Ernest Volinn

A Consensus Approach Toward the Standardization of Back Pain Definitions for Use in Prevalence Studies

Study Design. A modified Delphi study conducted with 28 experts in back pain research from 12 countries. Objective. To identify standardized definitions of low back pain that could be consistently used by investigators in prevalence studies to provide comparable data. Summary of Background Data. Differences in the definition of back pain prevalence in population studies lead to heterogeneity in study findings, and limitations or impossibilities in comparing or summarizing prevalence figures from different studies. Methods. Back pain definitions were identified from 51 articles reporting population-based prevalence studies, and dissected into 77 items documenting 7 elements. These items were submitted to a panel of experts for rating and reduction, in 3 rounds (participation: 76%). Preliminary results were presented and discussed during the Amsterdam Forum VIII for Primary Care Research on Low Back Pain, compared with scientific evidence and confirmed and fine-tuned by the panel in a fourth round and the preparation of the current article. Results. Two definitions were agreed on a minimal definition (with 1 question covering site of low back pain, symptoms observed, and time frame of the measure, and a second question on severity of low back pain) and an optimal definition that is made from the minimal definition and add-ons (covering frequency and duration of symptoms, an additional measure of severity, sciatica, and exclusions) that can be adapted to different needs. Conclusion. These definitions provide standards that may improve future comparisons of low back pain prevalence figures by person, place and time characteristics, and offer opportunities for statistical summaries.

Back sprain in industry : the role of socioeconomic factors in chronicity

A minority of industrial-back-sprain claimants account for most of the cost of industrial back sprain: those whose disability persists into “chronicity,” which is defined as 90 days or more off work. The data in this study demonstrate the effects of socioeconomic factors on chronicity. This analysis is based on State of Washington industrial insurance claims for back sprain. For both men and women, three socioeconomic factors significantly affect the risk of chronicity: age, wage, and the family status of being either widowed or divorced with no children. In addition, the Nam-Powers Socioeconomic Index is significant for men. Wage compensation ratio cannot be shown to be a factor in chronicity.

Use of the international classification of diseases (Icd-9-cm) to identify hospitalizations for mechanical low back problems in administrative databases

Large administrative databases are increasingly valuable tools for health care research. Although increased access to these databases provides valuable opportunities to study health care utilization, costs and outcomes and valid and comparable results require explicit and consistent analytic methods. Algorlthms for identifying surgical and nonsurgical hospitalizations for “mechanical” low back problems in automated databases are described. Sixty-six ICD-9-CM diagnosis and 15 procedure codes that could be applied to patients with mechanical low back problems were identified. Twenty-seven diagnosis and two procedure codes identify hospitalizations for problems definitely in the lumbar or lumbosacral region. Exclusion criteria were developed to eliminate nonmechanical causes of low back pain, such as malignancies, infections, and major trauma. The use of the algorithms is illustrated using national hospital discharge data.

Opioid Pharmacotherapy for Chronic Non-Cancer Pain in the United States: A Research Guideline for Developing an Evidence-Base

UNLABELLED This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence. PERSPECTIVE Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.

Patterns in low back pain hospitalizations: implications for the treatment of low back pain in an era of health care reform.

Objective: To examine patterns in both surgical and nonsurgical low back pain (LBP) hospitalizations through time and among geographic regions and to explore the practical implications of these patterns for health care reform. Setting. For time trends, the U.S. (1979–1987); for geographic variations, major regions of the U.S. (1987). Date Source: The National Hospital Discharge Survey. Results: Rates of both surgical and nonsurgical LBP hospitalization varied twofold among regions of the U.S., and average lengths of stay for these types of hospitalization varied considerably as well. The U.S. rate of LBP surgery increased sharply during the period covered by the study. Over the same time, the U.S. rate of nonsurgical LBP hospitalization declined, as did average lengths of stay for both types of LBP hospitalization. Conclusion: Wide variations in LBP hospitalization practices raise the issue of which practices are most appropriate. Outcomes research addresses this issue, as does research on patient preferences for certain types of treatment. As indicated by the increasing rate of LBP surgery, more research also needs to be done on changing physician practice style. If such research were to result in a reduction in LBP hospitalization, savings in health care costs would be considerable.

Back pain claim rates in Japan and the United States: Framing the puzzle

Study Design. This is a cross-national comparison of workers’ compensation claims for back pain in Japan and the United States (US). Objectives. The main objective is to juxtapose rates of back pain claims in Japan and Washington state. Because the Washington state rate closely matches rates for other US states as well as the rate for the US as a whole, it is used to represent the US rate. A puzzle is to be framed: Why are back pain claim rates in Japan and the United States so disparate? Summary of Background Data. Occupational back pain is common among workers in both Japan and the United States. Wage compensation for time off work is also substantial in both countries and potentially induces time off work at least as much in Japan as in the United States. Accordingly, back pain claim rates in Japan seemingly would be on the same order of magnitude as rates in the United States. Methods. Washington state rates are based on data from its state fund. Both Japan and Washington state rates are composed of the number of workers eligible to file worker compensation claims in a given year (denominator) and the number of back pain claims accepted during that year (numerator). Because rates may fluctuate from year-to-year, 5 years of data on rates are presented, 1995–1999. Central to the comparison are Japanese and Washington state rates of workers’ compensation claims for back pain with more than 3 days compensated time loss from work. Results. The back pain claim rate in 1999 was 60 times higher in Washington state than in Japan. The disparity in rates for the other years in the study (1995–1998) was similar. Conclusion. Back pain is common among workers both in Japan and the United States, but there is no simple or necessary relationship between that symptom and how it manifests itself in one country or another. Rather, the symptom is protean in its social manifestations. As for what shapes those manifestations—or, more specifically, what causes the startling disparity in back pain claim rates between Japan and the United States—that is a puzzle. Various solutions to the puzzle are discussed, but it remains essentially unsolved.

Why Does Geographic Variation in Health Care Practices Matter?: (and Seven Questions to Ask in Evaluating Studies on Geographic Variation)

One of the most active fields in health services research is the study of “geographic variation,” or disparities in rates of certain types of health care prctices among large areas (such as countries or regions of a country) or small areas (such as countries or hospital market areas); “small area analysis” in particular has received much attention in journals and the popular press. Increasingly, data upon which to base studies of geographic variation are becoming available. This article poses questions to ask in applying studies on geo-graphic variation to health care settings. Because findings from these studies may ultimately affect patient care, the questions are important for physicians as well as health services researchers. The questions are: 1) What events are to be analyzed? 2) What geographic units are to be analyzed? 3) How good are the data? 4) Are differences in rates due to chance alone? 5) Are high rates too high? 6) How is geographic variation to be explained? 7) What is the role of “presentation style” in explaining geographic variation?

The Dragon Strikes: Lessons from the Wenchuan Earthquake

Guo Chen, MD,* Wei Lai, MD,* Fei Liu, MD,* Qingxiang Mao, MD,† Faping Tu, MD,‡§ Jin Wen, PhD, Hong Xiao, MD,* Jian-cheng Zhang, MD,¶ Tao Zhu, MD,* Bin Chen, MD,‡ Zhao-yang Hu, PhD,* Rong-Mei Li,* Zhi Liang, MD,# Hu Nie, MD,¶ Hong Yan, MD,† Bang-Xiang Yang, MD,* Quan Du, MD,† Wen-Xia Huang,* Yao-wen Jiang, MD,¶ Anne Siu-king Kwan, MD,** Li Song, MD,* Chao-Meng Wu, MD,* Tia Xiang, MD,‡ Hong-wei Xu, MD,* Wayne Bond Lau, MD,†† Hai-Bo Song, MD,* Chuan-Bin Wen, MD,* Zhen-Hai Yao, MD, PhD,‡‡ Lan Zhang, MB,* Jianrong Zeng, MD,§§ Yue-E Dai, MD,* Bernard L. Lopez, MD,** Jian-qiao Zheng, MD,* Jihong Zhou, MD,† Theodore A. Christopher, MD,** Xin L. Ma, MD, PhD,** Hui Yu, MD,* Li-Li Xu, MD,* Qiao Guo, MD,* Zhi-Ping Song, MD,* Ernest Volinn, PhD, King Kryger, PhD, Yu Cao, MD,¶ Hengjiang Ge, MD,† Hui Liu, MD,* Chao-zhi Luo, MD,* Weike Tao, MD,§ Yun-Xia Zuo, MD, PhD,* and Jin Liu, MD*

The Boeing prospective study and beyond.

Study Design. The Boeing prospective study was reviewed. The Boeing prospective study, comprising two articles, was a large field study that explored why workers would or would not report occupational back pain problems. Objectives. The most immediate objective was to determine the extent to which conclusions drawn from the Boeing prospective study withstand critical examination. The ultimate purpose of this review was to develop guidelines for field studies of back pain in industry. Summary of Background Data. For more than a century, researchers have noted great variability among individuals in the reporting of back pain, but the explanations posed for this variability have been inconsistent. Because findings gain credibility roughly to the extent that they bear on the world outside the laboratory, field studies in particular hold great potential for clarifying the underlying explanation for individual variability in back pain reporting. The Boeing prospective study was a large and ambitious field study that examined this issue. Methods. The Boeing prospective study was examined through the lens of research conducted since it was published. The review used both the methodological and substantive literature. Results. The Boeing prospective study, based on a minority of workers originally solicited to participate in it (33–41%), accounted for 7% of the variation in why workers would or would not report a back pain problem. A number of issues that may have biased its results toward the null are examined. Conclusions. The highlighting of the Boeing prospective study’s limitations may be instructive not so much to criticize this one particular study but, rather, to anticipate problems that in general may be encountered in field studies of back pain in industry. Looking beyond the Boeing prospective study, the following guidelines for the conduct of such studies may be proposed: 1) Study designs should be based on explanations from which testable hypotheses may be derived; 2) Subgroups within the more general category of “back pain” should be delineated; 3) Both occupational exposures and psychosocial factors should be entered into the analysis; 4) Factors not apparent at the workplace should be considered; 5. Abstracts of articles should be carefully crafted.

Eastern Meditation Groups: Why Join?

This paper examines membership in a certain type of New Religious group-viz. those whose members leave the larger society of their own volition in order to participate in meditation and other practices from the East. The data include field observations, responses from a structured interview, and semi-structured, tape-recorded interviews. A model of membership is proposed: individuals with IA) a psychotherapeutic orientation who are IB) structurally available for II) in depth drug experimentation III) seek an alternative to the drug highs without the lows. In the great majority of societies, there is some built-in way of entering a meditative state, some release from the hereand-now other than drugs or alcohol. This society is one of the few exceptions. Members of New Religious groups such as the ashram may be seen as those who have found, in a corner of this society, a way of entering a meditative state.