News Category: Lumbar Spine

Back and leg pain in the older adult population is often caused by spinal stenosis (narrowing of the spinal canal). And a common cause of the stenosis is degenerative lumbar spondylolisthesis (one vertebra slips forward over another). In this study, the use of a Dynesys system to stabilize the spine is investigated.

The Dynesys is a long screw that goes through the pedicle into the vertebral body to hold it in place. The pedicle is the segment between the transverse process and the vertebral body. There are two transverse processes in each vertebra. They project out from either side where the lamina joins the pedicle. These bones attach to the back of the spinal column, forming a bony ring that encloses the spinal canal. They serve for the attachment of muscles and ligaments.

Using the Dynesys system eliminates the need for bone graft to complete the fusion. The patient is spared any suffering from the removal of bone at a donor site. But this is a fairly new procedure and long-term results aren’t available yet. This study presents the results after four years. A previous study by the same authors reported the results after the first two years.

The patients included in the study had a single level degenerative spondylolisthesis. They all had leg pain with or without back or buttock pain. Open surgery was performed to take pressure off the spinal nerves. The procedure is called a decompressive laminotomy. The lamina isn’t removed entirely. Just a portion is taken out to remove pressure from the spinal canal.

The Dynesys pedicle screws were placed without trying to change the position of the vertebrae. Everyone wore a back brace for three months. Then they gradually resumed their normal activities.

Data was collected for two years and reviewed. The results were published in 2006. The same patients were then followed for another two years. The same measures were used to assess clinical outcomes. These included pain (location and intensity), walking distance, lumbar spine mobility, and activity level. The researchers also looked at the patient’s occupation, pain medications used, and complications caused by the surgery. Any other spine surgeries done were also recorded.

Only 19 patients of the original group (26 total) could be studied. Several patients had died or developed other more serious medical conditions. One patient had moved out of the country. Several others had additional lumbar surgery after the first procedure to implant the Dynesys system.

Overall, the group reported good results. Partial or complete pain relief was possible for 84 per cent of the group. All but one patient reported improvement of some kind. Walking distance improved quite a bit. Two-thirds of the group were able to stop taking pain medication.

At the two-year check-up, X-rays showed four patients who had a loose or broken screw but the spinal segment was still stable. At the end of four years, this remained unchanged. But there was degeneration observed at the next spinal level in almost half the patients.

This was the first report of long-term results with the Dynesys stabilization system. The good news is that it is possible to decompress and stabilize degenerative lumbar spondylolisthesis without the added step of the bone harvesting and grafting. The segment remains stable over a four-year period of time.

The system does not prevent degeneration at the next spinal level. Rate of change at the adjacent vertebral level is about the same as reported after spinal fusion. But there is some evidence from other studies that the degeneration isn’t caused by the dynamic stabilization process. It could very well just be a natural progression of aging.

Further studies are needed with larger groups of patients over a longer period of time. For now, the authors conclude that dynamic stabilization is provided by the Dynesys system. It can be used instead of the more invasive bone grafting process.

Specific back strengthening doesn’t work any better than general exercise in the treatment of low back pain (LBP). This is the final conclusion of a multicenter study done in a military setting with male soldiers.

This study was conducted by the Royal Netherlands (Dutch) Army. But even though it is restricted to army soldiers, the findings can apply to other groups that employ workers involved in strenuous jobs. This could include police officers, fire fighters, and construction workers. Any other workers in occupations that involve pushing, pulling, bending, and lifting may benefit from this information.

The results of this study support findings from previous studies that exercise of any kind is helpful in recovering from an acute episode of LBP. Some subgroups of patients do need a specific exercise program. But to prevent acute LBP from turning into a chronic problem, the key is to get active and stay active during the recovery process.

This information is especially helpful in a military setting. Chronic back pain can reduce soldier productivity, run up the cost of health care, and negatively affect the injured soldier’s quality of life. Disability from chronic low back pain means higher costs in terms of disability pensions and replacement costs.

Previous studies done by this same group have shown that a 10-minute program to train lumbar extensor muscles works just as well as a more extensive multidisciplinary exercise program. They have continued with their studies looking for the best type of exercise needed for LBP. Frequency, intensity, and duration of for each type of exercise is being investigated.

In this study, one group was enrolled in a 10-week program of isolated lumbar extension training. A specific strengthening device called the Total Trunk Rehab machine was used. This machine is used for low back strength-training. There is a special knee-lock system and thigh-restraining belt that keep both the thighs and knees from moving. This helps isolate the muscles of the lumbar spine.

Everyone in the lumbar extension group worked out on the machine for 10 minutes under the supervision of a physical therapist. A total of 14 training sessions were completed (twice a week for seven weeks). Body mechanics, pace, motion, weight load, and number of repititions were observed and modified for safety.

In the second group, the soldiers received regular physical therapy (PT). PT consisted of a 10-week program of hands-on treatment such as manual therapy, joint mobilization, stretching exercises. Some patients received instruction in aerobic exercise or core strength training. Each session was 25 to 30 minutes long. The therapists could also include patient education and instructions in back function. The soldiers in this group did not use the Total Trunk Rehab device.

Results were measured using the Roland-Morris Disability Questionnaire (RMDQ). The RMDQ assesses physical function. A second tool called the Patient Specific Functional Scale was used to measure functional status. A third tool (the Tampa Scale for Kinesiophobia (TSK)) was used to measure how much patients’ fear of movement or fear of reinjury affected their activities.

Isometric back strength was measured on the lower back machine. Everyone was followed for a full year. Short-term results were observed at the end of five and 10 weeks. Long-term results were reported after six and 12 months. Patient satisfaction was also measured directly by asking each person if they were satisfied with their treatment.

The authors report no differences in outcomes between the two groups. Soldiers in each group improved equally no matter what measure was used to assess the results. Everyone was equally satisfied with their program. They were given a chance at the end of the study to switch to the other type of treatment.

There is some question as to whether the findings reflect treatment effects versus just the natural history of recovery (the soldiers just got better with time). The only way to sort this out would be to include a control group (soldiers who got no treatment). But in a military organization, this isn’t an acceptable option.

Future studies with civilians comparing three groups (strength-training, physical therapy, control) are advised. Different age groups for both genders should also be compared as this study only included young, otherwise healthy, adult males.

Does it matter if you see a physical therapist versus a physical therapist assistant for treatment of your low back pain (LBP)? Do you need to see a specialist within the physical therapy field? For example, is it better to see someone who has expert training in the treatment of low back pain? Or can a generalist help you get the same good results?

These are some of the questions posed by physical therapists in this study. They looked at whether the practice setting was linked with outcomes. They identified service delivery that had the best results. Service delivery referred to who saw the patient and how much time was spent with each one. And they considered whether or not the number of staff members at each clinic made a difference.

All data came from a data bank called Focus on Therapeutic Outcomes (FOTO). FOTO is the largest database containing information on outpatient rehabilitation patients and the results of their physical therapy treatment. Researchers use this international medical rehab data to study various aspects of healthcare.

Their sample was taken from 114 outpatient clinics employing 1,058 physical therapists. Only patients with LBP were included. Over a one-year period, there were 16,281 LBP patients who qualified for this study. Diagnoses included herniated disc, spinal stenosis, spondylosis, pain, and sprain or strain. Most of the patients had not had any surgery for their back problem.

All patients had completed a survey called the Short-Form-36 (SF-36). The SF-36 is a reliable tool that measures general physical and mental health. FOTO is then able to take all information into consideration and calculate the overall health status measure (OHS).

Eight functional scales are included in the OHS. These include general health, physical function, pain, vitality, mental health, emotional status, social function, and upper extremity impairments.

The researchers also looked at a variety of other factors. Size of the professional staff, ratio of physical therapists to physical therapist assistants, years of experience, and level of training were considered. Volume of patients seen in each clinic by each therapist was calculated. The portion of this made up of low back pain patients was also figured. Amount of time spent with individual patients by each therapist or assistant was reported. These last two variables made up a category called measure of utilization.

Scores were used to determine provider performance. Using these residual scores, clinics could be broken down into three groups based on patient results (effectiveness). Each clinic was given a low, middle, or high effectiveness rating.

Clinics with low or middle effectiveness (poor outcomes) and high health care utilization (many visits) had the worst performance. This means patients were seen many times by the staff but had poor results. High effectiveness (good results) with low utilization (few visits) was classified as best performance clinics.

What they found was that patients who saw a physical therapist assistant had the worst results. Patients who saw the therapist had the best results. The more patients with LBP seen at the clinic, the better the results. And the number of visits was lower when patients were treated by the physical therapist (versus the assistant).

The authors conclude that patients with low back pain get less effective care when treated by a physical therapist assistant. This supports results of other studies that show lower functional outcomes for LBP patients treated by an assistant. Higher volumes of patients results in more efficient (fewer visits), but not necessarily more effective care.

Surgical treatment for degenerative spine conditions often includes lumbar fusion. Patients are selected carefully for this procedure. The surgeon relies on evidence-based studies to discuss a reasonable treatment plan with the patient.

Most patients expect a certain level of improvement in pain, motion, and/or function before they will consider surgery as an option. Studies have been done to determine what would be considered a minimum level of improvement that signals a successful operation.

In this study, threshold of success is defined and measured for quality-of-life (QOL) improvement. What is QOL and how much does it have to improve to represent a benefit of surgery? These are the questions addressed for patients having a lumbar spine fusion for degenerative spine disease.

Patients having a lumbar spine fusion filled out questionnaires before and after surgery. Four well-known health-related self-report survey tools were used. These included the Medical Outcomes Study Short Form-36 (SF-36), the Oswestry Disability Index (ODI), a back pain rating scale, and a leg pain rating scale. All of these instruments help show when there has been a measurable clinical benefit of surgery.

A satisfaction survey was another tool used to measure quality of life. Patients were asked to rate five statements on a continuum from definitely true to definitely false. Some examples of the statements were: I can do the things that I thought I would be able to do after surgery. All things considered, I would have the surgery again for the same condition.

Each answer was given a point value and the scores added up to assess the quality-of-life outcomes of spine surgery. Based on scores, values were given to five intervals. These included most satisfied, satisfied, unsure, dissatisfied, and most dissatisfied.

Change in quality-of-life score was calculated from before surgery to one-year after surgery. Three measures were calculated: total score, net improvement, and per cent improvement or change. Per cent of change was labeled as much better or about the same. Satisfaction was divided into mostly satisfied or unsure.

The authors conclude that there was a relationship between the change in health-related quality-of-life and benefit perceived by the patient. And the threshold value to determine when it was worth having the surgery could be determined using these various surveys. Specific scores for each survey are reported as thresholds of clinical benefit. These thresholds represent how much patients’ scores had to improve before the surgery was considered worth having.

The authors point out that patients with a low score for preoperative health status will look like they had a larger per cent change compared to patients who weren’t so bad off before the operation. And the study only looked at health-related quality-of-life scores at the end of one-year postoperatively. Results might look different if other time intervals (shorter or longer) were used.

Are all levels of disc herniation the same? Can they be treated in the same way and still get the same results? The authors of this study look to see if disc herniation at an upper lumbar level responds the same to treatment as a disc herniation at the lower lumbar/sacral level.

They used data already collected from a large study called the Spine Patient Outcomes Research Trial (SPORT). They compared patients with three levels of disc herniation: L2-L3, L4-L5, and L5-S1. And they compared the results of two forms of treatment: nonoperative care and surgical treatment to remove the disc (discectomy).

The patients in each group were similar in terms of gender and body size (weight and height). There were more men than women in all three groups. And age varied from group to group with younger adults in the lower level herniations group and older adults in the upper lumbar group.

Symptoms were slightly different based on the level of herniation. Upper lumbar disc problems were more likely to cause back and anterior (front of the) thigh pain.
Lower lumbar disc herniation is usually accompanied by pain down the back of the leg called sciatica.

Leg symptoms were less severe with upper level herniations. Neurologic testing of reflexes and sensory or motor changes differ from upper lumbar to lower lumbar spine as well. The authors carefully detailed these differences based on the straight-leg raising test, femoral stretch test, reflexes, and muscle weakness.

Spine centers from across the United States are part of the SPORT. Patients included in this study had imaging studies that confirmed disc herniation as a cause of the symptoms. Each patient was selected randomly by a computer draw and placed in one of two groups based on treatment received. The groups were: the nonoperative therapy group and the surgical group.

Nonoperative care consisted of patient education and counseling, antiinflammatory drugs, steroid injections, physical therapy, and pain medication. Surgery was a discectomy to remove part or all of the disc.

The goal was to evaluate the effect of surgery based on herniation level. Measures of outcomes or results used included pain, function, and disability. Two instruments were used to measure these categories: the Oswestry Disability Index (ODI) and the Short Form-36 (SF-36). Patients were followed for two full years.

The authors found that no matter at what level the herniation occurred, surgery gave the best results. And patients with upper lumbar herniations did much better than patients with lower lumbar disc herniations. There was also greater improvement with nonoperative care for lower level herniations (compared to upper level problems).

This study showed that herniation level does affect treatment outcomes. This may have to do with the amount of space in the spinal canal as the spinal cord moves down the spine. The diameter of the spinal canal is smaller at the upper levels and gets larger further down the spine.

The direction of the herniation may also make a difference. Discs in the upper lumbar spine are more likely to protrude to the side close to the spinal nerves. It may be easier to remove the disc in this location compared to lower lumbar disc herniation, which is more likely to occur in the posterolateral (back and to the side) direction.

The authors of the study present four case studies of sudden onset coccydenia with calcium crystal deposition in the sacrococcygeal or intercoccygeal joints.

Common coccydenia is usually characterized by persistent or chronic pain. It is usually localized to the coccyx with sitting, or arising from sitting. It is usually caused by disc degeneration, instability, deformity of the coccyx, and trauma.

For several years, it has been known that calcium crystal deposition in an intervetebral disc can be the source of acute pain. Calcium crystal deposition has never been reported as the likely cause of acute onset coccydynia, however. Since sacrococcygeal and intercoccygeal joints can contain a thin intervertebral disc, it is reasonable to have calcium crystal deposition.

Forty percent of the time, plain lateral radiographs in standing and then in sitting will not reveal any abnormalities with common coccydynia. These standard radiographs demonstrated calcium crystal deposition of the sacrococcygeal or intercoccygeal joints in all four of the case studies presented. Following treatment with corticosteroids either orally or injected, three of the four subjects had normal radiographs. They also had significant or complete resolution of coccygeal pain.

First line treatment for common coccydynia is oral analgesics and sitting aides. If this is ineffective, corticosteroid injection into the caudal epidural space, sacrococcygeal space, or ganglion injections can be helpful. Removing the coccyx has been a treatment option when other treatments are ineffective.

The authors suggest that persons with sudden onset coccydynia should be evaluated with radiographs. If calcium deposition is found in the sacroccygeal or intercoccygeal joints, treatment should include short course of oral corticosteroids, or steroid injection into the involved joint.

There are many possible causes of low back pain (LBP). But when the sciatic nerve is irritated, patients are classified in a subset group as having radicular LBP. Treatment for this problem remains under investigation. In this study, the early use of an intramuscular corticosteroid injection for this problem is studied.

Adults ages 21 to 50 with LBP and a positive straight leg raise (SLR) test were included. The researchers defined a positive response to this test as pain that went down either leg (past the knee) when the leg was lifted straight up between 30 and 70 degrees. Pain with this motion is a strong sign of a herniated disc.

All patients were first seen in the emergency department. Their back pain had started within the last week. Anyone with a previous history of back pain was not allowed to participate in this study.

Patients were divided into two groups. One group received a single injection of methylprednisolone acetate along with antiinflammatory and narcotic medications for pain relief. The second group received a placebo injection (no steroid) and the same medications for pain and inflammation.

Patients were contacted one month after discharge from the emergency department. The main outcome of the study was pain intensity at that time. Other measures used to assess results included use of pain relievers, function, and any adverse effects from the medications. The Roland-Morris-18 functional disability scale was used to measure the effect pain had on daily and work activities.

The main measure of difference between the two groups was not pain intensity. Both groups had equal amounts of pain relief. Use of pain relievers and the disability scale were better measures of the benefit of methylprednisolone. Improvements were seen at the end of one week and at the end of one month. The authors say this finding suggests that methylprednisolone may actually affect the underlying disc problem.

Previous studies led to the suggestion that corticosteroid drugs should not be used for radicular LBP. But this study has shown a benefit when using them early in the onset of symptoms. The patient population was specific to those who were probably having pain from an acute disc herniation. The use of a steroid injection for patients without a positive straight leg raise is not advised.

The results of this study show that young adults may benefit from the early administration of an intramuscular steroid injection. Further study is needed to find out the best drug to use, optimal dose, timing, and method of delivery (e.g., intramuscular versus intravenous).

The authors reviewed available literature involving adjacent segment degeneration, ASDeg, and symptomatic adjacent segment disease, ASDis, following fusion or total disc replacement in the spine. Adjacent segment degeneration can be seen on radiographs. It does not necessarily cause symptoms. When the adjacent segment degeneration is identified on radiographs, and causes symptoms, it is considered adjacent segment disease.

Fusion of the segment is also called arthrodesis. Total disc replacement is also referred to as arthroplasty. The authors found 27 articles, none with class I or II evidence however, that fit the inclusion criteria. Twenty of the articles involved arthrodesis, and seven involved arthroplasty. A total of 1732 patients with arthrodesis was compared to 758 patients with arthroplasty.

The authors found that the odds of developing ASDeg remained larger when fusion was performed, with odds higher when the mean age was greater, or as the follow up period grew longer. Thirty four percent of arthrodesis patients were found to have ASDeg. This compared to an average of nine percent in arthroplasty patients. However, in one study, 53 patients who had a CHARITE disc replacement were found to have a 17 percent incidence of ASDeg after seventeen years. The authors concluded that there seems to be a correlation between fusion and the development of ASDeg compared to arthroplasty.

Fourteen percent of arthrodesis patients developed ASDis, whereas one to three percent of arthroplasty patients developed ASDis. The authors found that the length of follow up had a significant effect on the incidence of ASDis. The longer the follow up period, the greater the chance for developing ASDis. There is a stronger correlation between fusion and the development of ASDis compared to arthroplasty. This suggests that arthroplasy may have a protective effect against accelerating junctional degenerative changes and disease following surgery.

The authors noted that disc degeneration also correlated with a decreased lumbar range of motion. Those with five degrees or greater motion had zero percent prevalence of ASDdeg. Patients with less than five percent motion had a 34 percent prevalence of ASDeg. Those arthroplasty patients that maintained their motion did not develop any evidence of ASDeg.

Because the literature reviewed was not the most ideal in terms of reliability, the authors of the review could only give a class C, or lowest tier of recommendation, for the use of arthroplasty versus arthrodesis to reduce the development of adjacent segment degeneration and adjacent segment disease.

The authors sought to determine the incidence of lumbar disc changes among 104 patients with rheumatoid arthritis, RA. The subjects had had RA for 10 years or more. It is well known that 25 to 90 percent of patients with RA will have cervical spine involvement. The authors used radiographs and magnetic resonance imaging to examine a total of 520 disc levels in the lumbar spine. They then sought to determine if disease activity using Ochi’s classification, serum C-reactive protein, rheumatoid factor, platelet count, and Lansbury index correlated with radiographic findings. The subjects were evaluated whether or not they had report of low back pain.

The authors were looking for erosive or sclerotic changes of the anterior rim of the vertebral bodies, irregularity of vertebral end plate, and narrowing, fusion, or collapse of the intervertebral discs. The authors used a grading scale from zero to four. Zero was normal. Grade I was characterized by erosive or sclerotic changes of the anterior rim of the vertebral bodies on Xray, and signal intensity changes at the same level on MRI. Grade II lesions demonstrated irregularity of the vertebral end plates on plain Xray and on MRI. Grade III lesions where characterized by collapse of the intervertebral discs or the vertebral bodies. The authors then considered type A and B lesions for those lesions graded as II or III. Type A lesions were characterized by narrowing of the intervertebral space. Type B lesions had maintained intervertebral space or ballooning of the disc.

The authors found that 45 percent of patients had at least one lumbar lesion. The two types of lumbar disc lesions related to RA were disc narrowing and disc ballooning. Only one patient was found to have both a type A and type B lesion in their lumbar spine. The authors propose that there may be two types of RA. One may destroy mainly cartilage, and the other subchondral bone.

Ochi’s classification appeared to be useful in predicting the likelihood of lumbar disc lesions. Ochi’s classification includes three types based on the number of peripheral joints involved. Forty five of patients were included in the least erosive subset, LES, 28 patients in the more erosive subset, MES, and 31 patients in the mutilating disease subset, MUD.

The MUD patients had 61 percent grade II or III lesions. The authors felt that the extent of lumbar spine involvement correlated with the extent of RA in peripheral joints.

Laboratory values for CRP, rheumatoid factor, and platelet count did not seem to correlate with lumbar pathology.

The authors did not evaluate facet joint pathology in this study because of various factors but are known to be prone to erosion and intervertebral instability in patients with rheumatoid arthritis.

Every now and then it’s a good idea to step back and review a problem like lumbar disc herniation. What does the latest research say works best? Are there any changes in the guidelines or recommendations for the treatment of this problem?

In this article, Dr. R. W. Molinari from the Division of Spinal Surgery at the University of Rochester in New York summarizes all the important published studies on this topic over the past year. Both conservative (nonoperative) care and surgical management are included.

This information is especially important these days because lumbar discectomy (removal of a herniated disc) is the most common surgery performed in the United States for back and leg symptoms. There has been a trend toward microdiscectomy. Microdiscectomy is the removal of disc or disc fragments through an endoscope without an open incision or invasive procedures.

The effectiveness of this treatment is now being reported. Groups of patients with lumbar disc herniation treated with nonsurgical care have been compared to patients who had a microdiscectomy. When it came to pain intensity, disability, and quality of life, the results were no different between the two groups. However, the discectomy groups did have a faster recovery.

One study to keep in mind is the Spine Patient Outcomes Research Trial (SPORT). This study has patients enrolled from 13 different multidisciplinary spine clinics. Over 500 patients with lumbar disc herniation were included. All had symptoms of back and leg pain for at least six weeks.

In the SPORT study, outcomes between standard open discectomy and nonsurgical treatment were measured at regular intervals up to two years after treatment. Patients in both groups had good results. But critics of the study point out that at the end of two years, 40 per cent of the patients who were in the surgery group decided to try conservative care instead. And 40 per cent of the conservative care group crossed over to the surgical group and did have surgery. Results may be skewed by this crossover rate.

Based on research thus far, overall recommendations for surgery are as follows:

Lumbar disc herniation can cause both low back pain and sciatica (pain down the leg). Pressure on the spinal nerve root and chemicals released by the damaged disc cause this type of aching pain often with numbness and tingling. It’s a common disorder resulting in hospitalization, work absenteeism, and disability.

Most of the time, sciatica resolves (goes away) on its own. The symptoms usually fade away over a period of six to eight weeks. In some cases, recovery is much slower or doesn’t happen at all. Chronic pain of this type seems to affect women more than men. And women’s outcomes are reportedly worse over time.

If this is true, there may be ways to direct treatment based on gender. Studies show a general trend for women to report more pain in more parts of the body more often than men. In this study, the influence of gender and other predictive factors on sciatica are explored.

Patients involved in a study called the Sciatica Trial were included. All had severe sciatica caused by disc herniation. Pain was incapacitating and lasted six to 12 weeks. Patients were randomly placed in one of two groups. The first group had a long period of conservative (nonoperative) care. Some of the patients in this group had surgery late in the treatment.

Patients in the conservative care group were assured that the pain could subside in time — even if the intensity was high at the start. Pain medication was used when needed. Patients were advised to keep active according to currently accepted treatment guidelines.

Anyone who was afraid to move in order to avoid pain or further injury was sent to physical therapy to overcome this fear avoidance behavior (FAB). Anyone who did not respond to nonoperative care was offered surgery (microdiscectomy) after six months.

The second group had surgery early, often within two weeks of the start of the sciatica. Surgery was cancelled if the symptoms went away suddenly before the operation. The surgical procedure performed was a discectomy. This means that loose fragments of disc were removed from inside the disc space. Follow-up physical therapy was provided at home. A standard exercise program was prescribed.

Everyone was followed at regular intervals up to one year. Pain, time to recovery, function, disability, and return to work were used as outcome measures. Overall, women had a slower rate of recovery. Women were also more likely to have an unsuccessful recovery at the end of a year. Some women were completely recovered but others were much worse.

The effect of many other factors was analyzed. Besides gender, age, duration of sciatica, type of job, marital or partner status, and smoking habits were recorded. The men and women weren’t different at baseline except in one area. Women had worse sciatica at the start.

There was one other predictive factor of recovery. Patients with a positive Bragard’s sign were more likely to have a slower speed of recovery. The Bragard’s sign is a nerve stretch test. It is positive for abnormal nerve stretch if dorsiflexion of the foot makes the leg pain worse while raising the leg straight. Dorsiflexion is a flexion movement of the foot and ankle with the toes moving toward the face.

And there was one other important finding. Men were more likely to respond with a good result to early surgery. Women in the surgical group did seem to recover faster after early surgery compared to women in the conservative care group. Comparing men and women who had an unsatisfactory result, women also had higher pain intensity and greater disability.

At the end of the article, the authors went back to discuss further the finding that women have greater pain severity and disability at the time of diagnosis. This is consistent with other studies that show women are less likely to seek medical help until they are much worse than men. Female patients are less willing to agree to surgery so they delay medical treatment longer than men.

There isn’t enough information to really come up with a treatment plan that is based on gender. Based on current findings, it makes sense for the physician to make note of each patient’s gender when planning treatment. When gender-specific factors become more evident, then targeted treatment may become a reality.

The last 15 years of research has brought a change in the way patients with chronic low back pain (CLBP) are categorized and treated. In a landmark study back in 1994, a well-known physical therapist identified subgroups of low back pain patients. When treated based on their unique characteristics, more of these patients returned to work and reported less disability compared with patients in a standard treatment program.

That report set into motion a series of studies classifying low back pain patients based on a variety of factors. Some of these included fear of movement, intensity of pain, and self-efficacy (belief in oneself). Other areas investigated also included pain present during specific exercises and catastrophizing (believing the worst will happen).

In this study, patients were subgrouped based on their lifting patterns during a repetitive lifting task. This type of classification system is based on physical functioning of patients with CLBP.

Previous studies have shown differences in the way patients with CLBP lift compared to normal people (in other words, people who don’t have back pain). The focus of this study was to look at patients with CLBP and see if there are subgroups of motion differences during lifting within the group.

The procedure used to put patients into subgroups was called the Hidden Markov Model. This model is a statistical tool the authors used to see if the CLBP group were different in ways other than lifting patterns used. Two groups were included: a control group (normal healthy adults) and a group of adults with moderate to severe back pain lasting more than three months. Most of the patients had back pain for years.

Everyone completed a series of tests to assess pain, psychosocial, cognitive, and functional abilities. Some of the items investigated included gait (walking) speed, ability to perform activities of daily living, response of partner or spouse to the patient’s pain, and perceived level of disability.

Each person completed a questionnaire asking subjects to rate their own confidence (self-efficacy) in completing a repetitive lifting task. A physical therapist measured spinal flexion and extension motions.

Everyone was then tested on repeated lifting tasks using a BTE Work Simulator and a computerized Motion Analysis Model. These tools show changes in body angles over time for each lift. Other components of each lifting pattern also included body posture and force of the lift. Five lifting patterns were observed. These included the slow, low jerk lift, the squat starting lift, the fast, high jerk lift, the torso starting posture lift, and the two-segment lift. In the two-segment lift, the lower body moves faster than the upper body.

Two main subgroups were identified from this study: the guarded CLPB lifters and the high-performing CLBP lifters. Guarded refers to the fact that this group performed a slow, low jerk lifting pattern. High-performing lifters means they used four of the lifting patterns — all but the slow, low jerk method.

Further analysis showed that the high-performing lifters had less pain, more self-confidence, and could complete more lifts than the guarded group. They were more likely to use the squat style of lifting compared to the control group. Most likely this pattern is taught in treatment programs these CLBP patients have been in over the years. The high-performing lifters were more like the normal control subjects in their lifting patterns. They had a higher degree of self-efficacy (confidence) than the guarded lifters.

The guarded group with the jerk lifting pattern reported more intense and more frequent pain than the patients in the high-performing lift group. The authors think the increased pain levels may be why they choose to use this pattern. Using a jerk lift helps minimize muscle force to lift the load. Instead, more muscle groups are contracting to work together to perform the lift.

The authors conclude that subgroups of CLBP patients can be found based on lifting patterns. This is an indication that physical function can be used as a classification scheme when evaluating and treating people with CLBP. Finding ways to help patients increase their confidence level and change their pain perception may be helpful. More research is needed to change our current methods of rehabilitating these patients.

The most common cause of back pain in adults 65 and older is spinal stenosis. Stenosis is a narrowing of the spinal canal or openings for the spinal nerve roots. Changes associated with aging cause the spinal nerves to increase in size while the space around these structures gets smaller.

In this report, orthopedic surgeons review the signs and symptoms and differential diagnosis for spinal stenosis. Differential diagnosis means the surgeon first sorts out whether the low back pain (LBP) is mechanical, nonmechanical, or visceral. Then the diagnosis is narrowed down more specifically.

With mechanical LBP there is usually no known cause for the symptoms. All imaging studies are within normal limits. Nerve and muscle testing are considered normal. Degenerative disc disease, disc herniations, and fractures can cause mechanical LBP. But these are easily identified with X-rays, MRIs, or CT scans.

Infections and tumors pressing on the nerve structures create nonmechanical LBP. And conditions such as kidney infections, pelvic disease, peptic ulcers, and aortic aneurysms are visceral problems that can refer pain to the low back region.

MRIs may be the best tool for identifying spinal stenosis as the cause of the patient’s LBP. Multiplanar views can be taken showing details of the nerves, fat, discs, ligaments, and spaces. Electrodiagnostic tests of nerve and muscle function add information about level and severity of the affected nerve root.

Usually with stenosis there are multiple nerve roots involved. This helps separate stenosis from radiculopathy, which is more likely to affect a single nerve at a time. Radiculopathy refers to any process affecting the nerve(s). This could be a nerve that is inflamed, pinched, or has a lack of blood flow.

The differential diagnosis becomes more difficult when the patient has both stenosis and radiculopathy. And patients with diabetes can develop painful neuropathies affecting multiple nerves. The clinical picture looks a lot like spinal stenosis. That’s when electrodiagnostic tests help with the diagnosis.

Treatment is divided into conservative (nonoperative) care and surgical management. Unless the symptoms are severe or the patient is rapidly getting worse, conservative care is always advised first. Anti-inflammatory drugs, physical therapy, and steroid injections into the epidural space around the spinal cord may be tried.

If improvement doesn’t occur with conservative care, then decompressive surgery to take pressure off the neural structures is next. This is usually done by removing some or all of the bone around the nerve roots. Laminectomy to remove the lamina from around the spinal cord is still the number one surgical choice. The lamina is a column of bone that forms an arch around the spinal cord. Any bone spurs around the nerve are also scraped away. Any disc fragments are removed.

Other surgical procedures used to treat stenosis include fenestration and distraction laminoplasty. Fenestration is the drilling of holds in the lamina. Less bone is removed this way, which helps save spinal stability. This method is best used when only one opening around a single nerve root is affected.

Distraction laminoplasty describes a procedure in which the ligaments between two vertebra are removed. A special tool is used to distract (pull apart) the spinous processes of two vertebral bodies. The spinous process is the bump you feel along the back of the spine. It is really a projection of bone away from the vertebral body. Once the bones are distracted, the surgeon removes part of the facet (spinal) joint. The inner one-third of the lamina is also scraped away to make more room inside the spinal canal.

A newer technique is to place a spacer between two spinous processes. This is called an interspinous process spacer. Putting a spacer between two of these bony knobs holds the vertebrae in proper alignment and relieves the pressure from around the neural structures. The soft tissue structures are preserved with this technique. Local anesthesia can be used. Only a small incision is needed.

More and more surgeons are performing these surgeries endoscopically. This is called a minimally invasive procedure. Special training is required to achieve this level of surgical expertise. Serious complications can occur otherwise. The outcomes of these various surgical techniques continue to be investigated.

Some studies show no difference between patients who were treated surgically and those who received conservative care. Other long-term studies such as the Maine Lumbar Spine Study report significantly greater improvement after surgery compared to nonoperative care.

The differences in outcomes fade over time, though. By the end of 10 years, the results are fairly equal between the groups. And although surgery for spinal stenosis provides greater relief faster than nonoperative care, over time, the condition (and the painful symptoms) come back. These findings were supported by the results of another study: the Spine Patient Outcomes Research Trial (SPORT).

By looking at the long-term results of treatment, it appears that outcomes are improving as patient selection becomes more specific. Laminectomy is still the most commonly used procedure. Some of the less invasive techniques don’t remove enough bone and the surgery ends up a failure.

Research has been able to identify factors that predict which patients can improve the most with different types of surgical treatment. For example, patients with diabetes don’t do as well. They are more likely to develop infections after the operation and less likely to be satisfied with the results. And patients who don’t have severe stenosis (as seen on imaging studies) have a lower rate of improvement in back and leg pain.

Surgeons expect to see more and more cases of spinal stenosis in years to come. With the aging of America and more people developing stenosis, treatment results will continue to improve.

Scar tissue formation after lumbar disc surgery is a major cause of failed-back surgery syndrome. One in four patients are affected. Surgeons are looking for ways to keep this from occurring.

Different drugs and topical agents applied to the surgical area have been studied. These substances may act as a barrier to fibrosis (scar tissue). They may inhibit the development of scar tissue. So far, nothing has been found that works well.

In this study, an antibiotic called mitomycin C was tested. It has been used successfully to prevent fibrosis in eye surgery for glaucoma and after tracheal reconstructive surgery. Animal studies have shown it works after back surgery involving laminectomy. A laminectomy is the removal of vertebral bone from around the spinal cord.

Two groups of patients were included in this study. The ages and gender (male versus female) were matched between the two groups. The first group had mitomycin applied at the site of their discectomies (removal of herniated disc).

The antibiotic solution was applied to the space where the disc was removed. The surgeon was careful not to touch any of the nerve tissue with the mitomycin. Application time was limited to five minutes to avoid any toxic effects of the drug on nearby tissue. The second group just had the discectomy without the mitomycin application.

Results were measured three ways. First, postoperative neurologic function was assessed. Each patient filled out the Lumbar Spine Outcomes Questionnaire (LSOQ). The LSOQ scores pain, symptoms, and activities of daily living (ADLs). A neurologic exam was done to evaluate leg (motor) weakness.

Second, severity of pain and other physical symptoms such as numbness, tingling, and problems with bowel or bladder function were also measured. Each patient rated the degree that function and activities were impaired by pain. Objective measures included the number of days each month they couldn’t complete daily or work activities. Number of hours spent resting each day was recorded and compared between the two groups.

The first two measures were performed one week after surgery. The measures were repeated three, six, and 12 month after surgery. The third measurement of outcomes was by magnetic resonance images (MRIs) taken six months after surgery.

MRIs showed the presence and extent of fibrotic tissue forming in the area where the disc was removed. This is called peridural fibrosis. The amount of peridural fibrosis was graded on a scale from zero (none) to four (75 to 100 per cent filled with scar tissue). Grade two indicated 25 to 50 per cent of the space was filled with scar tissue. Grade three referred toan area that was 51 to 74 per cent filled.

After reviewing all of the data and MR images, the authors concluded there was no benefit to using mitomycin C to prevent peridural fibrosis. The two groups had equal results in all areas. One group did not have fewer complications or better results than the other. Scores on all the tests for pain and function were comparable between the two groups.

More study is needed to identify a biological or inert material that can be implanted in the peridural space to prevent fibrosis. Other factors as a cause of peridural fibrosis after discectomy should also be explored.

For example, would the mitomycin C work better if/when applied to a different site? Perhaps using it at the area where bone is removed (laminotomy or laminectomy) would work better. Or maybe the spine is overloaded when patients walk so soon after surgery. The load and pressure on healing tissue may start a series of steps that cause the formation of scar tissue. The authors suggest multicenter trials to further study this problem.

Sometimes back surgery is like Pandora’s box. It would be better left unopened. Once a person has had any kind of lumbar surgery, the risk of further surgery goes way up. Studies show almost a 10 per cent increase in rates of reoperation after lumbar surgery.

And it doesn’t seem to matter what the patient’s characteristics are or what the surgery was for — the rates still apply. In this study, surgeons take a look over 25 years’ worth of patients who had lumbar surgery. They wanted to single out one particular diagnosis and take a closer look.

Of the 1,100 charts reviewed, 259 had single-level lumbar discectomy (disc removal). The diagnosis was herniated nucleus pulposis (HNP). All patients included in the study had X-ray and MRI evidence of HNP. Back and leg pain (sciatica) were both present.

The procedure performed on each patient was a subtotal discectomy. A piece of bone was removed from the lamina. The lamina forms a roof-like structure over the back of the spinal canal. In this procedure, a thumbnail-sized piece of the lamina is removed (laminectomy). Sometimes a hole is drilled in the lamina (laminotomy to extract the protruding disc.

After the lamina is removed, the surgeon cut a box-shaped hole in the outer covering of the disc (anulus. Any loose disc material was removed without taking any of the anulus or the endplates. Endplates are tough, fibrous material sandwiched between the anulus of the disc and the vertebral bone.

Two independent reviewers classified each disc. They read the surgeon’s notes and reviewed X-ray reports and any other available records. A four-part system called the Carragee classification was used to label each disc as type 1, 2, 3, or 4.

Type 1 was a small fragment of disc or fissure (crack) in the disc covering. Type 2 was described as a disc fragment with annular defect. Type 3 was a fragment contained. Type 4 was no fragment/contained. Any cases of disc hardening or calcification were put in the Type 4 subgroup.

The Carragee system basically groups disc herniations based on whether or not disc material has protruded and how far out of the annular covering it has moved. Surgery can then be directed to remove any disc fragments and repair the defect in the annulus.

This study used the Carragee classification scheme to determine the success of a subtotal discectomy. The results showed a lower rate of failure and reoperation for HNP using partial or subtotal discectomy. The success rate was most noticeable with type 2 herniations. There was a 3.4 per cent reoperation rate using subtotal discectomy versus a 21.2 per cent for fragment excision.

The authors attribute their success to a difference in surgical technique. They used an aggressive method of disc removal. A special Loupe magnification made it possible to cut off or shave the spinous processes and interspinous processes. Then a laminotomy was done. The disc was removed from within the annular covering. Their discectomy patients had a lower rate of reoperation but more back pain and lower function compared with those who had just removal of loose disc fragments.

Many questions still remain after this study. First, Why is the reoperation rate lower with subtotal discectomy? Was it really the surgical technique that made a difference in outcomes? Second why does back pain occur more often after subtotal discectomy compared with fragment excision?

For now, it appears that subtotal discectomy works well and reduces reherniation rates. More study is needed to ensure low reherniation and reoperation rates. The authors also proposed making a Type 5 Carragee subgroup. Calcified or hard disc protrusion is not included in the current four subtypes. This study showed that calcified discs can reherniate and should be included in the classification.

Despite the efforts of doctors, physical therapists, and patients themselves, sometimes lumbar spinal fusion is inevitable. And whenever considering surgery, the benefits and disadvantages must be weighed against each other.

Fusion provides support and stability, thus reducing pain and improving function for many patients. But there’s some evidence that in the long-run, the next (adjacent) vertebral level can start to degenerate. Does this affect everyone? Or are just certain people at risk for this complication?

In this study, surgeons from Seoul, Korea looked for possible risk factors. If physicians could identify who’s at risk ahead of time, it might be possible to prevent this from happening. At the very least, patients would be aware of this potential problem when making the decision to have a spinal fusion.

A group of 48 men and women had an instrumented spinal fusion at L4-5. Instrumented means some type of hardware was used. Instrumentation prevents movement between the vertebrae and protects the graft so it can heal better and faster. In this study, anterior or posterior lumbar interbody fusion was done on each patient.

MRIs, CT scans, and X-rays were used to look for adjacent segment degeneration (ASD). Any one of eight criteria was used to define ASD. This included obvious disc degeneration or an angle change between the two segments. Disc herniation, spinal stenosis, bone spurs, and facet joint changes were also considered signs of ASD.

While following each patient for at least two years, data was collected on symptoms (pain, numbness, tingling, walking ability). Any other clinical signs present and recovery rate were noted. Age, gender (male or female), height and weight, bone density, and fusion length were also recorded.

The authors reported a 62.5 per cent rate of ASD. Most of the time, this was in the segment above the fused vertebra. A few patients had ASD at the level below the fusion or above and below at the same time.

Next, they looked at the differences between patients with ASD and those without ASD. They noticed that younger patients were more likely to develop degenerative changes. ASD did not appear to be linked with gender, body mass index (height or weight), or bone mineral density.

The group without ASD had better results in the first three months after surgery. But by the end of one year, there was no difference in function, success rate, or complications (except for the ASD) between the two groups.

Overall, good-to-excellent results were reported for 87 per cent of the total group (with or without ASD). Having ASD didn’t necessarily mean the patient had a bad result or poor outcome. Many times the patient didn’t even know this complication existed. In fact, only 6.7 per cent of the patients in this study had further surgery to fuse the next level.

The results of this study support evidence in other studies that ASD is caused by postoperative malalignment more than by mechanical factors. Mechanical factors refers to the increased stress and load transferred from the fused site to the adjacent segments. This was observed by the fact that the ASD group no longer had the same lumbar curve called lordosis that was present before the surgery. Postoperative lordosis may be related to the kneeling position of the patient on the operating table during the surgery.

And there was one final observation from this study. Patients who had anterior lumbar interbody fusion (ALIF) were less likely to develop ASD compared to those who had a posterior procedure. ALIF has the advantage of restoring normal lumbar lordosis without damaging posterior soft tissue and bony structures.

Overall, there were three statistically significant risk factors for ASD: age, lordosis, and type of fusion. It looks like older adults who have an ALIF with restoration of normal lumbar lordosis have the best chance for an excellent outcome without ASD.

For a long time, now we have had the understanding that disc surgery may not be any more effective than conservative (nonoperative) care. In long-term studies over 10 years or more, patients with painful back and leg pain from disc herniation had the same results with or without surgery. So, many patients toughed it out and avoided surgery.

But a new study from the Netherlands has some additional information to add that might change this practice. They found that the short-term benefits of disc surgery are actually a costs savings. The patient has less pain and better function early on. And even though the medical costs were greater, the cost to society was less.

How did they figure that? Well, decreased absenteeism and higher work productivity tipped the scales in favor of early surgical intervention. At the end of one year, the cost of early disc surgery to society was less than if the patient had struggled through a prolonged course of conservative care.

Looking at this problem from a purely statistical point-of-view, early surgery also translated into greater quality-adjusted life years (QALYs). QALYs is a way of measuring disease burden on a society. It includes both the quality and the quantity of life lived.

QALYs is a useful way to put a number on the benefit of a medical intervention such as disc surgery. They are based on the number of years of life that would be added by the treatment. Zero value (0) is used to represent death. Perfect health is assigned the value of one (1.0). If without surgery, the extra years would not be lived in full health, then the extra life-years are given a value between 0 and 1 to account for this.

A health economist studying this problem might offer the advice to do disc surgery to save money. But decisions aren’t always made in the health care system based on supply and demand or what’s best for society. Hospitals must look at what is the best use of their resources.

Patients with severe sciatica will likely get better sooner or later without surgery. Some experts argue that resources that might have been used to provide early surgery can be diverted to patients with more serious health concerns. Others stand firm in their belief that it is up to the patient to decide what’s best for him or her. Decisions should not be based on what’s best for society or the health care system.

Total disc replacement (TDR) is possible now for some patients in place of spinal fusion. Two of the disadvantages of spinal fusion are loss of motion at the fused segment and increased risk of adjacent level degeneration.

We know that disc replacements restore spine motion. But do they prevent accelerated degeneration at the level of replacement and at the next level segment above or below? That is the question that researchers attempted to answer with this study. It is the first study to compare degenerative changes in the discs and facet joints before and after TDR.

Patients with disc pain from degenerative disc disease were included in the study. One surgeon inserted a lumbar total disc replacement (TDR) in 46 patients. The ProDisc II device was used. The ProDisc is one of two types of total disc replacements. The other is called the CHARITÉ. Both types of implants are metal-on-polymer. The ProDisc is constrained in front-to-back and side-to-side shear but moves freely in twisting or rotational patterns. Reducing the shear force decreases the load on the facet joints.

Each patient was followed for at least two years. Results were measured first by comparing dynamic X-rays, MRIs, and CT images before and 26 months (or more) after surgery. Any changes in the discs or joints were compared with patient symptoms, range of motion, and function.

The researchers also looked at patient age, gender, height, weight, and vertebral level operated on. They also studied the relative size and position of the implant. They found improved pain levels and motion (flexion and extension) at the operated segment. There was very little sign of degeneration of the adjacent (next level) discs.

Facet (spinal) joint degeneration referred to as progression of facet arthrosis (PFA) was also evaluated. PFA usually occurs along with loss of disc height. As the discs degenerate, there is a loss of height or cushion between the vertebral bodies. This puts more pressure on the facet joints and creates changes such as bone spurs or hypertrophy (overgrowth) of the joint capsule.

It appears that PFA was more commonly seen in patients when disc replacements were placed at more than one level. PFA also occurred more often when the implant was placed off center. Women were affected more often than men. The reason for the gender difference is unknown at this time.

The most striking finding in this study was that disc and joint changes were fairly minimal at the adjacent segments. But changes were present in about one-third of the patients at the level of the TDR (also known as the index level). At the same time, there was improved pain, function, and quality of life even with the joint changes at the index level.

The authors point out two design flaws in their study. First, there was no control group (patients with degenerative disc disease who did not receive treatment). It’s possible that what they saw with the group in this study was nothing more than what would have happened anyway. That’s referred to as the natural history of a condition. And secondly, the sample size was fairly small. This same study should be repeated with a larger group of patients, including a control group.

For best results, surgeons are advised to make sure the implant is placed at the middle of the vertebral body on the frontal plane. This is especially important when TDRs are placed at more than one level at the same time. Malpositioning on the frontal plane puts an uneven load on the implant and on the facet joints. This can create further degeneration of an already compromised joint.

Many experts agree that exercise is an important part of treating low back pain. But studies so far only show that the effects of exercise on pain and function are small and don’t last. Why is that? Is it the type of exercise being used? The type of patients in the studies? Or some other factor?

In this report, a group of experts at a panel discussion and interactive workshop summarize their thoughts and suggestions on this topic. The forum met in Amsterdam, The Netherlands in June of 2006. They discussed a wide range of concerns about how exercise trials are conducted and reported. There is general agreement that many studies are of low quality.

Some of the factors considered in reviewing exercise-based research included the fact that exercise varies so much in type, frequency, intensity, and duration. There are land-based programs versus water or pool-based programs. Some studies focuse on trunk exercises while others measure walking distance.

Not all patients are alike. Some are afraid of movement while others simply don’t like to exercise. Are the results different for these patients compared to those who like to exercise and who do their exercises every day?

And what about measuring the results of exercise programs? Should it be based on change in symptoms, function, quality of life, or some other measure? There isn’t a consistent way to measure and report on results from study to study.

The panel also pointed out that the way some research is carried out just isn’t sound or unbiased. Sometimes it’s difficult to keep the groups from knowing who’s getting what kind of treatment. This is called blinding. It’s a necessary part of scientific research to avoid influencing responses to treatment.

It’s difficult to tell when the exercise was helpful and when it was the effects of concern, encouragement, and contact with the physical therapist who was guiding the exercise program. This factor is referred to as the patient-provider interaction. There are ways to measure the patient-provider interaction but many times this isn’t included in the study.

The panel made several suggestions for ways to improve research efforts. Stronger evidence is needed regarding exercises before recommending specific programs for patients with low back pain. Here are some of the ideas presented:

Healthcare costs for patients with low back pain (LBP) have climbed into the billions of dollars each year. And that’s the direct cost. It doesn’t include the indirect cost due to loss of productivity, work-time, or wages.

It has been proposed that one way to reduce total annual costs for the care of LBP is to reduce the number of recurrences of LBP. Physical therapy may be able to help in this matter. A previous study by these same authors showed that patients who received physical therapy were more likely to take an active approach and have better outcomes.

Patient compliance with a physical therapy program may improve symptoms faster. It’s also possible there could be a decrease in the number of second and third bouts of low back pain experienced by the patient. And the total associated costs would most certainly go down.

To test this idea out, patients between the ages of 18 and 60 with acute low back pain were studied. Acute LBP was described as anyone with symptoms a total of less than 90 days. All were covered by an insurance company called SelectHealth.

Type of therapy administered was collected by looking at the billing codes charged for each patient during the episode of care on file. The episode of care was said to be over when the therapist didn’t see the patient for 45 days or more. Charges for care beyond 45 days up to one year were also reviewed.

Success was defined as improving at least 50 percent on the Modified Oswestry Disability Questionnaire. The test was given to each patient before and after physical therapy care. Physical therapy received was divided into active or passive. Active therapy included exercise and therapeutic activities. Passive was described as head/cold, electrical stimulation, ultrasound, or other similar modalities.

The number of patients who received other healthcare was also collected. This included a wide range of health care services such as a visit to an urgent care center or the emergency department, use of antiinflammatories, or the use of other medications (opioids, muscle relaxers). Chiropractic care, steroid injections, and surgery were also included.

They found that patients who completed their physical therapy programs were less likely to use pain medication or muscle relaxers. They were also less likely to have extra imaging tests done or get a steroid injection.

Overall healthcare charges were less for those who were in physical therapy. It appears that completing a course of physical therapy can reduce the economic burden of low back pain. Evidence from previous studies that active methods have better long-term effects was supported by this study.