain sufferers compared to healthy controls . In addition , regression analysis revealed a significant and linear increase in postural sway with higher pain ratings for all included COP parameters . Statistically significant changes in mean sway velocity in antero-posterior and medio-lateral direction and sway area were reached with an incremental change in NRS scores of two to three points . Conclusions COP mean velocity and sway area are closely related to self-reported pain scores . This relationship may be of clinical use as an objective monitoring tool for patients under treatment or rehabilitation ABSTRACT Objective : Nociceptive and neuropathic components both contribute to pain . Since these components require different pain management strategies , correct pain diagnosis before and during treatment is highly desirable . As low back pain ( LBP ) patients constitute an important subgroup of chronic pain patients , we addressed the following issues : ( i ) to establish a simple , vali date d screening tool to detect neuropathic pain ( NeP ) components in chronic LBP patients , ( ii ) to determine the prevalence of neuropathic pain components in LBP in a large-scale survey , and ( iii ) to determine whether LBP patients with an NeP component suffer from worse , or different , co-morbidities . Methods : In co-operation with the German Research Network on Neuropathic Pain we developed and vali date d the painDETECT question naire ( PD‐Q ) in a prospect i ve , multicentre study and subsequently applied it to approximately 8000 LBP patients . Results : The PD‐Q is a reliable screening tool with high sensitivity , specificity and positive predictive accuracy ; these were 84 % in a palm-top computerised version and 85 % , 80 % and 83 % , respectively , in a corresponding pencil- and -paper question naire . In an unselected cohort of chronic LBP patients , 37 % were found to have predominantly neuropathic pain . Patients with NeP showed higher ratings of pain intensity , with more ( and more severe ) co‐morbidities such as depression , panic/anxiety and sleep disorders . This also affected functionality and use of health-care re sources . On the basis of given prevalence of LBP in the general population , we calculated that 14.5 % of all female and 11.4 % of all male Germans suffer from LBP with a predominant neuropathic pain component . Conclusion : Simple , patient-based , easy-to-use screening question naires can determine the prevalence of neuropathic pain components both in individual LBP patients and in heterogeneous cohorts of such patients . Since NeP correlates with more intense pain , more severe co‐morbidity and poorer quality of life , accurate diagnosis is a milestone in choosing appropriate therapy Introduction Low back pain ( LBP ) is the most common , costly and disabling musculoskeletal disorder worldwide , and is prevalent in healthcare workers . Posture is a modifiable risk factor for LBP shown to reduce the prevalence of LBP . Our feasibility research suggests that postural feedback might help healthcare workers avoid hazardous postures . The Effectiveness of Lumbopelvic Feedback ( ELF ) trial will investigate the extent to which postural monitor and feedback ( PMF ) can reduce exposure to hazardous posture associated with LBP . Methods This is a participant-blinded , r and omised controlled trial with blocked cluster r and om allocation . Participants will include volunteer healthcare workers recruited from aged care institutions and hospitals . A postural monitoring and feedback device will monitor and record lumbopelvic forward bending posture , and provide audio feedback whenever the user sustains a lumbopelvic forward bending posture that exceeds predefined thresholds . The primary outcome measure will be postural behaviour ( exceeding thresholds ) . Secondary outcome measures will be incidence of LBP , participant-reported disability and adherence . Following baseline assessment , we will r and omly assign participants to 1 of 2 intervention arms : a feedback group and a no-feedback control group . We will compare between-group differences of changes in postural behaviour by using a repeated measures mixed-effect model analysis of covariance ( ANCOVA ) at 6 weeks . Postural behaviour baseline scores , work-related psychosocial factors and disability scores will be input as covariates into the statistical models . We will use logistic mixed model analysis and Cox 's proportional hazards for assessing the effect of a PMF on LBP incidence between groups . Discussion Posture is a modifiable risk factor for low back disorders . Findings from the ELF trial will inform the design of future clinical trials assessing the effectiveness of wearable technology on minimising hazardous posture during daily living activities in patients with low back disorders . Trial registration number ACTRN12616000449437 Background : A pathological cause can not be identified for most new episodes of low back pain ( LBP ) presenting to the general practitioner . One important potential influence on susceptibility is previous pain experience . To accurately investigate the contribution of this phenomenon to the onset of new episodes of LBP a prospect i ve population study is required . Aims : To determine the relationship of prior pain in the back and other musculoskeletal sites to risk of subsequent new episodes of LBP . Methods : The population studied included all 2715 adults from the South Manchester Back Pain Study who were free of LBP during the month prior to the baseline survey . At baseline a detailed musculoskeletal pain history was obtained . New episodes of LBP over the subsequent 12 months were ascertained by : ( i ) prospect ively monitoring all primary care consultations in the study cohort ( consulting episodes ) and ( ii ) a follow‐up survey after 1 year to determine new episodes during that 12‐month period not leading to consultation ( non‐consulting episodes ) . Results : The 12‐month cumulative incidence of new consulting episodes was 3 % in males and 5 % in females , and for new non‐consulting episodes 31 % in males and 32 % in females . Those with a history of previous LBP had twice the rate of new episodes , both consulting and non‐consulting , compared to those with no LBP in the past . Neck pain or pain in other musculoskeletal sites at baseline also doubled the risk of a subsequent new episode of LBP . Adjusting for psychological distress and the other pain variables had little influence on the findings . Conclusion : In those currently free of LBP a previous history of the symptom substantially increases the risk of a further episode , with pain in other sites an equally strong independent predictor of subsequent LBP Aims : To identify the work factors that predict  intense low back pain ( LBP ) and LBP related sick leaves in nurses ’ aides . Methods : The sample comprised 4266 r and omly selected Norwegian nurses ’ aides , not bothered or only a little bothered by LBP during the previous three months , and not on sick leave when completing a mailed question naire in 1999 . Of these , 3808 ( 89.3 % ) completed a second question naire 3 months later and 3651 ( 85.6 % ) completed a third question naire 15 months later . Intensity of low back symptoms and certified sick leaves attributed to LBP during the observation period were assessed by self reports at the follow ups . Results : After adjustments for LBP during the three months prior to baseline , baseline health complaints , demographic and familial factors , and a series of physical , psychological , and social work factors , logistic regression analyses revealed the following associations : intense low back symptoms were predicted by frequent positioning of patients in bed , perceived lack of support from immediate superior , and perceived lack of pleasant and relaxing culture in the work unit . LBP related sick leaves were predicted by frequent h and ling of heavy objects , medium level of work dem and s , perceived lack of supportive and encouraging culture in the work unit , working night shifts , and working in a nursing home . Long term LBP related sick leaves were associated with changes of work or work tasks during the observation period that result ed in a perceived reduction of support and encouragement at work . Conclusions : Not only frequent mechanical exposures , but also organisational , psychological , and social work factors , such as night shift work , perceived lack of support from superior , and perceived lack of a pleasant and relaxing or supporting and encouraging culture in the work unit , are associated with an increased risk of intense low back symptoms and LBP related sick leaves in nurses ’ aides Background Chronic non-specific low back pain ( LBP ) is a prevalent ( 80 % ) and multi-dimensional illness . This study aims to test whether acupuncture , baclofen , or combined treatment with acupuncture and baclofen alleviates symptoms of non-specific chronic LBP in men . Methods Eight-four ( 84 ) men aged 50 - 60 years with non-specific chronic LBP were r and omly assigned to four groups : the baclofen group received only baclofen ( 30 mg/day ) ; the acupuncture group received only acupuncture at selected acupoints ; the acupuncture + baclofen group received combined treatment with acupuncture and baclofen treatments ; and the control group received no pain reduction treatment . After five weeks of treatment , visual analogue scale ( VAS ) and self-reported pain disability with the Rol and -Morris Disability Question naire ( RDQ ) were conducted for outcome measures . Results After treatment , the baclofen , acupuncture and acupuncture + baclofen groups all had lower VAS and RDQ scores . Significantly higher reduction and improvement in VAS and RDQ scores were found in the acupuncture and acupuncture + baclofen groups compared to the baclofen group . Conclusion The present study indicates that the combined treatment of acupuncture and baclofen is more effective than baclofen treatment alone to reduce pain in patients with non-specific chronic LBP.Trial registration Abstract Psychological factors consistent with fear‐avoidance models are associated with the development of chronic low back pain ( LBP ) . As a result , grade d activity ( GA ) and grade d exposure ( GX ) have been suggested as behavioral treatment options . This clinical trial compared the effectiveness of treatment‐based classification ( TBC ) physical therapy alone to TBC augmented with GA or GX for patients with acute and sub‐acute LBP . Our primary hypothesis was that GX would be most effective for those with elevated pain‐related fear . In total , 108 patients enrolled in this clinical trial and were r and omly assigned to receive TBC , GA , or GX . Outcomes were assessed by a blinded evaluator at 4 weeks and by mail at 6 months . The primary outcomes for this trial were disability and pain intensity , and the secondary outcomes were fear‐avoidance beliefs , pain catastrophizing , and physical impairment . There were no differences in 4‐week and 6‐month outcomes for reduction of disability , pain intensity , pain catastrophizing , and physical impairment . GX and TBC were associated with larger reductions in fear‐avoidance beliefs at 6 months only . Six‐month reduction in disability was associated with reduction in pain intensity , while 6‐month reduction in pain intensity was associated with reductions in fear‐avoidance beliefs and pain catastrophizing . This trial suggests that supplementing TBC with GA or GX was not effective for improving important outcomes related to the development of chronic LBP Background and Objective : Psychological factors are assumed to predict persistent or recurrent musculoskeletal pain . The influence of psychological factors in patients with low-back pain ( LBP ) or shoulder pain was explored to study whether there is similarity regarding the factors that predict persisting pain and disability . Methods : Patients presenting in primary care with a new episode of shoulder pain or non-specific (sub)acute low back pain ( LBP ) were enrolled in a prospect i ve study . In both patient groups ,  pain catastrophising , distress , somatisation and fear-avoidance beliefs  were measured at baseline . Primary outcome measures at 3 months were ( 1 ) persistent symptoms , and ( 2 ) < 30 % reduction in functional disability .  Multivariate logistic regression analysis was used to study the associations between psychological factors and outcome . Results : A total of 587 patients with shoulder pain and 171 patients with LBP were enrolled in the study . In patients with shoulder pain , most associations of psychological factors with outcome were weak and not significant . Only in patients with longer symptom duration at baseline ( ⩾3 months ) were higher scores on catastrophising significantly associated with persistent symptoms ( p = 0.04 ) . In patients with LBP , psychological factors were more strongly associated with poor outcome , although most associations were not significant . Conclusion : Psychological factors , with the exception of fear-avoidance beliefs , are more strongly associated with persistent pain and disability in patients with LBP than in those with shoulder pain . This seems to indicate that in a primary care population the influence of psychological factors on outcome may vary across patients with different types of pain Background Low Back Pain ( LBP ) remains a common and costly problem . Psychological obstacles to recovery have been identified , but psychological and behavioural interventions have produced only moderate improvements . Review s of trials have suggested that the interventions lack clear theoretical basis , are often compromised by low dose , lack of fidelity , and delivery by non-experts . In addition , interventions do not directly target known risk mechanisms . We identified a theory driven intervention ( Contexual Cognitive Behavioural Therapy , CCBT ) that directly targets an evidence -based risk mechanism ( avoidance and ensured dose and delivery were optimised . This feasibility study was design ed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients , and to test recruitment , delivery of the intervention and response rates prior to moving to a full definitive trial . Methods A r and omised controlled feasibility trial with patients r and omised to receive CCBT or physiotherapy . CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions . Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based .  Patients were eligible to take part if they had back pain for more than 3 months , and scored above a threshold indicating fear avoidance , catastrophic beliefs and distress . Results 89 patients were recruited .  Uptake rates were above those predicted . Scores for credibility and acceptability of the interventions met the set criteria . Response rates at three and six months fell short of the 75 % target . Problems associated with poor response rates were identified and successfully resolved , rates increased to 77 % at 3 months , and 68 % at 6 months . Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity . Numbers were too small for formal analysis . Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy ( increase of 7.9 versus 5.1 ) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group , these findings should be interpreted with caution . Conclusions CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery . Trial registration IS RCT N43733490 , registered 15/12/2010 OBJECTIVE --To investigate the risk factors for low back pain in hospital nurses , with particular emphasis on the role of specific nursing activities . METHODS --A cross sectional survey of 2405 nurses employed by a group of teaching hospitals was carried out . Self administered question naires were used to collect information about occupational activities , non-occupational risk factors for back symptoms , and history of low back pain . RESULTS --The overall response rate was 69 % . Among 1616 women , the lifetime prevalence of back pain was 60 % and the one year period prevalence 45 % . 10 % had been absent from work because of back pain for a cumulative period exceeding four weeks . Rates in men were generally similar to those in women . In women back pain during the previous 12 months was weakly associated with height , and was significantly more common in those who reported frequent non-musculoskeletal symptoms such as headache and low mood . After adjustment for height and non-musculoskeletal symptoms , significant associations were found with frequency of manually moving patients around on the bed , manually transferring patients between bed and chair , and manually lifting patients from the floor . In contrast , no clear increase in risk was found in relation to transfer of patients with canvas and poles , manually lifting patients in and out of the bath , or lifting patients with mechanical aids . Confirmation of these findings is now being sought in a prospect i ve study of the same population . CONCLUSIONS --This study confirms that low back pain is highly prevalent among nurses and is associated with a high level of sickness absence . People who often report non-musculoskeletal symptoms were significantly more likely to report low back pain . Specific manual h and ling tasks were associated with an increased risk of back pain ; however , no such association was found with mechanised patient transfers Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641 BACKGROUND Better insight into frequent comorbidities in patients with chronic ( ≥ 3 months ) low back pain ( LBP ) may help general practitioners when planning comprehensive care for these patients . OBJECTIVE To prospect ively study the prevalence of psychological , social , musculoskeletal and somatoform disorders in patients presenting with chronic non-specific LBP to general practitioners , in comparison to a contrast group of patients consulting in the same setting . METHODS This case-control study is embedded in a historical cohort , based on a primary care practice -based research network . All the health problems presented by the patients were prospect ively coded according to the international classification of primary care between 1996 and 2013 . The prevalence of psychological , social , musculoskeletal and somatoform disorders presented by the adult patients from 1 year before the onset of chronic LBP to 2 years after onset was compared to that of matched patients consulting without LBP , using conditional logistic regressions . RESULTS The 1511 patients with chronic LBP more often presented musculoskeletal disorders than the contrast group during the year before the onset of LBP and during the second year after it , with odds ratios ( 95%confidence intervals ) of 1.39 ( 1.20 - 1.61 ) and 1.56 ( 1.35 - 1.81 ) , respectively . They did not more often present psychological , social or non-musculoskeletal somatoform disorders . CONCLUSIONS General practitioners should consider all the musculoskeletal symptoms when caring for patients with chronic LBP . Rather than systematic ally screening for specific psychological , social or somatoform disorders , they should consider with the patient how LBP and any type of potential comorbidity interfere with his/her daily functioning Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Background / aims There is a paucity of prospect i ve cohort studies investigating the incidence of  low back pain ( LBP ) in rowing . We investigated ( 1 ) the prevalence and incidence of LBP among international-level rowers in New Zeal and , ( 2 ) the relationship between training volume and LBP and ( 3 ) the effect of LBP on rowers ’ ability to train and compete . Methods This was a prospect i ve cohort study of 76 New Zeal and representative rowers , including 46 men ( mean age 22 , SD=4 ) and 30 women ( mean age 21 , SD=4 ) . Data were collected using an online question naire repeated monthly for 12 months . Results The prevalence of LBP ranged from 6 % to 25 % throughout the year . The incidence of episodes of LBP was 1.67 per 1000 exposure-hours . A total of 72 episodes of LBP were reported by 40 rowers ( 53 % ) during 12 months . Of these , 45 % had an incidental effect on training . 29 % minor , 18 % moderate and 9 % had a major effect as determined by the length of time the training was interrupted . There was a high correlation between new LBP and total training hours per month ( r=0.83 , p<0.01 ) . A previous history of LBP was a risk factor in developing new LBP ( OR 2.06 , 95 % CI 1.22 to 3.48 , p=0.01 ) . Age was also a risk factor , with the likelihood of developing LBP increasing for every year ( OR 1.08 , 95 % CI 1.01 to 1.15 , p=0.02 ) . Conclusions LBP is common among New Zeal and representative rowers . There is a high correlation between training load and the development of LBP Background Clinicians , providers and guideline panels use absolute effects to weigh the advantages and downsides of treatment alternatives . Relative measures have the potential to mislead readers . However , little is known about the reporting of absolute measures in systematic review s. The objectives of our study are to determine the proportion of systematic review s that report absolute measures of effect for the most important outcomes , and ascertain how they are analyzed , reported and interpreted . Methods / design We will conduct a method ological survey of systematic review s published in 2010 . We will conduct a 1:1 stratified r and om sampling of Cochrane vs. non-Cochrane systematic review s. We will calculate the proportion of systematic review s reporting at least one absolute estimate of effect for the most patient-important outcome for the comparison of interest . We will conduct multivariable logistic regression analyses with the reporting of an absolute estimate of effect as the dependent variable and pre-specified study characteristics as the independent variables . For systematic review s reporting an absolute estimate of effect , we will document the methods used for the analysis , reporting and interpretation of the absolute estimate . Discussion Our method ological survey will inform current practice s regarding reporting of absolute estimates in systematic review s. Our findings may influence recommendations on reporting , conduct and interpretation of absolute estimates . Our results are likely to be of interest to systematic review authors , funding agencies , clinicians , guideline developers and journal editors RATIONALE Low back pain ( LBP ) remains a common and costly problem among the nursing profession . Several studies have indicated that LBP is attributed to mentally straining or dem and ing work , fatigue or exhaustion or general work satisfaction . AIMS This study aims to measure the magnitude of LBP among Hong Kong nurses and its association with the work-related psychological strain and patients h and ling activities . RESEARCH METHODS AND MEASURES : A cross-sectional study of Hong Kong hospital nurses was conducted . Three hundred and seventy-seven nurses were recruited from six district hospitals . They were registered nurses or enrolled nurses working full-time for at least 1 month in the current ward . One hundred and seventy-eight ( 47.2 % ) study subjects were r and omly selected from two district hospitals and 199 ( 52.8 % ) study nurses made up the convenience sample . Possible bias from psychological distress , socio-demographics and lifestyle factors was controlled for . Data were collected by face-to-face interviews . The data included work factors ( both psychological stress and patient h and ling activities related to work ) , demographics , psychological distress and lifestyle factors and the occurrence of LBP . RESULTS Of the 377 nurses interviewed , 153 ( 40.6 % ) reported having LBP within the last 12 months . With symptoms of LBP as the outcome , risks were increased where nurses self-reported that they only occasionally or never enjoyed their work [ adjusted odds ratio ( OR ) 2.07 ] , where frequent manual repositioning of patients on the bed was required ( adjusted OR 1.84 ) and where they were required to assist patients while walking ( adjusted OR 2.11 ) after adjustment for other potential confounders . CONCLUSION The results indicate that an association exists between work stress , manual lifting and LBP prevalence . The main route to prevention of LBP among nurses is likely to lie in improved ergonomics and psychological health in their work place . Good posture and correct transferring techniques in ward situations should be reinforced with h and s-on practice performed on nurses ' common types of clients BACKGROUND CONTEXT Previous research has documented various psychosocial risk factors with influence on outcome in low back pain ( LBP ) patients , but the value of clinical predictors has been less well documented . PURPOSE To identify clinical and psychosocial risk factors at baseline influencing disability and pain at 1 year in LBP patients sick-listed 3 to 16 weeks , and to look for differences between nonspecific LBP and radiculopathy . STUDY DESIGN Cohort study with 1-year follow-up based on a r and omized clinical trial . OUTCOME MEASURES Disability and change of disability , pain and change in pain at 1 year . METHODS In a r and omized clinical study evaluating multidisciplinary versus brief intervention , 325 patients were followed for 1 year . At baseline , they completed a question naire and went through a clinical low back examination , including measure of forward flexion and side flexion as well as tender point examination , a method to estimate diffuse tenderness . Furthermore , degenerative changes on plain X-rays of the lumbar spine were quantified , and sciatica was investigated by magnetic resonance imaging . RESULTS Radiculopathy was verified by magnetic resonance imaging in 111 ( 34 % ) patients . At 1 year , questions of disability in daily life activities and pain were answered by 60 % and 67 % , respectively . The intensity of back+leg pain and disability was closely correlated . Statistically significant predictors for both disability and back+leg pain at 1 year were intensity of back+leg pain , worrying and health anxiety , many tender points , and little or moderate exercise in leisure time . Two additional risk factors were identified in patients with radiculopathy : older age and " drinking alcohol less than once per month . " Furthermore , disability at 1 year was associated with initial disability and compensation cl aim , and back+leg pain at 1 year was associated with fear avoidance about physical activity and the duration of pain . Change in disability was more closely associated with return to work than change in pain . Disc degeneration was not associated with disability or pain at 1 year . General health was not statistically significantly associated with outcome when adjusted for back+leg pain , disability , and worrying and health anxiety . CONCLUSIONS Disability and pain at 1 year were associated with baseline disability and pain , diffuse tenderness , worrying and health anxiety , compensation cl aim , fear avoidance , and baseline exercise habits . Only in patients with verified nerve root affection , older age , and restrained alcohol seemed to play a role . The multivariate models were insufficient in predicting disability and pain , partly because disability and pain were also strongly associated with return to work Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain 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 ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied
Overall studies showed that nursing activities conferred increased risk for , and were associated with back disorders regardless of nursing technique , personal characteristics , and non-work-related factors .
Patient h and ling appears to confer the highest risk , but other nursing duties are also associated with elevated risk , and confound dose – response assessment s related to patient h and ling alone .
A threshold of nursing activities below which the risk of back disorders is not elevated has not been established .
Abstract Background : Although non-specific low back pain ( LBP ) is known to be multifactorial , studies from across the globe have documented their higher prevalence in nurses .
This systematic review was conducted to ascertain whether this much-documented association constitutes a causal relationship , and whether there is a discernible threshold of exposures associated with this elevated risk .