Nortin M. Hadler

Acute severe low back pain : a population-based study of prevalence and care-seeking

Study Design Telephone interviews were conducted with a random sample of adults in 4437 North Carolina households. The response rate was 79%. Objective The prevalence of low back pain and the correlates of care-seeking in a defined population were examined. Summary of Background Data Previous research on low back pain has used varying definitions of the illness of low back pain, and has admixed patients with acute and chronic low back pain. Acute low back pain was examined in this study as a distinct phenomenon separate from chronic low back pain. Methods Respondents completed a detailed interview regarding the occurrence of and care sought for back pain in 1991. Acute back pain was defined as functionally limiting pain lasting less than 3 months. Results From this sample, 485 individuals had at least one occurrence of acute severe low back pain in 1991, representing 7.6% of the adult population. Symptoms were reported less commonly in individuals older than age 60 years (5% vs. 8.5%) and in nonwhites compared with whites (5% vs. 8%). Thirty-nine percent of those with back pain sought medical care; 24% sought care initially from an allopathic physician, 13% from a chiropractor, and 2% from other providers. More prolonged pain, more severe pain, and sciatica were associated with care-seeking. Gender, income, age, rural residence, and health insurance status did not correlate with the decision to seek medical care. Younger age, male gender, and nonjob-related pain did correlate with the decision to seek care from a chiropractor. Conclusions Acute back pain is common. Care is often sought regardless of income and insurance status. Seeing a health care provider for acute back pain may not be discretionary from the perspective of the patient.

Care-seeking Among Individuals With Chronic Low Back Pain

Study Design. This was a stratified, random telephone survey of adults in North Carolina. Objective To determine the prevalance of chronic low back pain and the extent to which treatment is sought for this condition. Summary of Background Data Chronic low back pain is a major problem. Previous studies often have comb ined acute and chronic back pain. Methods Telephone interviews regarding back pain were conducted with 4437 North Caroliona adults during 1992. Results Chronic back pain affects 3.9% of the North Carolina population. Thirty-four percent considered themselves permanently disabled and 52% assessed their overall health as fair or poor. The median number of bed-disability days per year was three. Seventy-three percent saw a health care provider Of those who sought care, 91% saw a medical doctore, 29% saw a physical therapist, and 25% saw a chiropractor, Use of technology was extensive: 37% received a computed tomography scan, 25% received a magnetic resonance imaging scan, and 10.4% underwent surgery. Conclusions Chronic back pain is common, and the level of care-seeking and costs of care among those afflicted are extremely high.

A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial.

Fifty-four subjects volunteered to participate in a controlled study contrasting spinal manipulation with spinal mobilization without the rotational forces and leverage required to move facet joints. All suffered from regional low-back pain for less than 1 month, were ages 18–40, had never previously undergone any form of spinal manipulation, and denied a prior episode of backache within the previous 6 months. Randomization was stratified at outset into those who suffered for less than 2 weeks and those whose discomfort had persisted for 2–4 weeks. Outcome was monitored by a questionnaire assessing functional impairment. A treatment effect of manipulation was demonstrated only in the strata with more prolonged illness at entry. In the first week following manipulation, these patients improved to a greater degree (P=.009, t test) and more rapidly (P <.025, Wilcoxon rank-sum test).

Manual ability as a marker of dependency in geriatric women

Little is known about the factors responsible for the institutionalization of the elderly. This studys objective was to discover markers associated with nursing home placement. Fifty-six white ambulatory women over 63 yrs of age were selected from 3 settings encompassing a range of dependency: 20 women from nursing homes; 16 women who lived in their own homes but requiring social assistance and 20 totally independent women. Each woman was examined for factors that might be associated with her state of dependency: age, socioeconomic status, morale, education, strength of social network, number and type of medications, mental status, manual ability, medical problems and abnormalities on physical examination. The time required to perform any of 27 manual skills discriminated the 3 groups better than any other factor (P less than 0.0001). Three manual skills predicted group membership with 92% accuracy. Manual ability may be the best marker of dependency in elderly women and should be measured in studies concerned with geriatric health status.

Recurrence and care seeking after acute back pain: Results of a long-term follow-up study

OBJECTIVE To explore the relationship between type of initial care as well as the likelihood of recurrence and consequent care seeking behavior. RESEARCH DESIGN Prospective observational cohort recruited from 208 randomly selected North Carolina practices. Cohort study examined the recurrence of low back pain among patients free of back pain 3 months after their index visit to a practitioner for that problem. The following four practitioner strata were examined: primary care providers, chiropractors, orthopedic surgeons, and practitioners in a group model HMO. Patients were interviewed by telephone at 6 and 22 months after the initial visit. MAIN OUTCOME MEASURES Rates of disabling and non-disabling low back pain; functional status using the Roland back disability scale; and care seeking. RESULTS Rates of recurrence were substantial; functionally disabling recurrence rates varied between 8% and 14% between 3 to 6 months, and 20% to 35% between 6 to 22 months. Differences in rates among practitioner strata were statistically significant only between 6 to 22 months with higher recurrence rates for HMO patients. Functional status, number of bed days, and time off work were very similar among the practitioner strata. Care seeking, however, was greater among those patients who had initially seen a chiropractor for their back pain. Patients with recurrence saw the same practitioner type they had seen for the index episode 88% of the time. Satisfaction was slightly greater for patients who saw chiropractors when compared with patients seeing allopathic physicians. CONCLUSIONS The recurrence of low back pain is common. Severe disability is rare. Patients who had sought care from chiropractors are more likely to return for recurrences than patients who had initially sought care from MDs.

Knee Pain Is the Malady—Not Osteoarthritis

Excerpt Osteoarthritis is a well-defined pathoanatomic entity readily demonstrable by modern imaging techniques. For a century, the pathology that is this disease has been ingrained in the mind of ...

Diagnosis and treatment of backache

M ANY of the clinical tenets regarding regional low back illnesses are unproven, maybe even unprovable. We are seldom able to ascribe any episode of back illness to a particular back disease.’ The relationship between illness and usage remains undefined’ and few treatment modalities have been shown to be effective. Heuristic or not, these clinical tenets are all we have today. They underlie the judgements upon which we act for the sake of the patient. Herein, we will describe our synthesis of the literature and our approach to the patient with low back pain (LBP). Our judgements are not “right”they are the best we can do. By setting them down, we intend to engender the comparisons, discussions, and controversy that fuel clinical scholarship. At least 70% of us will experience LBP at some time in our lives.3*4 Acute LBP is a selflimited illness. Approximately 40% of patients remit in 1 wk, 60%85% in 3 wk, and 90% or more within 2 rno.& Even when LBP is considered a work-related compensable injury,’ only 10% have prolonged disability lasting more than 6 wk.’ Along with remittency,” LBP is characterized by a striking likelihood of recurrence. Hora14 noted recurrences in 90% of patients who had sought medical care because of LBP. He also found that the likelihood of recurrence is directly correlated with age of onset and severity of initial attack; recurrences are longer lasting. Conversely, the first attack of low back pain is usually the shortest and least severe. Back symptoms begin in the third-fourth decade,3S4*6 peak in incidence in the forties and early fifties, and decline rapidly thereafter. There has been no sex difference in incidence noted. This discussion will focus on regional diseases of the low back, which underlie these chronic intermittent and remittent clinical states. We will set down our approach as internists and rheumatologists to the patient presenting with backache. We will discuss the literature. as it relates to this approach. The format we have chosen is to raise a series of questions we bring to the bedside of such a patient.

Treatment of calcinosis universalis with low-dose warfarin

Patients with calcinosis universalis secondary to dermatomyositis or systemic sclerosis have increased levels of the calcium-binding amino acid, gamma-carboxyglutamic acid. The enzyme that effects gamma carboxylation of glutamic acid is warfarin-sensitive. Four patients with calcinosis universalis were treated with 1 mg per day of warfarin for 18 months in a non-blind initial study. Two patients had both decreased gamma-carboxyglutamic acid urinary concentration and decreased extra-skeletal uptake on technetium 99m-diphosphonate whole-body nuclear scanning. In a subsequent double-blind placebo study, two thirds of the patients receiving 1 mg per day of warfarin had decreases in extra-skeletal nuclear tracer uptake after 18 months, compared with none of the four patients receiving placebo. No patient had a change in clinical assessment, bleeding complication, or baseline normal prothrombin time. This low-dose warfarin regimen appears to have no demonstrable adverse effects, and these results suggest a beneficial effect on the progression of calcinosis in these rheumatic diseases.

Acute polyarticular gout

Abstract The clinical features of gout, manifest as an acute polyarthritis, are described in 102 patients. In 34 of these the diagnosis was based on the finding of monosodium urate crystals in synovial fluid. The mean age of the patients was 60 years, and 90 per cent were male. Acute polyarthritis was the first manifestation of gout in 39 per cent of all patients. Serum uric acid concentrations were less than 7.0 mg/dl in 13 of 34 patients with documented crystal-induced synovitis and in 15 of 68 of the remainder at the time of the acute attack. Eighteen of the 20 normouricemic patients reexamined were hyperuricemic before or after the polyarticular attack. The distribution of joints involved was usually asymmetric. Of all joints involved, 83 per cent were in the lower extremity, but in one third of the patients the foot was spared. Fever, leukocytosis and dramatic response to therapy with colchicine or anti-inflammatory drugs were the rule. Gout should be considered in the differential diagnosis of acute polyarthritis regardless of the absence of hyperuricemia or foot involvement.

Regional Back Pain

Most patients with low back pain have a regional backache — i.e., one that is not caused by systemic disease. They have suffered no overtly traumatic precipitating event, and they would be well wer...