Low back disorders are the second most frequent problems presented to health care providers. It is estimated that 60% to 80% of the general population will experience an episode of low back pain (LBP) during his or her lifetime.1–3 The annual prevalence rate is between 25% and 60%.4 LBP recurrence rates reportedly range from 24% to 80%.5,6 Back injuries are among the most common causes of reported occupational disorders with an incidence rate of 20 per 10,000 full-time workers and an average of 7 days away from work per injury.7 In addition, low back disorders are disproportionately expensive, accounting for 10% to 33% of workers’ compensation costs.8–10 Occupationally related back pain has a national direct annual cost estimate of $10.8 billion (US). However, this estimate is conservative as it does not include the indirect cost to employers who must rehire and retrain replacement workers, the loss of productivity, reduced quality work, administrative costs, and losses to the patient and patient's family (including productivity at home). Finally, it does not take into account those workers who do not file for disability, but nonetheless experience the effects of LBP.11
There are dozens of systematic reviews and guidelines that have been developed to address select elements of evaluation and treatment of LBP such as diagnostic imaging12,13 and manipulation14–16; there also are a few that are broad in scope.16–25 There was no recent guideline identified, nor any other guideline identified meeting current guidelines quality standards26–29 and addressing detailed and comprehensive low back disorders evaluation and management.
ACOEM's Low Back Disorders Guideline is designed to provide health care providers who are the primary target users of this guideline with evidence-based guidance on the evaluation and treatment of low back disorders, whether acute (up to 1 month duration), subacute (1 to 3 months’ duration), chronic (>3 months’ duration) Practice-Guidelines-Center/Guidelines-Methodology or postoperative. This guideline does not address several broad categories including congenital disorders or malignancies. It also does not address specific intraoperative procedures. This report is the first of three parts that summarizes findings for low back disorders, with this part focusing on the diagnostic evaluation sections from the ACOEM Low Back Disorders Guideline (2391 references). This report addresses the following questions from those addressed by the Evidence-based Practice Spine Panel:
- What evidence supports the initial assessment and diagnostic approach?
- What red flags signify serious underlying condition(s)?
- What diagnostic approaches and special studies identify clinical pathology?
- What is the evidence of work-relatedness for various diagnoses?
The primary target population is working-age adults, although the literature searches included articles addressing all adults. Thus, it is recognized that the principles may apply more broadly.
GUILDELINE DEVELOPMENT PROCESS
A detailed methodology document specifies evidence selection, scoring, incorporation of cost considerations, and formulation of recommendations.30,31 Briefly, the aim is to identify the highest quality evidence on any given topic. Guidance was drafted using tables of evidence that abstracted the evidence. Draft text and tables were forwarded to the multidisciplinary Panel (Russell Travis [chair], Roger M. Belcourt, Ronald Donelson, Marjorie Eskay-Auerbach, Jill Galper, Michael Goertz, Scott Haldeman, Paul D. Hooper, James E. Lessenger, Tom Mayer, Kathryn L. Mueller, Donald R. Murphy, William G. Tellin, Michael S. Weiss, and panel consultant Cameron W. MacDonald). The Panel reviewed the evidence and finalized the text and recommendations.
EVIDENCE REVIEW AND GRADING
All evidence related to low back disorders in searching four databases was included in this guideline (PubMed, EBSCO, Google Scholar, and Cochrane). These comprehensive searches for evidence were performed through January 2018 to help ensure complete study capture. There was no limit on the year of publication. Search terms for this report are available at: https://acoem.org/Practice-Resources/Practice-Guidelines-Center/Guidelines-Methodology. Reference lists of included articles were reviewed for inclusion. All included studies were scored for quality.30 Articles scoring moderate or high quality were included.30
The search strategies retrieved a total of 9972 articles, which were screened, with all potentially relevant study abstracts reviewed and evaluated against specified inclusion and exclusion criteria. A total of 116 articles met the inclusion criteria and were included in these guidelines. Remaining evidence included in these guidelines was received from the Panel members and a review of references in the included articles.
Articles meeting the inclusion criteria were critically appraised and scored for quality. Articles scoring moderate or high quality were included.30 A total of 101 were of high or moderate quality addressing low back disorders diagnostic evaluation. Evidence-based recommendations were developed and graded from (A) to (C) in favor and against the specific diagnostic test, with (A) level recommendations having the highest quality body of literature. Expert consensus was employed for insufficient evidence (I) to develop consensus guidance. Recommendations and evidence tables were reviewed and amended by the multidisciplinary Panel. This guideline achieved 100% Panel agreement for all developed guidance.
COMMENTS AND MODIFICATION
Guidance was developed with sufficient detail to facilitate assessment of compliance (Institute of Medicine [IOM])27 and auditing/monitoring (Appraisal of Guidelines for Research and Evaluation [AGREE]28). Alternative options to manage conditions are provided in other ACOEM guidelines when comparative trials are available.32–40 The guidance adhered to all AGREE,28 IOM,27 AMSTAR,29 and GRADE26 criteria.30 In accordance with the IOM's Trustworthy Guidelines, this guideline underwent external peer review by 13 medical/health professional societies and at least 18 individual external reviewers, and subsequent revisions to the guidance, and detailed records of the peer review processes are kept, including responses to external peer reviewers.27
Separate reports on this guideline's findings concerning medical management including noninterventional therapies and for injection therapies, surgery and rehabilitation are available.
The Evidence-based Practice Spine Panel and the Research Team have complete editorial independence from ACOEM and Reed Group, which have not influenced the guideline. The literature is continuously monitored and formally appraised for evidence that would materially affect this guidance. This guideline is planned to be comprehensively updated at least every 5 years or more frequently should evidence require it. All treatment recommendations are guidance based on synthesis of the evidence plus expert consensus. These are recommendations for practitioners, and decisions to adopt a particular course of action must be made by trained practitioners on the basis of available resources and the particular circumstances presented by the individual patient.
Comprehensive History and Physical Examination
No quality studies assess the utility and/or components of a history and physical examination. Nevertheless, the Panel's consensus recommendation is that a careful history and physical examination is naturally important for appropriate evaluation and diagnosis (Table 1), as well as to develop a good therapeutic relationship which is of importance for optimizing outcomes. The initial assessment of LBP has a unique emphasis on ‘ruling out’ serious underlying conditions (eg, kidney stone, infection, cancer, fracture). This ruling out process primarily relies upon the identification of ‘red flags.’41
Relatively common red flags for LBP in employed populations include trauma (eg, falls, significant motor vehicle crashes), history of cancer, immunosuppression, progressive neurological deficit, renal colic, and history of urinary tract infections. The absence of red flags and conditions generally rules out the need for special studies, referral, or inpatient care during the first 4 to 6 weeks. During this time, spontaneous recovery is expected, particularly if any significant workplace factors are mitigated.17 A minority of LBP-related cases are due to radiculopathy and those too typically resolve with non-interventional management.
A comprehensive evaluation and documentation include a history, prior treatment, vocation, avocational activities, current functional level, medical history, family history, social history including substance(s) use (tobacco, alcohol, and illicit substances), review of systems, laboratory testing, and imaging studies.
An evaluation using repeated end-range testing while monitoring for patterns of pain response determines the presence or absence of two common clinical findings, directional preference and pain centralization. The presumptive pain generator's directional preference is that single direction of testing that results in the pain centralizing, abolishing, or both. “Pain centralization” occurs when pain referred or radiating away from the spine retreats back toward or to the midline in response to a single direction spinal testing. Those patterns are typically assessed during end-range loading tests in various directions of spinal bending performed by the patient while both standing and recumbent. These findings characterize a large LBP subgroup for whom directional exercises appear to provide superior outcomes.42–49
Most LBP cases, whether acute or chronic, have pain in the lumbar spine. Pain may be experienced in the lower extremity, although spine pain predominates in LBP cases. The unique aspect of the diagnostic approach for LBP is that the vast majority of cases, estimated at over 95% in most employed populations,3,50–52 have no definable pathophysiological abnormality. Some practitioners refer to these LBP patients as having incurred “sprains” and/or “strains”; however, these labels are not ideal as there is no identifiable ligament or myotendinous injury. The use of those terms also confuses the proper use of those diagnoses elsewhere in the body, becomes problematic in determination of work-relatedness, and misdirects patients on the value of activity for early functional recovery. These patients are best termed as having the most precise diagnosis possible, that is, the symptom of LBP.
Pain that is solely or mostly traveling in a posterior thigh and calf generally, but not always, signifies radiculopathy, particularly when the radicular pain in the extremity substantially exceeds that in the back or is the sole symptom. As pain predominates among radicular pain patients, a history of paresthesias will generally require specific, focused questions to elicit.
Associated Factors and Risk Factors for Nonspecific LBP
There are many nonoccupational factors that have been associated with LBP. The most consistent and strongest is a prior history of LBP, which is one of the factors also confirmed in prospective studies.53–65 Aging has been associated with LBP in some studies,66–69 but many do not support a relationship with nonspecific LBP in contrast with degenerative spine conditions. Instead, aging has been consistently associated with degenerative back disorders.4,70–72 Additional reported risk factors for LBP include smoking,62,67,73–75 obesity,56,62,63,66,67,69,73–92 height,91 high triglycerides,93 hypertension,75 genetic factors,72,94–96 poor general health,97,98 poor sleep,62,73,99 pain-related fear,64,97 prolonged driving,62 deconditioning,100 and physical inactivity or lack of exercise.62,73,75,101 A pattern of increased risk associated with cardiovascular risk factors and cardiovascular risk factor scores has been observed.75 A U-shaped relationship between physical activity and risk of LBP has been reported in two epidemiological studies.51,102
A number of physical factors are reported to be associated with LBP, although most of the evidence is from retrospective studies without measured job factors. Yet, recent data from a prospective cohort study with measured job physical factors have supported high lifting forces, as measured by the Cumulative Lifting Index, as associated with increased risk of LBP.54,55,58 Cross-sectional studies have reported mostly unconfirmed associations between LBP and heavy physical work (particularly lifting heavy objects or lifting large and awkward objects),61,62,67,73,79,98,103–110 lifting weights above shoulder level,108 carrying,69,109 trunk in a bent or twisted posture,64,69,73 prolonged or highly repeated bending, inability to change posture regularly,64,111 standing and walking,112 frequent reaching or forceful pushing or pulling,108,113 kneeling,108 or squatting.108 Housework was shown to be a risk factor in a prospective cohort study.54,58 Prolonged sitting and whole body vibration70,73,114–116 are also suggested by some to be contributors. Work with scaffolding is a reported association.98 These activities are not exclusive to job functions and should be reviewed as they pertain to nonoccupational activities as well. Unaccustomed physically demanding work (or sports or hobbies), another probable risk factor, is under recognized and may be fairly potent.
Until recently, prospective data supporting work-relatedness of LBP were limited. Recent data suggest increased risk of LBP as assessed by the Cumulative Lifting Index that was derived from the Revised National Institute for Occupational Safety and Health (NIOSH) Lifting Equation.54,55,58,117 Yet, support for degenerative disorders remains unsubstantiated.
Reduced lifting programs have been found to be successful at reducing risk of LBP in settings of manual patient transfers,118–123 but not in most other settings. Programs have been ineffective for stress management, shoe inserts, insoles, back supports.124 Lifting advice and training also do not appear effective.125
It has also been theorized that these “stressors” do not cause back disorders. Rather, when a back disorder arises in an individual who does heavy physical work, the work is then more difficult to accomplish and the individual is more likely to file a workers’ compensation claim. This is compared to the sedentary worker who develops back pain and may continue to perform work though more carefully (reporting bias).126,127
Psychosocial factors, both occupational and nonoccupational, also have been reportedly associated with back disorders.128 These include task enjoyment, monotony,108 mental stress,73,108 work stress,67 job dissatisfaction,54,129 life dissatisfaction,73 high demand/low control,98,99 low supervisor support,99 low coworker support,99 and social isolation.62 Psychiatric symptoms such as anxiety, depression,54,58,61,130 low energy,62 emotional problems,62 and somatization are all apparent risk factors. Providers with high fear avoidant beliefs also may contribute by prescribing more sick leave, bed rest, and less return to normal function.131,132 Many cases of LBP in the general population are idiopathic and the mechanism of LBP has not yet been elucidated.
Associations With Degenerative Spine Conditions Including Sciatica
There are no quality studies of degenerative spine conditions including radiculopathy, and thus no true job physical risk factors are known. There is a poor correlation between LBP and degenerative findings on imaging studies,4 as well as between LBP and MRI findings of disc protrusion, nerve root displacement or compression, disc degeneration, and high intensity zone.133 The prevalence of nerve root contact is 11% to 23% and for displacement and/or compression 2% to 5%. Overall prevalence of disc degeneration in asymptomatic people is 54%, with a strong relationship with age.133 Prevalence of high-intensity zone (HIZ) or annular fissure overall is 28% to 56%.134
Risk factors for degenerative back conditions that include spinal stenosis are not well defined compared with those for nonspecific LBP. Nutrient vessels disappear to the disc, requiring diffusion.135 This may provide a mechanistic explanation for cardiovascular disease risk factor impacts, particularly on degenerative spine disorders.75 Degenerative disc changes have been well linked with inheritance,72,94–96,136–139 and genetic influences on the outcomes of spine surgery have also been reported.140,141 Available epidemiological studies suggest the risk factors for degenerative conditions include aging,4,70,71 male sex,71,142–144 obesity,71 heredity,4 and systemic arthrosis.145 Reported risks for spondylolysis include increasing age and male sex.71 Risks for degenerative spondylolisthesis include age and female sex.71 Risks for facet joint arthritis are increasing age and obesity.71 A trend towards greater spinal stenosis in those with a BMI >30 kg/m2 has been reported,71 but that study is likely underpowered. There are no quality ergonomic-epidemiological studies reported for degenerative spine conditions and job physical factors.
There are no proven risk factors for radiculopathy as it is a relatively rare event and quality epidemiological studies have not been reported. However, heavy lifting and activities that substantially increase the intradiscal pressures are theorized factors. Prolonged whole-body vibration such as prolonged driving is a reported, but disputed factor.114 Aside from age, smoking appears to be a factor. Spondylolisthesis is most often degenerative in nature. There are acute trauma-related cases in which causal analysis is straightforward and centers on whether the inciting trauma was in the context of work and that the magnitude of the event was sufficient to truly be an acute traumatic event.
There are no quality epidemiological studies that support theories that degenerative spondylolisthesis, spinal stenosis, degenerative facet disease, or sciatica/radiculopathy are occupational conditions. However, there is a biomechanical theory that physical factors may contribute through degenerative disease in the discs with resulting theoretically altered biomechanical forces in the facets resulting in or accelerating degenerative facet osteoarthrosis. Yet, there also is evidence that these conditions may have a genetic basis.146,147
Special Studies and Diagnostic and Treatment Considerations
Detailed discussion of various imaging studies follows this section. Lumbar spine x-rays are not recommended in patients with LBP in the absence of red flags for serious spinal pathology within the first 4 to 6 weeks. Among patients with evidence of radiculopathy, imaging in the acute pain setting is also not recommended as the natural history is for such problems to resolve with conservative care. Table 1 provides a general comparison of the abilities of different techniques to identify physiologic insult and define anatomic defects. An imaging study may be appropriate for a patient whose limitations due to consistent symptoms have persisted for 1 month or more to further evaluate the possibility of potentially serious pathology such as a tumor or with progressive neurologic deficit(s).
Diagnostic Testing and Other Testing
Diagnostic tests can be categorized into three broad categories: (1) anatomical, (2) functional, and (3) physiological. Anatomical tests help to define anatomy and include roentgenograms, magnetic resonance imaging (MRI), bone scans, computerized tomography (CT), and myelograms. Functional tests include those that assess voluntary lifting, pushing, or pulling capacities. Physiological tests include electromyography (EMG). Tests such as discography attempt to bridge the gap between two of these testing domains and are organizationally included in this document in one domain. In considering which test to order, it is important to be able to address two key questions:
- What is the specific question to be addressed?
- What will be done with the results?
The first question must be clearly addressed and the second must result in an unequivocal answer used for a decision point with the results having a significant probability of altering the clinical management. Otherwise, the test is almost never indicated.
The operant characteristics of the test being ordered are critical to the proper interpretation of the results. For example, lumbosacral spine MRIs are more likely to be “abnormal” by age 40 in normal individuals (show normal aging changes), and herniated discs are not infrequently found in screening studies of asymptomatic teenagers and young adults.134,148–166 The pretest probability of disease, determined by a careful clinical evaluation, is critical to address the probability that the abnormality identified on the image is actually causing the individual's symptoms. At present, there is not one type of imaging method that shows a clear advantage over others. Generally, MRI is superior for imaging soft tissue including intervertebral disc herniations.
There are many additional diagnostic tests possible for the evaluation of LBP and spinal conditions. In the absence of moderate- to high-quality studies, other tests are Not Recommended, Insufficient Evidence (I), Low Confidence.30
FUNCTIONAL CAPACITY EVALUATIONS
Functional capacity evaluations (FCEs) consist of a comprehensive battery of performance-based tests to attempt to provide the treating physician with detailed information on an individual's ability for work and activities of daily living.167–190 As FCEs are performance-based tests, participation with full, maximal efforts is critical. FCE evaluators attempt to determine physical effort based on a combination of physiological and biomechanical factors and movement/performance consistency. Thus, FCE testing is best performed by the treating therapist during the episode of care when the results can be compared with prior observations, inform treatment, help assess progress, and provide useful information about physical function. However, most FCEs are performed on 1 day. Of the 781 articles found in this systematic review, five articles were initially included of which three are moderate-quality studies incorporated into this analysis191–193 and there are two low-quality studies.194,195 These studies were 1-day FCEs performed outside the clinical context. The correlation between pain ratings and functional abilities is weak.196–202 Studies suggest FCEs are unable to predict safe re-entry to the workplace following rehabilitation of work-related back pain/injury,170,203,204 yet as return to work includes psychosocial and environmental factors, the inability to predict return to work may be unsurprising. As reliability and validity have not been proven, FCEs should be regarded as demonstrating what a patient was willing to do. In a prospective cohort study of 1438 consecutive work-related back patients, all underwent an FCE before return to work. In the control group, the FCE was used to write return-to-work guidelines, whereas in the study group it was ignored and the worker was returned usually to full duty. Ignoring the FCE improved outcome.205
FCEs are a recommended option for evaluation of disabling chronic LBP where the information may be helpful to attempt to objectify worker capability, function, motivation, and effort vis-à-vis either a specific job or general job requirements (Recommended, Insufficient Evidence (I), Moderate Confidence). There are circumstances where a patient is not progressing as anticipated at 6 to 8 weeks and an FCE can evaluate functional status and patient performance to match performance to specific job demands, particularly in instances where those demands are medium to heavy. That said, functional testing is recommended to be performed as a routine aspect of physical and occupational therapy which should obviate the need for a full day FCE. There is no recommendation for or against the use of FCEs for chronic stable LBP or after completion of postoperative recovery among those able to return to work (No Recommendation, Insufficient Evidence (I), Low Confidence). Functional capacity evaluations are not recommended for evaluation of acute LBP, acute or subacute radicular syndromes, or postsurgical back pain problems within the first 12 weeks of the postoperative period (Not Recommended, Insufficient Evidence (I), High Confidence).
X-rays are commonly utilized for evaluation of LBP, particularly that which is chronic, persistent and accompanied by red flags or trauma12,206 Similar to most diagnostic studies, MRI is usually considered the gold standard comparison. There are five quality studies incorporated into the recommendation.207–210 In general, routine x-ray is not recommended for acute nonspecific LBP (Moderately Not Recommended (B), High Confidence) but is recommended in the setting of red flags207,209–212 where the acute LBP could be due to fracture, neoplasia, infection, or systemic illness, where subacute or chronic LBP is not improved as a means of ruling out other conditions (Recommended, Insufficient Evidence (I), High Confidence). Flexion and extension views are recommended for evaluating symptomatic spondylolisthesis (chronic, severe mechanical pain suspected as an instability), in which there is consideration for surgery or other invasive treatment or occasionally in the setting of trauma (Recommended, Insufficient Evidence (I), Moderate Confidence).
MAGNETIC RESONANCE IMAGING
MRI has been evaluated in 8 high-quality150,213–219 and 30 moderate-quality155,161,164,220–246 studies. The sensitivity and specificity of CT or MRI are challenging to define as they require a “gold standard” that is difficult to define in back pain because the final diagnosis often is based on the same imaging modality being tested; therefore, these clinical studies may be prone to incorporation bias, artificially inflating the sensitivity and specificity with some assuming MRI has 100% sensitivity and specificity.
Open MRIs have lower resolution and are not recommended other than when the patient's weight exceeds the closed MRI unit's specifications or suffers from claustrophobia that is not sufficiently alleviated with a preprocedure low-dose anxiolytic. Standing MRI units are designed to evaluate the discs and spine under usual conditions of axial loading and can be used in other positions. Magnets are typically weaker than conventional MRI, resulting in lower resolution. There are currently no quality studies on which to recommend standing MRI for uses outside of research settings, and interpretation of normal findings of increased disc bulging with standing are unclear, therefore standing or weight-bearing MRI is not recommended for back or radicular pain syndrome conditions (Not Recommended, Insufficient Evidence (I), Moderate Confidence).
MRI is recommended for patients with acute LBP during the first 6 weeks for evaluating progressive neurologic deficit, cauda equina syndrome, history of neoplasia (cancer), persistent fever plus elevated erythrocyte sedimentation rate without other infectious source, or atypical presentation, for example, clinical picture suggests multiple nerve root involvement (Recommended, Insufficient Evidence (I), High Confidence). MRI is moderately not recommended for acute radicular pain syndromes in the first 6 weeks unless the problems are severe and not trending towards improvement assuming the MRI confirms ongoing nerve root compression consistent with clinical examination and surgery is being considered. Repeat MRI imaging without significant clinical change in symptoms and/or signs, such as development of neurological deficit, is also not recommended (Moderately Not Recommended (B), Moderate Confidence).
MRI is moderately recommended for patients with subacute or chronic radicular pain syndromes lasting at least 4 to 6 weeks in whom the symptoms are not trending towards improvement and prompt surgery is being considered, assuming the MRI confirms a nerve root compression consistent with clinical examination. In cases where an epidural glucocorticosteroid injection is being considered for temporary relief of acute or subacute radiculopathy, MRI at 3 to 4 weeks (before the epidural steroid injection) may be reasonable (Moderately Recommended (B), Moderate Confidence).
MRI is recommended for selecting chronic LBP patients to rule out concurrent pathology unrelated to injury. This is not recommended before 3 months and only after other treatment modalities (including NSAIDs, aerobic exercise, and directional preference exercises) have failed (Recommended, Insufficient Evidence (I), Moderate Confidence). MRI is not recommended for evaluation of acute, subacute, or nearly all chronic LBP cases. MRI is indicated for discrete, potentially surgically treatable disorders such as radiculopathy, spondylolisthesis, and spinal stenosis.
CT is primarily used to define fractures not visible on plain x-rays or when MRI is unavailable or contraindicated (especially for implanted ferrous device).247 Due to the greater soft tissue contrast of MRIs, there is less current need for CT.12,248 Yet, CT is widely thought to be sufficient to evaluate most patients with suspected disc herniations even though it is not as successful for soft tissue imaging.249–251 There are four high-252–255 and four moderate-quality256–259 evaluating CT utility.
Routine CT is not recommended for acute, subacute, or chronic nonspecific LBP, or for radicular pain syndromes (Not Recommended (C), High Confidence). CT is, however, recommended for patients with acute or subacute radicular pain syndrome who failed to improve within 4 to 6 weeks and if there is consideration for an epidural glucocorticoid injection or surgical discectomy (see Epidural Steroid Injection). If there is strong consideration for surgery, then CT myelography should be considered instead of CT alone (Recommended (C), Moderate Confidence). If there is a contraindication to MRI and surgery is considered moderate to high probability, then CT myelography is a consideration instead of CT followed by another CT with myelography.
MYELOGRAPHY (INCLUDING CT MYELOGRAPHY AND MRI MYELOGRAPHY)
Myelography is the injection of a radiocontrast media into the thecal sac with subsequent imaging and was historically combined with standard roentgenograms as the most common method to diagnose herniated discs, spinal stenosis, or other forms of neurological compromise.260–263 It was subsequently paired with CT (CT myelography) or rarely MRI (MRI myelography). However, it has been almost completely replaced by MRI that produces superior resolution of images. Consequently, there may be little use for myelography,264 though many spine surgeons use CT myelography to help with surgical decision-making in cases in which MRI is equivocal or not possible. There are two high-213,214 and two moderate-quality265,266 studies. Myelography is recommended in uncommon situations, such as contraindications for MRI such as implanted metal that preclude MRI, equivocal findings of disc herniation on MRI suspected of being false positives, spinal stenosis, and/or a postsurgical situation that requires myelography (Recommended, Insufficient Evidence (I), High Confidence).
Bone scans show increased radioactive uptake and are most commonly used for evaluating many types of metastases,267–269 infection, inflammatory arthropathies, occult fractures,270–272 or other significant bone trauma.273 There are no quality studies evaluating bone scans for diagnosis of typical occupational LBP patients. Reported sensitivity and specificity were not satisfactory for evaluating chronic LBP patients, and the population studied was felt to be too small to develop normative values.274 Although not used for the evaluation of most LBP, it is a good diagnostic test for specific situations, including evaluations of suspected metastases, infected bone (osteomyelitis), inflammatory arthropathies, and trauma (fractures). Aside from specific indications which involve a minority of LBP patients, the routine use of bone scanning is not recommended in diagnosing LBP (Not Recommended, Insufficient Evidence (I), High Confidence).
SINGLE PROTON EMISSION COMPUTED TOMOGRAPHY
Single proton emission computed tomography (SPECT) is a three-dimensional imaging technique that, for LBP issues, has been primarily used for the diagnosis of inflammatory arthropathies, for example, ankylosing spondylitis affecting the SI joints and other structures which are difficult to image.275–282 There is one high-283 and four moderate-quality284–287 studies, but no quality evidence with patient-related outcomes that SPECT is helpful in improving care of acute, subacute, or chronic LBP, or radicular pain syndromes or other LBP-related conditions. However, one study found SPECT helpful in evaluating patients with inflammatory arthropathies, particularly if there are concerns about the SI joints.288 Some data suggest SPECT may outperform bone scanning. Additional studies are needed to determine if SPECT adds something to the diagnosis, treatment and outcomes beyond that obtained by a careful history, physical examination, plain x-rays, and clinical impression before it can be recommended for evaluating facet arthropathies. SPECT is not currently recommended for LBP and/or related disorders ( Not Recommended, Insufficient Evidence (I), Low Confidence).
Among spine patients, EMG has been used primarily to evaluate radiculopathy.289 As imaging studies (especially CT and MRI) have progressed, the need for EMG has declined. However, EMG remains helpful in certain situations. Needle EMG may help determine if radiculopathy and/or spinal stenosis is present and can help address acuity.290 These include ongoing pain suspected to be of neurological origin, but without clear neurological compromise on imaging study. Electrodiagnostic studies, which must include needle EMG, are recommended where a CT or MRI is equivocal and there is ongoing pain that raises questions about whether there may be a neurological compromise that may be identifiable (ie, leg symptoms consistent with radiculopathy, spinal stenosis, peripheral neuropathy, etc.).290–297 Also, may be helpful for evaluation of chronicity and/or aggravation of a preexisting problem (Moderately Recommended, Evidence (B), High Confidence). Electrodiagnostic studies are not recommended for patients with acute, subacute, or chronic LBP who do not have significant leg pain or numbness (Not Recommended, Evidence (C), Moderate Confidence). Electrodiagnostic studies are recommended for patients with subacute or chronic LBP highly suspicious for lumbar spinal stenosis when MRI findings may be negative (Moderately Recommended (B), High Confidence).
Surface electromyography (sEMG) has been used to diagnose LBP298–314 and involves the recording of summated muscle electrical activity by skin electrodes (such as those used in an electrocardiogram or EKG). There are four moderate-quality studies incorporated into this analysis313,315–317 and no quality evidence of diagnostic efficacy, and thus, is not recommended to diagnose LBP (Not Recommended, Insufficient Evidence (I), High Confidence).
Ultrasound is seldom used for diagnostic purposes in the spine other than for unusual specific purposes such as detection and guided drainage of superficial abscesses.318–324 There is one high-320 and one moderate-quality325study showing no diagnostic efficacy and thus, it is not recommended for diagnosing LBP (Not Recommended, Insufficient Evidence (I), High Confidence). For most situations, CT and MRI are superior imaging techniques.
Thermography has been used to assess LBP and radicular pain syndromes and other conditions.326 There are no quality studies but two low quality studies using thermography,327 and in the absence of quality evidence of efficacy, thermography is not recommended for diagnosing acute, subacute or chronic LBP or radicular pain (Not Recommended, Insufficient Evidence (I), Moderate Confidence).
Fluoroscopy has been used for evaluation of LBP. Although used for guided procedures, there are no recent quality studies using fluoroscopy to evaluate either LBP or radicular pain. There are no evidence-based indications for this technique and is not recommended for evaluating acute, subacute or chronic LBP (Not Recommended, Insufficient Evidence (I), Moderate Confidence).
Videofluoroscopy has been used for evaluation of LBP, particularly searching for possible spinal instability. There are two low-quality studies. There are no quality studies demonstrating improved clinical outcomes and, therefore, videofluoroscopy for the assessment of acute, subacute, or chronic LBP is not recommended (Not Recommended, Insufficient Evidence (I), Moderate Confidence).
Discography attempts to determine if chronic spinal pain is caused by disc pathology. Discography is typically used in patients with chronic spinal pain without significant leg pain, as MRI and/or CT provide adequate anatomic information for surgical decisions on decompressive surgery for patients with significant radiculopathy. However, discography is not standardized, which complicates the evaluation of the studies. There are 2 high-328–330 and 22 moderate-quality331–352 studies, and a systematic review353 all of which suggest low positive predictive value and thus, discography, either performed as a solitary test or when paired with imaging (eg, MRI), is moderately not recommended for acute, subacute, or chronic LBP or radicular pain syndromes (Strongly Not Recommended (A), High Confidence).
MRI is sometimes paired with discography for evaluation of the intervertebral discs.337–339,342,345 There are five moderate-quality studies incorporated, but no quality evidence showing discography with MRI improves outcomes with herniated discs, and, therefore, it is not recommended for evaluating herniated discs (Not Recommended (C), Moderate Confidence).
Myeloscopy is minimally invasive and may theoretically be used solely for diagnostic purposes but is most often performed in conjunction with adhesiolysis. There are three moderate-quality studies,354–356 but there are no quality controlled studies with improvement in large scale, medium- to long-term studies.357,358 Myeloscopy is an invasive study with potential complications, is costly, without quality evidence of efficacy, and is not recommended for diagnosing acute, subacute, or chronic LBP, spinal stenosis, radicular pain syndromes, or postsurgical back pain (Not Recommended, Insufficient Evidence (I), Low Confidence).
Diagnostic testing is not indicated for the vast majority of LBP patients. Some evidence suggests imaging may increase medicalization, and thus unnecessary additional testing, treatment, and resultant delayed recovery. Simple diagnostic tests likely have the potential to significantly increase adverse effects. Patients with red flags, trauma, persistence despite treatment, progressive neurological deficits, and surgical indications are examples of exceptions to the rule of avoiding testing of most patients.
1. Griffith LE, Hogg-Johnson S, Cole DC, et al. Low-back pain definitions in occupational studies were categorized for a meta-analysis using Delphi consensus methods. J Clin Epidemiol
2. Heliovaara M, Sievers K, Impivaara O, et al. Descriptive epidemiology and public health aspects of low back pain. Ann Med
3. Thiese M, Hegmann KT, Wood E, et al. Prevalence of low back pain by anatomic location and intensity in an occupational population. BMC Musculoskelet Disord
4. Livshits G, Popham M, Malkin I, et al. Lumbar disc degeneration and genetic factors are the main risk factors for low back pain in women: the UK Twin Spine Study. Ann Rheum Dis
5. Balague F, Mannion AF, Pellise F, et al. Non-specific low back pain. Lancet
6. Hoy D, Brooks P, Blyth F, et al. The epidemiology of low back pain. Best Pract Res Clin Rheumatol
7. U.S. Department of Labor, Bureau of Labor Statistics. Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work, 2012. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics; 2013.
8. Atlas SJ, Chang Y, Keller RB, et al. The impact of disability compensation on long-term treatment outcomes of patients with sciatica due to a lumbar disc herniation. Spine
9. Eccleston S, Petrova P, Zhao X. The Anatomy of Workers’ Compensation Medical Costs and Utilization. 6th ed. (10 volume). Cambridge, MA: Workers Compensation Research Institute; 2007.
10. Webster BS, Snook SH. The cost of 1989 workers’ compensation low back pain claims. Spine
11. Silverstein B, Viikari-Juntura E, Kalat J. Use of a prevention index to identify industries at high risk for work-related musculoskeletal disorders of the neck, back, and upper extremity in Washington state, 1990-1998. Am J Ind Med
12. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet
13. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med
14. Bronfort G, Haas M, Evans R, et al. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J
15. Bronfort G, Haas M, Evans RL, et al. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J
16. Koes B, van Tulder M, Lin C-WC, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J
17. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J
2006; 15 (Suppl. 2):S192–S300.
18. Chou R, Atlas SJ, Stanos SP, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine
19. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine
20. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med
21. Chou R, Huffman LH. American Pain Society, American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med
22. Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine
23. Chou R, Qaseem A, Owens DK, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med
24. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J
25. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J
2006; 15 (Suppl. 2):S169–S191.
27. Institute of Medicine. Standards for Developing Trustworthy Clinical Practice Guidelines. Washington, DC: National Academies Press; 2011.
28. Brouwers M, Kho M, Browman G, et al. AGREE II: advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J
29. Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol
31. Harris JS, Weiss MS, Haas NS, et al. Methodology for ACOEM's Occupational Medicine Practice Guidelines—2017 Revision. J Occup Environ Med
41. Wassenaar M, van Rijn RM, van Tulder MW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J
42. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms—a systematic review. Man Ther
43. Browder DA, Childs JD, Cleland JA, et al. Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther
44. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine
45. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed.Waikanae, New Zealand: Spinal Publications; 2003.
46. Petersen T, Larsen K, Nordsteen J, et al. The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial. Spine
47. Werneke MW, Hart DL, Cutrone G, et al. Association between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther
48. Werneke MW, Hart DL, Resnik L, et al. Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther
49. Long A, May S, Fung T. The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? J Man Manip Ther
50. Krismer M, van Tulder M. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol
51. Thiese MS, Hegmann KT, Garg A, et al. The predictive relationship of physical activity on the incidence of low back pain in an occupational cohort. J Occup Environ Med
52. Deyo R, Rainville J, Kent D. What can the history and physical examination tell us about low back pain? JAMA
53. Eriksen W. Do people who were passive smokers during childhood have increased risk of long-term work disability? A 15-month prospective study of nurses’ aides. Eur J Public Health
54. Garg A, Boda S, Hegmann KT, et al. The NIOSH lifting equation and low-back pain, Part 1: association with low-back pain in the backworks prospective cohort study. Hum Factors
55. Garg A, Kapellusch JM, Hegmann KT, et al. The NIOSH lifting equation and low-back pain, Part 2: association with seeking care in the backworks prospective cohort study. Hum Factors
56. Hestbaek L, Leboeuf-Yde C, Kyvik KO. Are lifestyle-factors in adolescence predictors for adult low back pain? A cross-sectional and prospective study of young twins. BMC Musculoskelet Dis
57. Hoogendoorn WE, van Poppel MN, Bongers PM, et al. Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine
58. Kapellusch JM, Garg A, Boda S, et al. Association between lifting and use of medication for low back pain: results from the backworks prospective cohort study. J Occup Environ Med
59. Linton SJ. A review of psychological risk factors in back and neck pain. Spine
60. Papageorgiou AC, Croft PR, Thomas E, et al. Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study. Pain
61. Smedley J, Egger P, Cooper C, et al. Prospective cohort study of predictors of incident low back pain in nurses. Br Med J
62. Tubach F, Leclerc A, Landre MF, et al. Risk factors for sick leave due to low back pain: a prospective study. J Occup Environ Med
63. Van Nieuwenhuyse A, Crombez G, Burdorf A, et al. Physical characteristics of the back are not predictive of low back pain in healthy workers: a prospective study. BMC Musculoskelet Dis
64. Van Nieuwenhuyse A, Somville PR, Crombez G, et al. The role of physical workload and pain related fear in the development of low back pain in young workers: evidence from the BelCoBack Study; results after one year of follow up. Occup Environ Med
65. van Poppel MN, Koes BW, van der Ploeg T, et al. Lumbar supports and education for the prevention of low back pain in industry: a randomized controlled trial. JAMA
66. Heuch I, Heuch I, Hagen K, et al. Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trondelag Health Study. Spine
67. Karahan A, Kav S, Abbasoglu A, et al. Low back pain: prevalence and associated risk factors among hospital staff. J Adv Nurs
68. Knox JB, Orchowski JR, Owens B. Racial differences in the incidence of acute low back pain in United States military service members. Spine
69. Ozguler A, Leclerc A, Landre MF, et al. Individual and occupational determinants of low back pain according to various definitions of low back pain. J Epidemiol Community Health
70. Frymoyer JW, Newberg A, Pope MH, et al. Spine radiographs in patients with low-back pain. An epidemiological study in men. J Bone Joint Surg Am
71. Kalichman L, Guermazi A, Li L, et al. Association between age, sex, BMI and CT-evaluated spinal degeneration features. J Back Musculoskelet Rehabil
72. Wickstrom G. Effect of work on degenerative back disease. A review. Scand J Work Environ Health
1978; 4 (Suppl. 1):1–12.
73. Miranda H, Viikari-Juntura E, Punnett L, et al. Occupational loading, health behavior and sleep disturbance as predictors of low-back pain. Scand J Work Environ Health
74. Shiri R, Karppinen J, Leino-Arjas P, et al. The association between smoking and low back pain: a meta-analysis. Am J Med
75. Leino-Arjas P, Solovieva S, Kirjonen J, et al. Cardiovascular risk factors and low-back pain in a long-term follow-up of industrial employees. Scand J Work Environ Health
76. Cust G, Pearson JC, Mair A. The prevalence of low back pain in nurses. Intl Nursing Rev
77. Pedersen O, Petersen R, Schack Staffeldt E. Back pain and isometric back muscle strength of workers in a Danish factory. Scand J Rehabil Med
78. Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in schoolchildren: the role of mechanical and psychosocial factors. Arch Disease Childhood
79. Aro S, Leino P. Overweight and musculoskeletal morbidity: a ten-year follow-up. Intl J Obesity
80. Barton JE, Haight RO, Marsland DW, et al. Low back pain in the primary care setting. J Fam Pract
81. Bostman OM. Body mass index and height in patients requiring surgery for lumbar intervertebral disc herniation. Spine
82. Bovenzi M, Zadini A. Self-reported low back symptoms in urban bus drivers exposed to whole-body vibration. Spine
83. Gyntelberg F. One year incidence of low back pain among male residents of Copenhagen aged 40–59. Danish Med Bull
84. Heliovaara M, Knekt P, Aromaa A. Incidence and risk factors of herniated lumbar intervertebral disc or sciatica leading to hospitalization. J Chronic Dis
85. Karvonen MJ, Viitasalo JT, Komi PV, Nummi J, Jarvinen T. Back and leg complaints in relation to muscle strength in young men. Scand J Rehabil Med
86. Leboeuf-Yde C. Body weight and low back pain. A systematic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine
87. Raanaas R, Anderson D. A questionnaire survey of Norwegian taxi drivers’ musculoskeletal health, and work-related risk factors. Int J Ind Ergonom
88. Videman T, Sarna S, Battie MC, et al. The long-term effects of physical loading and exercise lifestyles on back-related symptoms, disability, and spinal pathology among men. Spine
89. Wright D, Barrow S, Fisher AD, et al. Influence of physical, psychological and behavioural factors on consultations for back pain. Br J Rheumatol
90. Croft PR, Rigby AS. Socioeconomic influences on back problems in the community in Britain. J Epidemiol Community Health
91. Hershkovich O, Friedlander A, Gordon B, et al. Associations of body mass index and body height with low back pain in 829,791 adolescents. Am J Epidemiol
92. Shiri R, Karppinen J, Leino-Arjas P, et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol
93. Leino-Arjas P, Kaila-Kangas L, Solovieva S, et al. Serum lipids and low back pain: an association? A follow-up study of a working population sample. Spine
94. Battie MC, Videman T, Levalahti E, et al. Heritability of low back pain and the role of disc degeneration. Pain
95. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Familial predisposition and heritability estimation. Joint Bone Spine
96. Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine
97. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA
98. Elders LA, Burdorf A. Prevalence, incidence, and recurrence of low back pain in scaffolders during a 3-year follow-up study. Spine
99. Hoogendoorn WE, Bongers PM, de Vet HC, et al. Psychosocial work characteristics and psychological strain in relation to low-back pain. Scand J Work Environ Health
100. Verbunt JA, Smeets RJ, Wittink HM. Cause or effect? Deconditioning and chronic low back pain. Pain
101. van Oostrom SH, Monique Verschuren WM, de Vet HC, et al. Ten year course of low back pain in an adult population-based cohort—the Doetinchem Cohort Study. Eur J Pain
102. Heneweer H, Vanhees L, Picavet HS. Physical activity and low back pain: a U-shaped relation? Pain
103. Bergenudd H, Nilsson B, Uden A, et al. Bone mineral content, gender, body posture, and build in relation to back pain in middle age. Spine
104. Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine
105. Bigos SJ, Spengler DM, Martin NA, et al. Back injuries in industry: a retrospective study. II. Injury factors. Spine
106. Chaffin DB, Park KS. A longitudinal study of low-back pain as associated with occupational weight lifting factors. Am Ind Hyg Assoc J
107. Dehlin O, Hedenrud B, Horal J. Back symptoms in nursing aides in a geriatric hospital. An interview study with special reference to the incidence of low-back symptoms. Scand J Rehabil Med
108. Harkness EF, Macfarlane GJ, Nahit ES. Risk factors for new-onset low back pain amongst cohorts of newly employed workers. Rheumatol (Oxford)
109. Wai EK, Roffey DM, Bishop P, et al. Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J
110. Waters TR, Putz-Anderson V, Garg A, et al. Revised NIOSH equation for the design and evaluation of manual lifting tasks. Ergonomics
111. Wai EK, Roffey DM, Bishop P, et al. Causal assessment of occupational bending or twisting and low back pain: results of a systematic review. Spine J
112. Roffey DM, Wai EK, Bishop P, et al. Causal assessment of occupational standing or walking and low back pain: results of a systematic review. Spine J
113. Roffey DM, Wai EK, Bishop P, et al. Causal assessment of occupational pushing or pulling and low back pain: results of a systematic review. Spine J
114. Bible JE, Choemprayong S, O’Neill KR, et al. Whole-body vibration: is there a causal relationship to specific imaging findings of the spine? Spine
115. Roffey DM, Wai EK, Bishop P, et al. Causal assessment of occupational sitting and low back pain: results of a systematic review. Spine J
116. Waters T, Genaidy A, Barriera Viruet H, et al. The impact of operating heavy equipment vehicles on lower back disorders. Ergonomics
117. Garg A, Hegmann KT, Moore JS, et al. Study protocol title: a prospective cohort study of low back pain. BMC Musculoskelet Dis
118. Engst C, Chhokar R, Miller A, et al. Effectiveness of overhead lifting devices in reducing the risk of injury to care staff in extended care facilities. Ergonomics
119. Garg A, Owen B. Reducing back stress to nursing personnel: an ergonomic intervention in a nursing home. Ergonomics
120. Garg A, Owen B, Carlson B. An ergonomic evaluation of nursing assistants’ job in a nursing home. Ergonomics
121. Hegmann K, Garg A. McCunney R. Ergonomic issues in medical centers. Lippincott Williams & Wilkins, Medical Center Occupational Health and Safety
. Philadelphia, PA: 1999.
122. Owen BD, Garg A. Reducing risk for back pain in nursing personnel. AAOHN J
123. Owen BD, Garg A. Reducing back stress through an ergonomic approach: weighing a patient. Intl J Nurs Stud
124. Bigos SJ, Holland J, Holland C, et al. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J
125. Martimo KP, Verbeek J, Karppinen J, et al. Manual material handling advice and assistive devices for preventing and treating back pain in workers. Cochrane Database Systematic Rev
126. Hadler N. Occupational Muscoluskeletal Disorders. Baltimore, MD: Lippincott, Williams, & Wilkins; 2005.
127. Waddell G. The Back Pain Revolution. Edinburgh, Scotland: Churchill Livingstone; 2004.
128. Bigos SJ, Battie MC, Spengler DM, et al. A longitudinal, prospective study of industrial back injury reporting. Clin Orthop Relat Res
129. Williams RA, Pruitt SD, Doctor JN, et al. The contribution of job satisfaction to the transition from acute to chronic low back pain. Arch Phys Med Rehabil
130. Currie SR, Wang J. More data on major depression as an antecedent risk factor for first onset of chronic back pain. Psychol Med
131. Coudeyre E, Rannou F, Tubach F, et al. General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain
132. Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health care providers: are we fear-avoidant? J Occup Rehabil
133. Endean A, Palmer KT, Coggon D. Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies: a systematic review. Spine
134. Stadnik TW, Lee RR, Coen HL, et al. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology
135. Eyring EJ. The biochemistry and physiology of the intervertebral disk. Clin Orthop Relat Res
136. Battie MC, Videman T, Kaprio J, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J
137. Karppinen J, Solovieva S, Luoma K, et al. Modic changes and interleukin 1 gene locus polymorphisms in occupational cohort of middle-aged men. Eur Spine J
138. Matsui H, Kanamori M, Ishihara H, et al. Familial predisposition for lumbar degenerative disc disease. A case-control study. Spine
139. Sokoloff L. The Biology of Degenerative Joint Disease. Chicago, IL: University of Chicago Press; 1969.
140. Calmels P, Queneau P, Hamonet C, et al. Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study. Spine
141. Dai F, Belfer I, Schwartz CE, et al. Association of catechol-O-methyltransferase genetic variants with outcome in patients undergoing surgical treatment for lumbar degenerative disc disease. Spine J
142. Caplan PS, Freedman LM, Connelly TP. Degenerative joint disease of the lumbar spine in coal miners: a clinical and x-ray study. Arthritis Rheum
143. Lawrence J, Aitken-Swan J. Rheumatism in miners: Part 1. Rheumatic complaints. Br J Ind Med
144. Schmorl G, Junghanns H. The Human Spine in Health and Disease. New York, NY: Grune and Stratton; 1971.
145. Lawrence J, de Graaff R, Laine A. Jeffrey M, Ball J. Degenerative joint disease in random samples and occupational groups. The Epidemiology of Chronic Rheumatism
. Oxford, England: Blackwell; 1963. 98–119.
146. Battie MC, Videman T. Lumbar disc degeneration: epidemiology and genetics. J Bone Joint Surg Am
2006; 88 (Suppl. 2):3–9.
147. Patel AA, Spiker WR, Daubs M, et al. Evidence for an inherited predisposition to lumbar disc disease. J Bone Joint Surg Am
148. Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am
149. Boden SD, Sumner DR. Biologic factors affecting spinal fusion and bone regeneration. Spine
150. Carragee E, Alamin T, Cheng I, et al. Are first-time episodes of serious LBP associated with new MRI findings? Spine J
151. Chung CB, Vande Berg BC, Tavernier T, et al. End plate marrow changes in the asymptomatic lumbosacral spine: frequency, distribution and correlation with age and degenerative changes. Skeletal Radiol
152. Haig AJ, Tong HC, Yamakawa KS, et al. Predictors of pain and function in persons with spinal stenosis, low back pain, and no back pain. Spine
153. Haig AJ, Tong HC, Yamakawa KS, et al. Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Arch Phys Med Rehabil
154. Healy JF, Healy BB, Wong WH, et al. Cervical and lumbar MRI in asymptomatic older male lifelong athletes: frequency of degenerative findings. J Comput Assist Tomogr
155. Jarvik JJ, Hollingworth W, Heagerty P, et al. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data. Spine
156. Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med
157. Kjaer P, Leboeuf-Yde C, Sorensen JS, et al. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine
158. Mikhael MA, Ciric IS, Kudrna JC, et al. Recognition of lumbar disc disease with magnetic resonance imaging. Comput Radiol
159. Parkkola R, Rytokoski U, Kormano M. Magnetic resonance imaging of the discs and trunk muscles in patients with chronic low back pain and healthy control subjects. Spine
160. Salminen JJ, Erkintalo MO, Pentti J, et al. Recurrent low back pain and early disc degeneration in the young. Spine
161. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J
162. Schelhas K, Smith MD, Gudry CR, et al. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine
163. Tong HC, Haig AJ, Yamakawa KS, et al. Specificity of needle electromyography for lumbar radiculopathy and plexopathy in 55- to 79-year-old asymptomatic subjects. Am J Phys Med Rehabil
164. Visuri T, Ulaska J, Eskelin M, et al. Narrowing of lumbar spinal canal predicts chronic low back pain more accurately than intervertebral disc degeneration: a magnetic resonance imaging study in young Finnish male conscripts. Mil Med
165. Weinreb JC, Wolbarsht LB, Cohen JM, et al. Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women. Radiology
166. Weishaupt D, Zanetti M, Hodler J, et al. MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers. Radiology
167. Abdel-Moty E, Fishbain DA, Khalil TM, et al. Functional capacity and residual functional capacity and their utility in measuring work capacity. Clin J Pain
168. Chan G, Tan V, Koh D. Ageing and fitness to work. Occup Med
169. Gouttebarge V, Wind H, Kuijer PP, et al. Reliability and validity of functional capacity evaluation methods: a systematic review with reference to Blankenship system, Ergos work simulator, Ergo-Kit and Isernhagen work system. Intl Arch Occup Environ Health
170. Gross DP, Battie MC. Functional capacity evaluation performance does not predict sustained return to work in claimants with chronic back pain. J Occup Rehabil
171. Gross DP, Battie MC, Asante A. Development and validation of a short-form functional capacity evaluation for use in claimants with low back disorders. J Occup Rehabil
172. Ilmarinen J, Tuomi K, Eskelinen L, et al. Background and objectives of the Finnish research project on aging workers in municipal occupations. Scand J Work Environ Health
1991; 17 (Suppl. 1):7–11.
173. Jones T, Kumar S. Functional capacity evaluation of manual materials handlers: a review. Disabil Rehabil
174. Kaplan GM, Wurtele SK, Gillis D. Maximal effort during functional capacity evaluations: an examination of psychological factors. Arch Phys Med Rehabil
175. King PM, Tuckwell N, Barrett TE. A critical review of functional capacity evaluations. Phys Ther
176. Kuijer PP, Gouttebarge V, Brouwer S, et al. Are performance-based measures predictive of work participation in patients with musculoskeletal disorders? A systematic review. Intl Arch Occup Environ Health
177. Mahmud N, Schonstein E, Schaafsma F, et al. Functional capacity evaluations for the prevention of occupational re-injuries in injured workers. Cochrane Database Syst Rev
178. Marfeo EE, Haley SM, Jette AM, et al. Conceptual foundation for measures of physical function and behavioral health function for Social Security work disability evaluation. Arch Phys Med Rehabil
2013; 94:1645–1652. e2.
179. Mayer TG, Gatchel RJ, Mayer H, et al. A prospective two-year study of functional restoration in industrial low back injury. An objective assessment procedure. JAMA
180. McFadden S, MacDonald A, Fogarty A, et al. Vocational assessment: a review of the literature from an occupation-based perspective. Scand J Occup Ther
181. Oesch P, Meyer K, Bachmann S, et al. Comparison of two methods for interpreting lifting performance during functional capacity evaluation. Phys Ther
182. Reneman MF, Kool J, Oesch P, et al. Material handling performance of patients with chronic low back pain during functional capacity evaluation: a comparison between three countries. Disabil Rehabil
183. Spanjer J, Groothoff JW, Brouwer S. Instruments used to assess functional limitations in workers applying for disability benefit: a systematic review. Disabil Rehabil
184. Tramposh AK. The functional capacity evaluation: measuring maximal work abilities. Occup Med
185. Tuomi K, Ilmarinen J, Martikainen R, et al. Aging, work, life-style and work ability among Finnish municipal workers in 1981-1992. Scand J Work Environment Health
1997; 23 (Suppl 1):58–65.
186. van Abbema R, Lakke SE, Reneman MF, et al. Factors associated with functional capacity test results in patients with non-specific chronic low back pain: a systematic review. J Occup Rehabil
187. Wind H, Gouttebarge V, Kuijer PP, et al. Effect of Functional Capacity Evaluation information on the judgment of physicians about physical work ability in the context of disability claims. Intl Arch Occup Environ Health
188. Gibson L, Strong J. Safety issues in functional capacity evaluation: findings from a trial of a new approach for evaluating clients with chronic back pain. J Occup Rehabil
189. Gibson L, Strong J, Wallace A. Functional capacity evaluation as a performance measure: evidence for a new approach for clients with chronic back pain. Clin J Pain
190. Spanjer J, Krol B, Brouwer S, et al. Reliability and validity of the Disability Assessment Structured Interview (DASI): a tool for assessing functional limitations in claimants. J Occup Rehabil
191. Gross DP, Asante AK, Miciak M, et al. A cluster randomized clinical trial comparing functional capacity evaluation and functional interviewing as components of occupational rehabilitation programs. J Occup Rehabil
192. Lemstra M, Olszynski WP, Enright W. The sensitivity and specificity of functional capacity evaluations in determining maximal effort: a randomized trial. Spine
193. Oesch PR, Kool JP, Bachmann S, et al. The influence of a Functional Capacity Evaluation on fitness for work certificates in patients with non-specific chronic low back pain. Work
194. Brouwer S, Reneman MF, Dijkstra PU, et al. Test-retest reliability of the Isernhagen Work Systems Functional Capacity Evaluation in patients with chronic low back pain. J Occup Rehabil
195. Cheng AS, Cheng SW. The predictive validity of job-specific functional capacity evaluation on the employment status of patients with nonspecific low back pain. J Occup Environ Med
196. Brouwer S, Dijkstra PU, Stewart RE, et al. Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain. Disabil Rehabil
197. Gross DP, Battie MC. Construct validity of a kinesiophysical functional capacity evaluation administered within a worker's compensation environment. J Occup Rehabil
198. Reneman MF, Jaegers SM, Westmaas M, et al. The reliability of determining effort level of lifting and carrying in a functional capacity evaluation. Work
199. Reneman MF, Schiphorts Preuper HR, Kleen M, et al. Are pain intensity and pain related fear related to functional capacity evaluation performances of patients with chronic low back pain? J Occup Rehabil
200. Schiphorst Preuper HR, Reneman MF, Boonstra AM, et al. Relationship between psychological factors and performance-based and self-reported disability in chronic low back pain. Eur Spine J
201. Smeets RJ, van Geel AC, Kester AD, et al. Physical capacity tasks in chronic low back pain: what is the contributing role of cardiovascular capacity, pain and psychological factors? Disabil Rehabil
202. Eriksen J, Sjogren P, Bruera E, et al. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain
203. Gross DP, Battie MC. The prognostic value of functional capacity evaluation in patients with chronic low back pain: part 2: sustained recovery. Spine
204. Gross DP, Battie MC, Cassidy JD. The prognostic value of functional capacity evaluation in patients with chronic low back pain: part 1: timely return to work. Spine
205. Hall H, McIntosh G, Melles T, et al. Effect of discharge recommendations on outcome. Spine
206. Rubinstein SM, van Tulder M. A best-evidence review of diagnostic procedures for neck and low-back pain. Best Pract Res Clin Rheumatol
207. Djais N, Kalim H. The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain. APLAR J Rheumatol
208. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA
209. Kendrick D, Fielding K, Bentley E, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial. Br Med J
210. Kerry S, Hilton S, Dundas D, et al. Radiography for low back pain: a randomised controlled trial and observational study in primary care. Br J Gen Pract
211. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin North Am
212. Deyo RA, Mirza SK, Heagerty PJ, et al. A prospective cohort study of surgical treatment for back pain with degenerated discs; study protocol. BMC Musculoskelet Disord
213. Aota Y, Niwa T, Yoshikawa K, et al. Magnetic resonance imaging and magnetic resonance myelography in the presurgical diagnosis of lumbar foraminal stenosis. Spine
214. Bischoff RJ, Rodriguez RP, Gupta K, et al. A comparison of computed tomography-myelography, magnetic resonance imaging, and myelography in the diagnosis of herniated nucleus pulposus and spinal stenosis. J Spinal Disord
215. Boos N, Rieder R, Schade V, et al. 1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine
216. Chawalparit O, Churojana A, Chiewvit P, et al. The limited protocol MRI in diagnosis of lumbar disc herniation. J Med Assoc Thai
217. Lei D, Rege A, Koti M, et al. Painful disc lesion: can modern biplanar magnetic resonance imaging replace discography? J Spinal Disord Tech
218. Pui MH, Husen YA. Value of magnetic resonance myelography in the diagnosis of disc herniation and spinal stenosis. Australas Radiol
219. Suri P, Hunter DJ, Katz JN, et al. Bias in the physical examination of patients with lumbar radiculopathy. BMC Musculoskelet Disord
220. Karppinen J, Malmivaara A, Tervonen O, et al. Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine
221. Schenk P, Laubli T, Hodler J, et al. Magnetic resonance imaging of the lumbar spine: findings in female subjects from administrative and nursing professions. Spine
222. Beattie PF, Meyers SP, Stratford P, et al. Associations between patient report of symptoms and anatomic impairment visible on lumbar magnetic resonance imaging. Spine
223. Boos N, Semmer N, Elfering A, et al. Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imaging: predictors of low back pain-related medical consultation and work incapacity. Spine
224. Borenstein DG. Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol
225. Carragee EJ, Alamin TF, Miller JL, et al. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J
226. Carrino JA, Lurie JD, Tosteson AN, et al. Lumbar spine: reliability of MR imaging findings. Radiology
227. Elfering A, Semmer N, Birkhofer D, et al. Risk factors for lumbar disc degeneration: a 5-year prospective MRI study in asymptomatic individuals. Spine
228. Hanly JG, Mitchell MJ, Barnes DC, et al. Early recognition of sacroiliitis by magnetic resonance imaging and single photon emission computed tomography. J Rheumatol
229. Hu ZJ, He J, Zhao FD, et al. An assessment of the intra- and inter-reliability of the lumbar paraspinal muscle parameters using CT scan and magnetic resonance imaging. Spine
230. Jarvik JG, Hollingworth W, Heagerty PJ, et al. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine
2005; 30:1541–1548. discussion 1549.
231. Jarvik JG, Maravilla KR, Haynor DR, et al. Rapid MR imaging versus plain radiography in patients with low back pain: initial results of a randomized study. Radiology
232. Jia LS, Shi ZR. MRI and myelography in the diagnosis of lumbar canal stenosis and disc herniation. A comparative study. Chinese Med J
233. Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology
234. O’Neill C, Kurgansky M, Kaiser J, et al. Accuracy of MRI for diagnosis of discogenic pain. Pain Physician
235. Siddiqui AH, Rafique MZ, Ahmad MN, et al. Role of magnetic resonance imaging in lumbar spondylosis. J Coll Physicians Surg Pak
236. Suri P, Boyko EJ, Goldberg J, et al. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskelet Disord
237. Videman T, Battie MC, Gibbons LE, et al. Associations between back pain history and lumbar MRI findings. Spine
238. Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. Am J Neuroradiol
239. Barz T, Melloh M, Staub LP, et al. Nerve root sedimentation sign: evaluation of a new radiological sign in lumbar spinal stenosis. Spine
240. Kleinstuck F, Dvorak J, Mannion AF. Are “structural abnormalities” on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain? Spine
241. Lee JH, Lee SH. Physical examination, magnetic resonance image, and electrodiagnostic study in patients with lumbosacral disc herniation or spinal stenosis. J Rehabil Med
242. Li AL, Yen D. Effect of increased MRI and CT scan utilization on clinical decision-making in patients referred to a surgical clinic for back pain. Can J Surg
243. Lurie JD, Tosteson AN, Tosteson TD, et al. Reliability of magnetic resonance imaging readings for lumbar disc herniation in the Spine Patient Outcomes Research Trial (SPORT). Spine
244. Modic MT, Masaryk T, Boumphrey F, et al. Lumbar herniated disk disease and canal stenosis: prospective evaluation by surface coil MR, CT, and myelography. Am J Roentgenol
245. Yan L, Li J, Zhao W, et al. The study of epidurography and multispiral CT scanning examinations in the diagnosis of lumbar nerve root canal stenosis. Orthopedics
246. Mayerhoefer ME, Stelzeneder D, Bachbauer W, et al. Quantitative analysis of lumbar intervertebral disc abnormalities at 3.0 Tesla: value of T(2) texture features and geometric parameters. NMR Biomed
247. van Rijn RM, Wassenaar M, Verhagen AP, et al. Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J
248. French SD, Green S, Buchbinder R, et al. Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions. Cochrane Database Syst Rev
249. Boden SD. The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine. J Bone Joint Surg Am
250. Ren XS, Selim AJ, Fincke G, et al. Assessment of functional status, low back disability, and use of diagnostic imaging in patients with low back pain and radiating leg pain. J Clin Epidemiol
251. Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine
252. Iversen T, Solberg TK, Romner B, et al. Accuracy of physical examination for chronic lumbar radiculopathy. BMC Musculoskelet Disord
253. Nakao S, Yoshida M, Yamada H, et al. A new 3-dimensional computed tomography imaging method to diagnose extraforaminal stenosis at the lumbosacral junction. J Spinal Disord Tech
254. Slebus FG, Braakman R, Schipper J, et al. Non-corresponding radiological and surgical diagnoses in patients operated for sciatica. Acta Neurochir
255. Willen J, Danielson B. The diagnostic effect from axial loading of the lumbar spine during computed tomography and magnetic resonance imaging in patients with degenerative disorders. Spine
256. Beauvais C, Wybier M, Chazerain P, et al. Prognostic value of early computed tomography in radiculopathy due to lumbar intervertebral disk herniation. A prospective study. Joint Bone Spine
257. Carrera GF, Williams AL, Haughton VM. Computed tomography in sciatica. Radiology
258. Gilbert FJ, Grant AM, Gillan MG, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial. Radiology
259. Kalichman L, Kim DH, Li L, Guermazi A, et al. Computed tomography-evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain. Spine J
260. Carmody RF, Yang PJ, Seeley GW, et al. Spinal cord compression due to metastatic disease: diagnosis with MR imaging versus myelography. Radiology
261. Kardaun JW, Schipper J, Braakman R. CT, myelography, and phlebography in the detection of lumbar disk herniation: an analysis of the literature. Am J Neuroradiol
262. Kent DL, Haynor DR, Larson EB, et al. Diagnosis of lumbar spinal stenosis in adults: a metaanalysis of the accuracy of CT, MR, and myelography. Am J Roentgenol
263. Loblaw DA, Perry J, Chambers A, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group. J Clin Oncology
264. Thornbury JR, Fryback DG, Turski PA, et al. Disk-caused nerve compression in patients with acute low-back pain: diagnosis with MR, CT myelography, and plain CT. Radiology
265. Bakhsh A. Role of conventional lumbar myelography in the management of sciatica: An experience from Pakistan. Asian J Neurosurg
266. Engelhorn T, Rennert J, Richter G, et al. Myelography using flat panel volumetric computed tomography: a comparative study in patients with lumbar spinal stenosis. Spine
267. Baker RR, Holmes ER 3rd, Alderson PO, et al. An evaluation of bone scans as screening procedures for occult metastases in primary breast cancer. Annals Surg
268. McNeil BJ. Value of bone scanning in neoplastic disease. Semin Nucl Med
269. Szot W, Kostkiewicz M, Zajac J, et al. Prostate cancer in patients from rural and suburban areas--PSA value, Gleason score and presence of metastases in bone scan. Ann Agric Environ Med
270. Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord
271. Pillai A, Jain M. Management of clinical fractures of the scaphoid: results of an audit and literature review. Eur J Emerg Med
272. Chakravarty D, Sloan J, Brenchley J. Risk reduction through skeletal scintigraphy as a screening tool in suspected scaphoid fracture: a literature review. Emerg Med J
273. Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone. Radiography, scintigraphy, and MR imaging. Clin Sports Med
274. Zafeirakis A, Kasimos D, Sioka C, et al. Evaluation of a quantitative diagnostic sacroiliac bone scan index in cases of chronic low back pain in young male adults. Hell J Nucl Med
275. Brenner AI, Koshy J, Morey J, et al. The bone scan. Semin Nucl Med
276. Delbeke D, Schoder H, Martin WH, et al. Hybrid imaging (SPECT/CT and PET/CT): improving therapeutic decisions. Semin Nucl Med
277. Kosuda S, Kaji T, Yokoyama H, et al. Does bone SPECT actually have lower sensitivity for detecting vertebral metastasis than MRI? J Nucl Med
278. Leone A, Cianfoni A, Cerase A, et al. Lumbar spondylolysis: a review. Skelet Radiol
279. Maus T. Imaging the back pain patient. Phys Med Rehabil Clinics North Am
280. O’Neill C, Owens DK. Role of single photon emission computed tomography in the diagnosis of chronic low back pain. Spin J
281. Rinkus K, Knaub M. Clinical and diagnostic evaluation of low back pain. Semin Spine Surg
282. Takemitsu M, El Rassi G, Woratanarat P, et al. Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography. Spine
283. Ryan RJ, Gibson T, Fogelman I. The identification of spinal pathology in chronic low back pain using single photon emission computed tomography. Nucl Med Commun
284. Bodner RJ, Heyman S, Drummond DS, et al. The use of single photon emission computed tomography (SPECT) in the diagnosis of low-back pain in young patients. Spine
285. Gunzburg R, Servais F, Verhas M. Tomoscintigraphy of the lumbar spine: prospects and clinical application. Eur Spine J
286. Harisankar CN, Mittal BR, Bhattacharya A, et al. Utility of single photon emission computed tomography/computed tomography imaging in evaluation of chronic low back pain. Indian J Nucl Med
287. Pneumaticos SG, Chatziioannou SN, Hipp JA, et al. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology
288. Hanly JG, Barnes DC, Mitchell MJ, MacMillan L, Docherty P. Single photon emission computed tomography in the diagnosis of inflammatory spondyloarthropathies. J Rheumatology
289. Sandoval AE. Electrodiagnostics for low back pain. Phys Med Rehabil Clinics North Am
290. Kang PB, Preston DC, Raynor EM. Involvement of superficial peroneal sensory nerve in common peroneal neuropathy. Muscle Nerve
291. Chiodo A, Haig AJ, Yamakawa KS, et al. Needle EMG has a lower false positive rate than MRI in asymptomatic older adults being evaluated for lumbar spinal stenosis. Clin Neurophysiol
292. Lazaro R. Electromyography in musculoskeletal pain: a reappraisal and practical considerations. Surg Neurology Intl
293. Coster S, de Bruijn S, Tavy D. Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy. J Neurology
294. Haig A, Tong H, Yamakawa K, et al. The sensitivity and specificity of electrodiagnostic testing for the clinical syndrome of lumbar spinal stenosis. Spine
295. Hasankhani EG, Omidi-Kashani F. Magnetic resonance imaging versus electrophysiologic tests in clinical diagnosis of lower extremity radicular pain. ISRN Neurosci
296. Tong HC. Incremental ability of needle electromyography to detect radiculopathy in patients with radiating low back pain using different diagnostic criteria. Arch Phys Med Rehabil
297. Yagci I, Gunduz OH, Ekinci G, et al. The utility of lumbar paraspinal mapping in the diagnosis of lumbar spinal stenosis. Am J Phys Med Rehabil
298. Ahern DK, Follick MJ, Council JR, et al. Comparison of lumbar paravertebral EMG patterns in chronic low back pain patients and non-patient controls. Pain
299. Cholewicki J, Greene HS, Polzhofer GK, et al. Neuromuscular function in athletes following recovery from a recent acute low back injury. J Orthop Sports Phys Ther
300. Demoulin C, Crielaard JM, Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine
301. Finneran MT, Mazanec D, Marsolais ME, et al. Large-array surface electromyography in low back pain: a pilot study. Spine
302. Humphrey AR, Nargol AV, Jones AP, et al. The value of electromyography of the lumbar paraspinal muscles in discriminating between chronic-low-back-pain sufferers and normal subjects. Eur Spine J
303. Leach RA, Owens EF Jr, Giesen JM. Correlates of myoelectric asymmetry detected in low back pain patients using hand-held post-style surface electromyography. J Manipulative Physiol Ther
304. Lehman G. Kinesiological research: the use of surface electromyography for assessing the effects of spinal manipulation. J Electromyogr Kinesiol
305. Meyer JJ. The validity of thoracolumbar paraspinal scanning EMG as a diagnostic test: an examination of the current literature. J Manipulative Physiol Ther
306. Mohseni-Bandpei MA, Watson MJ, Richardson B. Application of surface electromyography in the assessment of low back pain: a review article. Phys Ther Rev J
307. Reger SI, Shah A, Adams TC, et al. Classification of large array surface myoelectric potentials from subjects with and without low back pain. J Electromyogr Kinesiol
308. Ritvanen T, Zaproudina N, Nissen M, et al. Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy. J Manipulative Physiol Ther
309. Roy S, Bonato P, Knaflitz M. EMG assessment of back muscle function during cyclical lifting. J Electromyogr Kinesiol
310. Roy SH, De Luca CJ, Emley M, et al. Classification of back muscle impairment based on the surface electromyographic signal. J Rehabil Res Dev
311. Roy SH, Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther
312. Rzanny R, Grassme R, Reichenbach JR, et al. Investigations of back muscle fatigue by simultaneous 31P MRS and surface EMG measurements. Biomed Tech (Berl)
313. Sihvonen T, Partanen J, Hanninen O, et al. Electric behavior of low back muscles during lumbar pelvic rhythm in low back pain patients and healthy controls. Arch Phys Med Rehabil
314. Mannion AF, Taimela S, Muntener M, et al. Active therapy for chronic low back pain part 1. Effects on back muscle activation, fatigability, and strength. Spine
315. Butler HL, Hubley-Kozey CL, Kozey JW. Changes in electromyographic activity of trunk muscles within the sub-acute phase for individuals deemed recovered from a low back injury. J Electromyogr Kinesiol
316. McNeill T, Huncke B, Pesch RN. Chemonucleolysis: evaluation of effectiveness by electromyography. Arch Phys Med Rehabil
317. Ramprasad M, Shenoy DS, Singh SJ, et al. The magnitude of pre-programmed reaction dysfunction in back pain patients: experimental pilot electromyography study. J Back Musculoskelet Rehabil
318. de Graaf I, Prak A, Bierma-Zeinstra S, et al. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine
319. Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anaesthesia
320. Klauser A, Halpern EJ, Frauscher F, et al. Inflammatory low back pain: high negative predictive value of contrast-enhanced color Doppler ultrasound in the detection of inflamed sacroiliac joints. Arthritis Rheum
321. Rhodes DW, Bishop PA. A review of diagnostic ultrasound of the spine and soft tissue. J Manipulative Physiol Ther
322. Rubaltelli L, De Gerone E, Caterino G. Echographic evaluation of tubercular abscesses in lumbar spondylitis. J Ultrasound Med
323. Anderson DJ, Adcock DF, Chovil AC, et al. Ultrasound lumbar canal measurement in hospital employees with back pain. Br J Ind Med
324. Lee SW, Chan CK, Lam TS, et al. Relationship between low back pain and lumbar multifidus size at different postures. Spine
325. Pulkovski N, Mannion AF, Caporaso F, et al. Ultrasound assessment of transversus abdominis muscle contraction ratio during abdominal hollowing: a useful tool to distinguish between patients with chronic low back pain and healthy controls? Eur Spine J
2012; 21 (Suppl 6):S750–S759.
326. Newman RI, Seres JL, Miller EB. Liquid crystal thermography in the evaluation of chronic back pain: a comparative study. Pain
327. Swerdlow B, Dieter JN. An evaluation of the sensitivity and specificity of medical thermography for the documentation of myofascial trigger points. Pain
328. Gill K, Jackson R. Frymoyer J. CT-Discography. The Adult Spine: Principles and Practice
. New York, NY: Raven Press; 1991. 443–456.
329. Jackson RP, Becker GJ, Jacobs RR, et al. The neuroradiographic diagnosis of lumbar herniated nucleus pulposus: I. A comparison of computed tomography (CT), myelography, CT-myelography, discography, and CT-discography. Spine
330. Jackson RP, Cain JE Jr, Jacobs RR, et al. The neuroradiographic diagnosis of lumbar herniated nucleus pulposus: II. A comparison of computed tomography (CT), myelography, CT-myelography, and magnetic resonance imaging. Spine
331. Derby R, Howard MW, Grant JM, et al. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine
332. Carragee EJ, Alamin TF, Miller J, et al. Provocative discography in volunteer subjects with mild persistent low back pain. Spine J
333. Carragee EJ, Barcohana B, Alamin T, et al. Prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography. Spine
334. Carragee EJ, Alamin TF, Carragee JM. Low-pressure positive Discography in subjects asymptomatic of significant low back pain illness. Spine
335. Carragee EJ, Lincoln T, Parmar VS, et al. A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine
336. Alamin TF, Kim MJ, Agarwal V. Provocative lumbar discography versus functional anesthetic discography: a comparison of the results of two different diagnostic techniques in 52 patients with chronic low back pain. Spine J
337. Birney TJ, White JJ Jr, Berens D, et al. Comparison of MRI and discography in the diagnosis of lumbar degenerative disc disease. J Spinal Disord
338. Collins CD, Stack JP, O’Connell DJ, et al. The role of discography in lumbar disc disease: a comparative study of magnetic resonance imaging and discography. Clin Radiol
339. Gibson MJ, Buckley J, Mawhinney R, et al. Magnetic resonance imaging and discography in the diagnosis of disc degeneration. A comparative study of 50 discs. J Bone Joint Surg Br
340. Ito M, Incorvaia KM, Yu SF, et al. Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. Spine
341. Laslett M, Oberg B, Aprill CN, et al. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J
342. Linson MA, Crowe CH. Comparison of magnetic resonance imaging and lumbar discography in the diagnosis of disc degeneration. Clin Orthop Related Res
343. Madan S, Gundanna M, Harley JM, et al. Does provocative discography screening of discogenic back pain improve surgical outcome? J Spinal Disord Tech
344. Osti OL, Fraser RD. MRI and discography of annular tears and intervertebral disc degeneration. A prospective clinical comparison. J Bone Joint Surg Br
345. Schneiderman G, Flannigan B, Kingston S, et al. Magnetic resonance imaging in the diagnosis of disc degeneration: correlation with discography. Spine
346. Carragee EJ, Chen Y, Tanner CM, et al. Can discography cause long-term back symptoms in previously asymptomatic subjects? Spine
347. Carragee EJ, Chen Y, Tanner CM, et al. Provocative discography in patients after limited lumbar discectomy: a controlled, randomized study of pain response in symptomatic and asymptomatic subjects. Spine
348. Manchikanti L, Singh V, Pampati V, et al. Provocative discography in low back pain patients with or without somatization disorder: a randomized prospective evaluation. Pain Physician
349. Walsh TR, Weinstein JN, Spratt KF, et al. Lumbar discography in normal subjects. A controlled, prospective study. J Bone Joint Surg Am
350. Derby R, Kim BJ, Chen Y, et al. The relation between annular disruption on computed tomography scan and pressure-controlled diskography. Arch Phys Med Rehabil
351. Derby R, Kim B, Lee S, et al. Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? Spine J
352. Derby R, Lee SH, Kim BJ, et al. Pressure-controlled lumbar discography in volunteers without low back symptoms. Pain Med
353. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther
354. Bosscher HA, Heavner JE. Diagnosis of the vertebral level from which low back or leg pain originates. A comparison of clinical evaluation, MRI and epiduroscopy. Pain Pract
355. Manchikanti L, Rivera JJ, Pampati V, et al. Spinal endoscopic adhesiolysis in the management of chronic low back pain: a preliminary report of a randomized, double-blind trial. Pain Physician
356. Richardson J, McGurgan P, Cheema S, et al. Spinal endoscopy in chronic low back pain with radiculopathy. A prospective case series. Anaesthesia
357. Manchikanti L, Singh V. Epidural lysis of adhesions and myeloscopy. Curr Pain Headache Rep
358. Raffaeli W, Righetti D, Andruccioli J, et al. Periduroscopy: general review of clinical features and development of operative models. Acta Neurochir Suppl