Data Driven Daubert Defendable Care Code

- Activity Paradigm and Reliable Data for Back Problems

Stanley J. Bigos, MD*, Jane E. McKee, MSN, ARNP†

*Prof. Emeritus Orthopedic Surgery and Environmental Health, U of Washington & †Nurse Practitioner, Spine Resource Consultants - Seattle, WA.

INTRODUCTION

Evidence Based Medicine has become a buzzword for clinicians who intend to practice data driven care to improve outcomes.[1]  Recent developments emphasizing reliable information offer the clinician insulation from administrative and legal hassles beyond just improving care for patients.  In this chapter we hope to offer both an understanding of the recent developments and a simpler activity oriented application of data driven care for patients with back problems.

The Agency for Health Care Policy and Research (AHCPR) first established evidence based guidelines in the 1990s including Guide # 14 Acute Low Back Problems in Adults.[2]  A review seven years later validated the reliability of information determined by the methodological evidence table process.   Shekelle et al, recommended little change for the Guide #14 original “Finding and Recommendation Statements,” only suggested adding some prevention and more tempered recommendations for the limited effectiveness of back schools, lumbar corsets and epidural steroid injections.

[3]  Subsequent publications of similar quality demanded by the framework of the original methodological process strengthened the original findings. 

The interest in reliable information was not limited to AHCPR.  In 1993 the United States Supreme Court decision troubled by expanding class action suit decisions based on “conventional wisdom” that is susceptible to later repudiation, changed the Federal Rules of Evidence (F.R.E.) in Daubert vs. Merrill Dow by demanding experts have reliable data to substantiate their opinion.[4]  This first Federal Rules of Evidence alteration in 70 years has since expanded to include medical testimony.[5]  The 1993 criteria for reliable information are hauntingly similar to the AHCPR #14 Evidence table criteria determined in 1992.

Unfortunately, the primary care clinician’s time constraints make complicated algorithms or endless reviews of the literature impractical.  One failing of the AHCPR Guide is the apparent complexity of algorithms demanded by the agency.  While useful for simpler guideline topics, algorithms for back problems became labrinthine.  Some panel members thought a staggered release would have made the message more tangible for clinicians.  Lost in this complexity of the AHCPR Guide #14 Quick Reference Guide was the theme of treating a reduced activity tolerance rather than just back pain to support the real guide’s “Finding and Recommendation Statements.”  Then 2/9/1995, two months after the Guide was released, the activity paradigm was truly born with the publication of Malmivaara et al., emphasizing overcoming the patients fear of anything serious causing back symptoms and recommending normal as possible activity as far more successful than resting for two days or using passive McKenzie-like exercises.[6]  This set the stage for a simpler application of reliable data by emphasizing two major issues, “anything serious” and encouraging “normal as possible activity,” to avoid unnecessary loss of comfortable activity tolerance through inactivity that can only be regained by conditioning that can in itself be uncomfortable.

Activity Paradigm

The AHCPR guide No. 14 avoided the back pain treatment approach for a more objective activity related diagnosis of reduced activity tolerance due to back or related leg symptoms.  Approaching the patient’s reduced activity tolerance allows the concept to be applied whether treating the first acute episode, a recurrent episode or an activity alteration that accompanies chronic back problems.  In the past decade reliable data supports the most successful outcomes to curb the negative impacts of back problems is the product of applying the activity paradigm to the activity intolerance rather than just treating the pain.^{6,[7],[8],[9],[10],[11],[12]} Contrary to prior conventional wisdom, the activity paradigm seems to also speed recovery from the pain as well, even in those with more physically demanding job tasks.⁶

The initial premise is based on eliminating any dangerous cause of symptoms (history, physical examination and Red Flags for tumor, infection, cauda equina or significant trauma).  This is intended to detect medically treatable diagnoses and set the stage to overcome the patient’s fears and activity avoidance, an issue brought to light by Burton et al, to assure the patient that there is nothing serious causing symptoms and not to fear activity.¹¹  The clinician may have difficulty convincing every patient of the importance of avoiding debilitation by keeping activity “normal as possible”.  For doubters, further efforts are essential to assure the patient that there is “nothing serious” causing symptoms.  Five subsequent prospective studies support the activity approach, including a marketing approach testing the mantra “Don't take back pain lying down,” now greatly outweigh the conventional wisdom of activity avoidance (for which there is no supporting data) to avoid harming your spine.^6-12

Today, evidence based medicine and the activity paradigm offer clinicians a reliable data driven care code that is defendable by the US Supreme Court’s Federal Rules of Evidence.  Reliable information married to the activity paradigm can expedite the detection of the non-physical issues that are immune to our medical devices.  The following is but one example of how US Daubert defendable data driven care can limit both physical debilitation and unnecessary disability, while helping patients recover sooner from back problems by keeping patients more active and more productive.  We are now armed with reliable information to guide physical care while following a proven activity approach. While showing concern for the patient’s problem, reliable information can help us address serious problems through AHCPR Guide #14 “Red Flags” before we display honest relief that there is no hint of anything dangerous.²  The goal is to alleviate the patient’s fear of activity before confidently promoting as normal as possible activity to avoid debilitation.   

Example of Applying Activity Paradigm at Work

The authors’ utilized the activity approach to reliable care in a primary care setting in a pilot study 1999 – 2000.[13]  Subsequently, the approach was given the moniker of D4C2 (Data-Driven, Daubert-Defendable Care Code) due to the influence of data driven care also meeting the evidence criteria of the US Supreme Court Daubert decision.  In this article we hope to share the basic concepts and our experience using reliable information through the activity paradigm to treat working patients.

Applying Reliable data to Back Problems through the Activity Paradigm

The impact of the activity paradigm pivots upon two issues by aggressively treating the activity intolerance rather than just chasing the pain.  The first issue is to determine, then convince, the patient that nothing dangerous is causing symptoms.  Use of the reliable approach of the AHCPR Guide #14 “Red Flags” and logic toward seeking physical and neurological findings before considering imaging studies avoids diagnostic confusion.  The second pivotal issue comes to light according to the patient’s response to your recommendation to keep activity as “normal as possible.”  This commonly requires real life analogies (see treatment and activity). The patient’s response to both issues should trigger the clinician to take actions aimed at avoiding disability and sorting out physical and non-physical issues.  The goal is to differentiate pain issues from back issues, which makes the use of reliable information more obvious in four areas I - Initial Assessment, II - Initial Care, III - Diagnositic Considerations for Delayed Recovery and IV. Further Treatment including a review of the Concerned Approach to difficult issues.

I. INITIAL ASSESSMENT - Identifying the Problem

“Red Flags” to seek serious conditions, along with the history and physical examination are the initial important step to determine if the patient’s problem requires urgent attention or special studies.

Initial Patient Decisions

Serious                               If not è Activity Issue (Neuro+ & Neuro -)                  Non-Activity

Red Flags?                                                                                                          Pain Issue

Dx approach until                     1. Assure “Not dangerous”                           Pain Approach

  R/O or safe for                       2. Rec. “Normal Activity”

     activity

A. “Red Flags” (Table 1) can be detected through questionnaires of Past Medical History, Review of Systems and Present Medications. The addition of a Pain Drawing to a Visual Analog Scale can save time and improve the quality of information you gather to determine if symptoms are due to something serious.

Table 1:  Red flags for potentially serious conditions[14]

Possible fracture	Possible Tumor or infection	Possible Cauda Equina Syndrome
From medical history
Major trauma, such as vehicle accident or fall from height. Minor trauma or even strenuous lifting (in older or potentially osteoporotic patient).	Age over 50 or less than 20. History of cancer. Constitutional symptoms, such as recent fever or chills or unexplained weight loss. Risk factors for spinal infection; recent bacterial infection (e.g., urinary tract infection); IV drug abuse; or immune suppression (from steroids, transplant, or HIV). Pain that is worse when supine; severe nighttime pain.	Saddle anesthesia. Recent onset of bladder dysfunction, such as urinary retention, increased frequency, or overflow incontinence. Severe or progressive neurologic deficit in the lower extremity.
From physical examination
		Unexpected laxity of anal sphincter. Perianal/ perineal sensory loss. Major motor weakness: quadriceps (knee extension weakness); ankle plantar flexors, everters, and dorsiflexers (foot drop).

In the absence of serious problem, the history and physical exam helps to determine if the patient has an activity or a pain problem. Those without a limitation, those who refuse activity or those invalid by other medical issues, should not be confused as having a back problem and basic pain paradigms are more appropriate.

The patient’s responses to queries about “RED FLAGs” set the stage for the specific history, either to further explore hints of something serious or to continue to categorize the back problem. The H&P together then classifies an activity problem as neurologic, (Neuro +) or non-neurologic (Neuro -).  The neurologically positive or negative provides a prognosis for expected recovery and guides the type of workup should the patient be one of the unfortunate who are slow to recover. 

B. Specific History: A pointed history of Present Illness provides needed understanding of the Quality of Symptoms, severity according to Limitations, Prior Similar Problems and the patient’s goals.  The input will guide the physical examination and subsequent recommendations.

1) Quality of Symptoms

Guided by a pain drawing, ask the patient to prioritize from worst to least the areas involving Pain, Weakness, Numbness, Stiffness. You want to know if radicular symptoms are intermittent since electro-diagnostic studies rarely detect surgically significant findings without 3-4 weeks of constant symptoms.

2) Limitations provide insight into the Severity of the symptoms described.    

     What activities does your back not let you do? ___________

     Date Limitation began?      Incident? ____________________________

     Specific Limitations now:

             “Without fearing that you are doing damage - How many:     

1. minutes can you can SIT, without fearing damage? _________________

2. minutes can you  STAND, without fearing damage? _________________

3. minutes or distance you can WALK*, without fearing damage? ___________         

4. pounds can you  LIFT,  without fearing  damage? _________________

Answers of less than 20 lb or 20 minutes are extreme (less than an invalid) and deserve probing the low potential for damage with reasonable use of the symptomatic back.  If limited not by fear of damage ask the patient to determine if the limit is based upon bringing on or worsening symptoms.

*If walking is limited to less than 300 yards in the elderly, inquire if, “After you have walked as far as possible, can you just stand there to rest to relieve the pain?” (If yes, consider vascular claudication). True neuro-claudication requires the individual to sit, bend over or squat a few minutes before continuing (see spinal stenosis in Section III).

The most important issue is the perceived activity level at which the patient fears further damage. Fear of damage strongly predicates how a patient responds to subsequent activity recommendations.  Should a patient decline considering normal activity, responses to the initial questions about sitting, standing, walking and lifting allows the clinician’s a reference for negotiating any limited daily activity. Early in the history, patients usually attempt to put the best foot forward.  Early face-to-face inquiry tends to provide more reasonable responses. 

Knowing when limitations began helps to determine when the patient qualifies as the slowest 10% to recover (over 4 weeks) for consideration of further studies as warranted depending upon their symptoms and life situation.

3) Prior spine, musculoskeletal or other reasons for a debilitating period of limited activity and was surgery required?  If present when and what were the latest related spine tests performed.

4) The patient’s response to, “What brings you here today and what do you want me to do for you?” can be a time saver and provide important guidance by how it is answered questions to the point the patient is seeking.

C. Physical Examination

The physical examination clues further categorize the problem as neurologically positive or neurologically negative, which can impact both expected recovery rate and type of workup should the patient be one of the slowest 10% to recover reasonable activity tolerance.  The only objective examination findings, whether positive or negative, are findings circumferential measurements for atrophy & reflexes.  Most of the examination maneuvers are subjective, though some techniques can be qualified by a simple second augmentation maneuvers.

Subjective data like sensation and range of motion totally depend upon the patient’s interpretation or volition, while others can be further qualified with a second maneuver.  The ankle can then be flexed up and down and the limb rotated each way to augment determining whether a pain response to Straight Leg Raising is due to tension on the sciatic nerve rootlets or not. Straight leg raising is the most reproducible finding of the physical examination maneuvers.² With the aide of these qualifying techniques expect increased pain with ankle dorsi-flexion and limb internal rotation of the raised leg (but not with ankle plantar-flexion and external rotation that reduce the tethering of the nerve roots). This along with straightening of the knee during examination in the sitting position helps to differentiate neurological from non-neurological issues (See figure Sitting Knee Extension).

The following examination should take no longer than 4.5 minutes performed with the patient wearing shorts or a gown.

Standing:

1) Normal walking, walking on heels (L4-5) and walking on the toes (S1-2) followed by a squat and rise (L2-S1) assesses the general strength (For safety have patient hold onto a table or counter before attempting to squat).

From behind patient:

2) Observe the back during suggested extension, side bending, rotation and flexion to estimate range relative to expected for age.

There is no need to pull or push to see if the spinal range of motion is full beyond the patient’s volition.  Seek hints of uncoordinated muscular activity or guarding (commonly termed dysmetria, spasm, etc,) as the range can vary widely among individuals.  Uncoordinated muscle guarding is but a mild non-specific finding that may indicate something is amiss but is not specific when the motion is asymmetric. 

Sitting:

4) Ankle and knee reflexes (objective data whether positive or negative)

5) Circumferential measurements more than 1-2 cm at an equal distance above and below the knee signify possible atrophy (considered Objective if greater than 2 centimeters difference [Is it due to swelling or atrophy?).

6) Lower extremity joints: sitting hip rotation asymmetry (internal rotation loss may signify hip Degenerative Joint Disease), knee stability (flexed/extended), foot & ankle motion.

Figure 1: Sitting Knee Extension⁵²

Straightening the limb during the knee or foot examination helps to qualify nerve root tension.  A significantly positive supine Straight Leg Raising should elicit fall back or complaints of discomfort with sitting knee extension.

7) Muscle strength (Note, a slight loss of strength is most easily detectable in large muscles.) Observe from strongest to weakest by testing quadriceps (L2-4), hamstrings L5-S1 before ankle dorsiflexers (L4-5), ankle everters (L5-S1), great toe extensors (L5), toe flexors (S1-2).

Figure 2: Common expressions of nerve root compromise[15]

Supine:

9) Abdomen & pulses:  Palpation of the abdomen is especially important for sero-negative spondylo-athropathies (Ankylosing Spondylitis, Reactive spondylitis, etc.) along with pulses the elderly or in the presence of a positive “RED FLAG” where aneurysm, peripheral vascular disease or other internal organ issues must be addressed.

10) Straight-leg Raising (SLR) each lower limb asking the patient “I am going to raise your leg and tell me to stop if this bothers you – say, “Stop!” Then determine the angle and ask “Where is the pain?” back?  Same side or Opposite - hip? -thigh? -knee? -below the knee?” (See Figure 3A, 3B, Fig. 4)

Figure 3A: Testing Sciatic Nerve Tension with Straight leg raising (L4-S2) ¹⁵

Fig 3A.  Between 30-70^o you gain the greatest hint of nerve root irritation when symptoms below the knee are elicited.

Lift straight limb slowly and ask the patient to, “Tell me “Stop” or “Stop damit!” - If this bothers you.”  Record the approximate degree of the angle and location of the symptoms (below the knee, above the knee or the back only).

Note: As symptoms abate, pain tends to regress distal to proximal and numbness regresses proximal to distal allowing greater angles of Straight-leg Raising (not uncommon to have high Straight Leg Raising causing proximal pain with distal numbness as a residual with or without surgery).

Fig 3B.  Augmentation to qualify Straight Leg Raising. ¹⁵

Dorsi-flexion & Internal Rotation should increase symptoms.

While holding the limb at, or near, the painful angle, dorsi-flex then plantar-flex the ankle, externally and internally rotate the raised straight limb.   Note the maneuver(s) that increases pain.

Check for Augmentation of nerve root irritation with straight-leg-raise at the level where pain is first realized with other maneuvers.

With the Straight Leg Raised to level of pain is it:

            “Worse? With Plantar-flexion of the ankle - (shouldn’t be)

            “Worse? With Dorsi-flexion of the ankle - (should be)

            “Worse? With External Rotation of the whole limb - (shouldn’t be)

            “Worse? With Internal Rotation of the whole limb - (can be)

Perform an opposite (or crossed) leg raise. A reproduction of symptoms in the symptomatic limb when raising the unaffected limb is the strongest predictor of potential anatomic lesion with imaging. The raised opposite leg rarely is affected by any augmentation with ankle motion or limb rotation.

Figure 4: Testing Sciatic Nerve Tension with crossed Straight-leg-raising (L4-S2). ¹⁵

Augmentation of symptoms with dorsiflexion or internal rotation is  UNCOMMON.

In the presence of neck symptoms evaluate neck motion for guarding, then upper extremities joints stability, muscle wasting (atrophy), and neurologic integrity as assessed in motor, sensory, and reflex examination (always to include Babinski).  Anterior neck palpation, and at least partial cranial nerve and cerebellar testing (finger to nose coordination, Romberg) are also warranted.  Always let your history alert you to a possibility of lung cancer (Pancoast tumor), and CNS disease in the presence of neck and arm symptoms.  Shoulder problems are many times a difficult part of the differential diagnosis with radicular neck symptoms. Without neck or shoulder complaints, it is reasonable to at least check the biceps, triceps and brachioradialis reflexes and gross grip and arm strength.

D. Special Studies Consideration in the presence of Red Flags. The same studies can be confusing in the absence of “RED FLAGs” or activity limitations of LESS than four weeks. Changes on X-rays and other imaging changes are common even at an early age and are poor screening tools.

The following red flags warrant the suggested testing:

For Metabolic, Tumor, Infection concerns, consider your laboratory studies (CBC, Chem. panel, UA, Thyroid Stimulating Hormone, Rheumatoid Factor Sedimentation rate).

New Bowel & Bladder symptoms or obvious multilevel neurologic dysfunction warrant immediate consultation for specialist’s choice of imaging techniques (MRI or Myelo-CT scan) to avoid duplication.

For a question of Fracture due to significant trauma, X-ray or later  bone scan (more sensitive at 7-10 days) may detect abnormalities that may need to be defined further by CT scan.

Other findings may trigger specific approaches based upon specific leads from history & physical examination.

Table 2: Decisions and Timing Summary¹⁵ - Since 90% recover within 4 weeks from each episode, special studies are considered in the few patients with “RED FLAGs.”  The type of Diagnostic tests are determined by the type of Symptoms (neurological or not) and most importantly the Duration (4 wks?)of unreasonable activity limitation relative to the patients needs.  Workup is usually sooner for patients whose job is in jeopardy.

Caud.Eq. = Cauda Equina syndrome which indicates multiple nerve roots are in jeopardy, especially those related to bowel or bladder function or severe multi-level leg paralysis threatening paraplegia.

II. INITIAL CARE - Assurance, Comfort, True Treatment & Education

Initial care is determined by the History, “Red Flags” and Physical Exam’s ability to establish the correct paradigm for the patient.  Serious problems need urgent referral and once adequately attended to, the patient can re-enter the activity paradigm.  The point of the patient’s entry depends upon any delay for workup or treatment in a different paradigm. If reduced activity is prolonged, conditioning is usually needed to overcome the debilitating impact.  The patient can enter the activity paradigm at initial care if less than a few weeks have lapsed. 

The activity paradigm is either therapeutic or further distinguishes physical and non-physical issues as the patient’s responds to your assurance of “nothing serious” and “normal as possible” activity recommendations to help avoid disability.  After “RED FLAGs” are eliminated, you can address these 2 major issues in the activity paradigm.  First, you may appropriately display to the patient your relief that “nothing serious” was detected to combat the patient’s fears of physical damage.  If you successfully alleviated the patient’s fears, you will be rewarded with a patient’s willingness to return to reasonably normal activity.  The next issue stresses the importance of keeping daily activity as normal as possible, after offering help with symptoms.  Should the patient refuse reasonable activity quickly get some help!  Should the patient demand more than one week of limited duty that requires alternative activity to maintain some endurance – quickly get some help! 

Get another opinion, as soon as possible, from a colleague or coerce a quick consult from a specialist within the first few days.  Make your consultant’s job easy.  Explain that you only need help convincing the patient there is nothing serious or provide the indications of a serious problem.  Make it clear that there is no need for someone to takeover the care or be bothered with recommending limitations or treatment.  Ask only for a quick opinion about anything serious to either alleviate patient fears or detect evidence of something other than plain old back pain or sciatica. 

Table 3: Major diagnostic entities related to specific treatment¹⁵

If you hear a response of either discogenic pain, facet syndrome, fibromyalgia or all the other hypothetical terms noted in Table 3 from your consult, you can readily again show your emotional relief to the patient and assure him or her that there is “nothing dangerous” before again stressing the importance of maintaining “normal as possible” daily activity to avoid having to go through “spring training” to get comfortable again once the back symptoms pass.  If you’re getting nowhere after two consults, suggest the insurance carrier obtain another opinion ASAP.  Hopefully, the consult will be with a professional specialist, rather than someone with a propensity for chasing the holy grail of pain with a arsenal of invasive procedures.

It is important to remember that the AHCPR “Finding and Recommendation Statements” and their literature base provide only guidelines not rules.  If a patient is obstinate about receiving an x-ray because you cannot convince the patient that it won’t be helpful – get two views.  Whining for an MRI is a different story.  It is not only inappropriate, but as the sole clue it can be very confusing (see Diagnostic Considerations).  The goal is to do everything reasonable to keep the patient as active as possible.  An algorithm should not thwart your goal – algorithms are only to keep the goal in mind. 

Thus be creative in the initial goal of convincing the patient there is “nothing serious” to keep the patient’s activity “as normal as possible” to avoid the unnecessary debilitation of inactivity and work related socioeconomic complications.  Assurance, comfort and real treatment (activity) need be addressed for all patients and reiterated to the slowest to recover.  The following are points for enhancing the patient’s understanding.

1. Assure about Expectations - no hint of anything dangerous

            “We are pretty good at finding serious conditions and at this time we have no hint of anything bad causing your symptoms.  Reality is that no one has won the Nobel Prize to explain the cause of back problems that temporarily limit about 1/3 of us by age 30, 3/4 of us by age 40 and virtually all of us by age 50. At this time we have no hint of anything abnormal.  Most limitations resolve in a few weeks.  If you are in the slowest 10% to recover we will consider special studies again to seek anything serious.  It is good news when we can’t explain the exact cause because the outcome is better and we can usually avoid a need for spring training-like conditioning to regain comfortable activity tolerance.  Now we need to help you feel more comfortable without prolonging your pain.”

2. Comfort help

a. Clinical Comfort Help - “There are many means of helping with comfort but nothing totally wipes out the pain.  Thus, we recommend the most effective combination to allow you to most comfortably stay as active as possible to avoid debilitation and minimize how much work reconditioning you would have to do later. Remember! It usually takes twice as long to regain conditioning than it does to lose it.  We can only take the edge off the pain.  We have all heard of darv-acet, perc-acet, lord-acet, rox-acet and crap-acet.  The -acet is Acetaminophen.  If a product is of questionable value, add an acet, aspirin or ibuprofen!  They seem to block the pain highway at a different place than other medications, thus, works well in combination.  We usually recommend a safe-acet.  The worst part of an episode may last for up to 5 days, but that length of time is rare.  That is the longest you might need intense help with comfort.  Most often medication will allow you to continue with most of your normal activities.  We try to avoid medication that might cloud your mind or disrupt your normal activity anymore than necessary.” 

            Without a hint of kidney or liver dysfunction, or a mitigating factor of advanced age, a combination of Acetaminophen and NSAIDs are adequate and usually as effective as more dangerous methods.  If patients feel manipulation has helped before, remind them that it only helps symptoms and does not correct the problem without conditioning.  Newer Cox-2 inhibitor NSAIDs for patients with peptic ulcer disease or other co-morbidity, enhance our ability to keep people active and safely avoid mind-altering medications that interfere with activities, sleep and needed conditioning.

Table 4: Comfort Help¹⁵

Medication or manipulation (for back pain only) should always be accompanied by encouragement of normal activity to avoid disability.  If the patient chooses less than normal activity, negotiate reasonable work activities according to the 2^nd question of the history [Specific history: 2 the patient’s fears of sitting, standing, walking, lifting]?  Prescribe some safe simple conditioning to aid recovery [walk, cycle, jog] to help the patient minimizes the debilitation of reduced activity along with comfort aid of meds or manipulation.  If you cannot convince the patient to stay active – get a quick consult and maybe a specialist to address hints of anything dangerous.  Debilitation carries many physical complications and if work is involved many non-physical complications.

3. Treatment = Maintaining or Improving Comfortable Activity Levels.

To treat musculoskeletal problems remember the old Groucho Marx joke - ”Doctor, doctor, after surgery will I be able to play the violin?” Doctor: “I would hope so.” Response: “Good! Cause I could never play it before”. Neither surgery, manipulation, injections, medication nor rest will train you to play the violin, run a marathon, do strenuous activity or return comfortably to your normal activity after being away from it for a while.  Only conditioning permits you to comfortably tolerate unaccustomed activities.

            Distinguish the difference between hurt and harm.  Conditioning activities need not be more stressful on the back than sitting at bedside before rising in the morning.  Assure patients that though conditioning may not be totally comfortable, nothing need be recommended that is dangerous to the spine and that there is no way to maintain or build activity tolerance without activity (see Explaining Conditioning in section IV).  Once activity tolerance is lost, due either to deconditioning or structural change, only conditioning like spring training for athletes, boot camp for soldiers or continuing to garden in the spring can improve your comfortable activity level. 

If the patient avoids some normal activity, a low stress endurance activity can be used to limit the debilitation and reduce the need for “spring training” to regain sufficient endurance to reasonably tolerate regular daily activities. If a patient’s comfort would allow attendance in physical therapy, then a similar level of activity at work or light duty offers better therapy, while limiting the potentially serious complications related to work absence. 

Activity Issue (Neuro (-) or Neuro (+)

           (Assure no danger & Recommend Normal Activity)

RESPONSE ACTION

1. Normal Activity                              Support

2. Limited Choice                               Negotiate Activity

Level* and Normal

Activity ASAP

3.  Refuse Activity                                -2^nd Opinion + Warning against inactivity

   (concern for debilitation)

4.  Refuse Activity                                -Specialist (anything dangerous)

- Warning against inactivity

5. Refuses activity                                 -Rec. Insurer seek opinion ASAP                                                                                             if work related

Summary

The key to avoiding debilitating inactivity and disability requires early clinician action according to the patient’s response to assurance of “nothing serious” and recommendation of “normal as possible” activity.  Many issues can cause your patient to avoid reasonable activity.  As needed, your quick colleague- or specialist- consults seek whether this presentation seems to be back or back-related leg symptoms or true indications of a “RED FLAG.”  Do not abdicate the patient’s care.  Reiterate warnings against inactivity by stressing importance of return to “normal activity” as soon as possible to avoid both physical and non-physical complications.  Your patient’s best protection from common non-physical issues is to avoid over-medicalizing problems.  Should your consultations not work, suggesting the Insurance system procure another opinion quickly can bring the presence or absence of non-physical issues into focus earlier and markedly reduce unnecessary treatment complications, hassles and second-guessing.

For patients with extremely physical job tasks or those who choose not to return to normal activity, recommend additional daily exercise to limit debilitation.  The limitations can be negotiated according to the patient’s description in the present history about “how long” and “how much” lifting, sitting and standing seems dangerous to as close to normal activity as possible. A twenty pound lifting restriction close to the body is rather extreme, even for a short period of time, as pouring milk or coffee, washing dishes, cooking, brushing one’s teeth over the sink or having a bowel movement generally more stressful on the back.  It is especially important to realize no data provides a hint of improvement in the long-term outcome by taking someone off work. Adding specific endurance recommendation to any negotiated limitations, both helps to limit debilitation and stresses the importance of staying active.

  a.  General Conditioning for Stamina to avoid debilitation limiting regular activity

Speed Walking or Stationary Cycling - 30 continuous minutes (minimum heart rate of 120 for those over age 40 or of 130 for those under age 40) or Jogging for 15-20 minutes. Begin chosen activity five days per week.  NOTE: consider swimming for the only the severely debilitated or those with severe lower extremity joint problems to prepare for walking or cycling.

   After 5 days per week of conditioning for 6 weeks, general stamina can be maintained thereafter with 2 sessions per week (like an airplane, it takes more energy to get up to altitude than stay there - 2 days / week of conditioning is all that is needed to maintain it).

   b.  Resume work or specific restricted activity ASAP.

4. Education & Reassurance should be part of visits for those who do not recover within a few weeks:

            Reiterate initial assurances, expectations and the importance of normal activity. Reassure the patient that if not significantly better by the end of 4 weeks special studies will be considered to again seek potentially serious conditions.

III. DIAGNOSTIC CONSIDERATIONS for DELAYED RECOVERY (more than 4 weeks)

Considerations for Limitations beyond 30 days      

 Expect reasonable activity -     Neuro (-) 90%   Neuro (+) 50% by 30 days

If not improving and limited – consider workup

Neuro (+) Sciatica below the knee

Physical Exam or EMG (include SomatoSensory Evoked Potentials [SSEP] for elderly neuro-claudication)

Consider if imaging is worthwhile to seek concordant correctable lesion

         (CAUTION- ONLY STRONG CONCORDANT FINDING PREDICT A GOOD SURGICAL OUTCOME)

Neuro (-) Medical review to consider:

Labs for constitutional

                        Bone Scan for structural

   (consider if specific imaging is worthwhile)

Until someone wins the Nobel Prize for back problems, ninety percent of our patients will not be diagnosable despite our diagnostic efforts.  The insurance company’s insistence on having a diagnosis has spawned many non-descript terms (ICD-9 code) like sprain, strain, internal disc derangement, facet syndrome, myofaciitis, fibromyalgia or other terms that scientifically mean “I don’t know”.  We usually seek a workup for two reasons.  The first reason seeks to confirm hints of serious “Red Flags” or more chronic general medical problems that can cause slow recovery.  The second workup reason is slow recovery as determined by the natural history.  After four continuous weeks of limitation the patient’s degree of life interference helps to determine the need for a workup to identify a potentially correctable lesion.  At present surgical correction relates to decompressing nerve roots compromised by either disc herniation causing sciatica or the aging of spinal stenosis causing neuro-claudication in the absence of acute fracture or dislocation.  Many surgical cases do not lead to good results.  The results of fusion for reasons other than fracture or dislocation are not encouraging.[16]  Reliable information indicates that good surgical outcomes are only predicted by strong concordant physical and special study findings.[17]^,[18] Moreover, when we are surgically successful we only speed the recovery with no obvious long-term advantage.  Therefore, it is reasonable to demand physiologic evidence of compromise (concordant motor, sensory and reflex changes or Positive Sharp Waves & Fibrillation potentials on EMG) before considering anatomic imaging pictures when a patient’s needed activities are thwarted for more than four weeks. 

Does a picture of a telephone tell you if it was ringing at the moment when the picture was taken?  Does a picture of a box tell you if it is heavy?  Of course not!  Neither does a picture of disk material or ligamentous tissue adjacent to the nerve’s dural sac tell you if it is compromising the nerve root’s function.  Only physiologic evidence detects nerve root compromised. 

Demanding physiological evidence of neurological compromise before getting imaging studies also avoids confusion.  Normal aging changes that include disc herniation are present 30% of the time in asymptomatic 30 year olds and increasing with age.¹⁴ Thus, without other concordant findings, the MRI can confuse the hopeful diagnostician, patient and clinician.  The lesson to be learned is that imaging studies are important for planning surgery but can be confusing as a sole diagnostic tool without the guidance afforded by physiological evidence since imaging findings are so commonly found in normal symptom free subjects.[19]

Table 5: Normal Anatomic findings with increasing age. ¹⁴

On the graph in Table 5, look for an age along the age in years line and move your finger toward the top of the page to see your chances of having something labeled an abnormality on your imaging studies if you never had back symptoms.  This emphasizes the need for gaining some physiologic evidence to determine the potential cause of symptoms before seeking concordant imaging pictures needed only to guide invasive procedures, not for a diagnosis. Using imaging alone for diagnosis we risk finding common age related changes that may or may not relate to the symptoms.

            Demanding concordant physiologic and anatomic test results increases clarity.  Subsequently, decision-making about elective spine surgery, not predicated on fracture or dislocation, is like being on “Wheel of Fortune” with Vanna White turning the letters around.  The more letters one can read, the greater the chance of identifying the phrase correctly.  No level of technical skill can overcome improper identification of the source of the problem. Only concordant strong findings predict a good outcome.  A diagnosis requires more than imaging studies alone, as they provide no physiologic evidence of neural compromise. Alone, imaging studies confuse commonly preexisting age related disc changes with the cause of present symptoms.

Physiologic Evidence- In the absence of a fall or other event that may cause a fracture, the following use of special tests to identify neurologic (sciatica) or non-neurologic (back) disturbances in function:

General Medical (if not already done for “RED FLAGs”)

     -Laboratory studies (Sedimentation Rate, Blood Count, Urine Analysis) are used as a metabolic general screen if the patient appears ill.

Structural

     -Bone Scan indications include a general structural screen for bony physiologic reactions to change in structure as fracture/dislocation or architecture (tumor, infection, spondylitis and aging).

Neurologically (+)

     -EMG (Electromyography) is considered for constant or near constant limb neurological symptoms of radiculopathy for four or more weeks (testing sooner may provide false negative as changes takes 3-4 weeks to be detected). Determine motor compromise with more than one Positive Sharp wave or Fibrillation Potential (if S1 is effected, look for a slowed h-reflex) before seeking concordant anatomic verification (if motor testing above the ankle is 3/5 or weaker consider anatomic studies).  An EMG is not needed if motor, sensory and reflex changes are concordant for an obvious L4, L5 or S1 nerve root involvement. These changes indicate strong physiologic evidence to explain 4 or more weeks of sciatica related limitation.

    -SEP (Somato-Sensory Evoked Potentials) are most helpful in the elderly patient with neuro-claudication from spinal stenosis symptoms especially in the presence of some EMG changes indicating acute motor dysfunction. SEP may determine which nerve roots are slow in sensory transmission.  SEP can be more sensitive but less specific for active compromise than EMG motor changes.

Caution against Misleading Discography

Neither the results of the AHCPR methodologic process, other reliable literature reviews like the Cochrane Collaboration nor subsequent articles of similar quality find support for use of diagnostic discography.[20]  Anatomic and clinical studies indicate anatomically 75% of discograms are expected abnormal at age 28 and 100% at age 42 years.[21]^,[22],[23]  Benefit of the doubt has been proffered based upon concordant symptom being reproduced with disc injection.  Dr. Carragee’s 4 published studies from December 1999 to December 2000 are a significant addition to the reliable literature questioning the reliability of a patient’s response to diagnostic injection.[24]^{,[25],[26],[27]}  The unreliability of high intensity zone and concordance response for patients was quite condemning, especially for patients with symptoms over six months or with abnormal psychological testing.  Moreover, discography caused significant symptoms for at least a year after the discogram in patients denying prior back symptoms.  Dr. Carragee’s 2002 presentation at the ISSLS highlighted a study that found discography unable to differentiate a back disabled group from a group who were just aware that they had back symptoms occasionally but enjoyed unlimited activity.[28]  Thus, reliable data that would meet criteria for either one of the above-mentioned reviews does not support Intra-Discal Electro-Thermal nucleoplasty (IDET) or a fusion procedure based upon discography.  While opponents attack Carragee’s work no reliable counter to the findings is available.

Diagnostic Impressions

Sciatica due to Herniated Disc - A history of back related leg symptoms with physiologic evidence of nerve root compromise either by very strong concordant physical examination or EMG (over 90% at L5 or S1 level) changes that are also concordant with obvious anatomic findings on MRI (or in special cases myelogram) are indications for surgical consideration. The procedure removes the nerve offending disc and any loose nuclear material within the disc (discectomy) usually through hemi-laminectomy (widening the opening between the lamina). However, if the patient can function with less than 3+ EMG findings recovery commonly occurs within a few months without surgery but with a recurrence rate of about 60% in the next few years.  Surgically decompressing the neural contents, in the presence of strong evidence, can reduce the symptom recurrence rate to about 10% depending upon the balance between subsequent conditioning and the backs daily physical demands. Fewer days of work are missed due to back problems for manual workers during the first 4 years following surgery.  There seems no difference after 4 years as surgery seems a luxury for speeding recovery when there are very strong findings.[29]  Generally, the more obvious the findings, the more assured is the recovery following surgical intervention17^,18 A risk of recurrence of herniated disc at the same level is between two and four percent.[30]

Important point!  Surgery does not make the back 18 years of age again.  The back will still be limited depending upon individual variation concerning the muscular conditioning relative to the physical demands.

Neuroclaudication from Spinal Stenosis - Patient history usually reveals a slow gradual decrease in activity tolerance especially with walking (neuro-claudication) and standing or prolonged extension of the lumbar spine.  Symptoms in the back with leg and/or foot symptoms in the patient with spinal stenosis are relieved by flexion of the lumbar spine, which decreases the ligamentous enfolding that can crimp the intra-dural neural contents.  Consider screening for diabetes or other general metabolic problems with neuroclaudication before age 60 years.  Most patients have a history of at least intermittent symptoms for months before seeking medical care.  Physical examination tends to be indistinct due to the slow progression of neural compression.  Patients commonly do not have straight leg raise sciatic tension signs and weakness, atrophy and diminished reflexes, as changes have a tendency to be symmetrical thus, insidious and difficult to determine.  EMG changes also tend to be minimal due to the gradual nature of the compression. EMG can help in differentiating new from old changes when acute EMG findings are present (sharps, fibs). SEPs aid EMG in surgical planning as an additional guide to which nerve root foramina need special attention during surgical decompression.  Anatomic studies (either MRI or Myelo-CT scan) verify the structural need for central decompressing laminectomy. Foraminal decompression commonly requires partial anterior facetectomy and perhaps partial removal of the inferior pedicle.  Surgical decompression is not preventative and should be performed only when the patient feels compromised enough by the walking limitations to undertake the risks.  Without surgery about 1/3 get worse, 1/3 remain the same and 1/3 improve while 5 years of relief with surgery is a good result.  True bowel & bladder compromise can result from stenosis impacting the cauda equinae and is an emergency indication for decompression.  Those who respond to surgery tend to be those most limited in walking distance (neuro-claudication < 300 yards).  Segmental fusion is considered if there is accompanying Spondylolisthesis (degenerative slip) with motion. 

Spondylolisthesis - Three and one half percent of adults in the United States have slippage of either L4 vertebra on L5 or L5 vertebra on the sacrum.  Most slips are associated with bony disruption between the facets (spondylolysis) early in life.  When one vertebra slips forward more than 25% of the anterior-posterior diameter of the vertebrae below, the nerves at the involved level can become compromised.  The limb findings and EMG changes are commonly more vague than with a herniated disc and may be bilateral or unilateral.  Surgical decompression is similar to Spinal Stenosis with fusion usually required, unless the disc is sufficiently aged which makes the segment stiffer and stable as commonly found in spinal stenosis.  Thus, there is a greater chance of further slip with decompression with younger discs in the presence of underdeveloped facet joints.  From a clinical outcome standpoint, the younger the patient (less than 30 years of age), the better the result with fusion. A tricky diagnostic dilemma can develop when vague natural back symptoms occur in the patient with a spondylolisthesis.  Since 25-40% of back patients have accompanying leg symptoms, a slip noticed on x-ray can lead to the unverified misdiagnosis of a long-standing slip being the cause of the symptoms.  A slip of less than 25% and even up to 50% may not cause more back trouble during the working years than no slip at all.[31]  Later the slip can complicate elderly spinal stenosis but even then most slipped segments stiffen rarely leaving residual motion that would require fusion to augment decompression (also see Segmental Instability).

Medical Arthritis - Sero-negative spondyloarthopathy consists of Ankylosing Spondylitis, Reiter’s’ Syndrome, Psoriatic Spondylitis and related expressions of spinal symptoms. Except for the Psoriatic type, these arthridities more commonly occur in men with an onset at age 20-40. These tend to be multi-system diseases that are best managed by medical survielence and a combination of therapies that maximize patient functioning.  Once stiff and brittle, minor trauma can cause fractures with serious consequences. Early diagnosis presents as back symptoms lasting longer than three months, worse in the morning (especially stiffness) than evening, improved by mild activity, and taking more than ninety minutes to get as good as they get for the day.[32]

Segmental Instability - The concept of increased motion at one segment (other than spondylolisthesis) is based upon the relative increased motion that allows measurable stress shielding of the adjacent segments.  As with fatiguing a wire to break it, until a weak spot develops the spine bends uniformly with the full length sharing the load.  Finally a weak spot develops (Figure 5).  Then the weak spot, being more lax, takes up more and more of the stress and shields the remaining stiffer areas from having to bend.

Figure 5: Fatiguing a Wire¹⁵

First stresses bends the wire uniformly

Until there is a weak spot (where it will

eventually break) that takes all the stress,

shielding any bending stress elsewhere.

We can evaluate stress shielding with two lateral radiographs centered at the site of a possible pathological increase in motion (weak spot or hyper-mobile segment).  By superimposing the two films, the translation and angular motion can be evaluated and correlated to similar principles as determining the weak spot in a wire.  For example, the hyper-mobile segment takes up all the stress allowing 11 degrees (15 degrees at L5-S1) more motion than adjacent motion segments or more than 5 mm slipping translation.[33]

Fusion is indicated for infection, tumor, fracture or dislocation. As yet the only reasonable elective indication for fusion is for a slip with motion when laminectomy is required to decompress spinal stenosis causing neuro-claudication or similarly involved younger patients with spondylolysis (pars inter-articularis defect) and spondylolisthesis (slip).  Most fusions performed today are based upon instability criteria that as yet do not related to a predictable outcome.^2,20

Motion films provide us with at least some semblance of objective evaluation for instability though our clinical correlation for aged disc without fracture or dislocation are sketchy at best.  So ask your radiologist if there is more than 5 mm of translation or more than 11 degrees motion (not just slip) at one motion segment compared to the adjacent motion segment(s).

Fusion must be approached with caution according to Fitzler et al.’s Volvo award winning randomized trial published 2001.  The authors found a paltry improvement for fusion as depicted in Figure 6.¹⁶  Rapid convergence toward similar complaints by the two groups from 26% difference at 6 months to only 15% difference on a 100-point visual analog pain scale at two years also found only a 15% better chance of reporting being “much better” (29%-14%).  The non-operative group had markedly less potential placebo impact being offered nothing new and no potential cure.  The results were unimpressive as the authors had to include the caveat “fusion … rarely cures the patient.”  The “rare cure” caveat must be weighed relative to a reported 17% complication rate with the fusion surgery. Nine percent of the surgery patients had either life threatening complications or complications that require immediate re-operation.16 In this study as in multiple others trials, a solid fusion or lack thereof, did not influence either a good or a bad result.16 ^,34,35,36 Such findings continue to question the whole premise of the procedure.

Figure 6 Modified from Fritzell et al, Spine 2001¹⁶

Worth 17% complication rate - 9% life? threatening or re-op.?

The reliable literature at present cannot justify instrumentation fusion for back pain.  Information now available from at least 7 quality randomized trials indicates that hardware only adds complications.^16,[34]^{,[35],[36],[37],[38],[39]}

IV. FURTHER TREATMENT AFTER DIAGNOSTIC OR SURGICAL PROCEDURES

We return to a treatment paradigm with an emphasis on maximizing comfortable activity tolerance whether the problem is due to the period of reduced activity common of aging or altered structural or neurologic status.  At this point nothing should stand in the way of needed conditioning.  This treatment emphasizes progressive actively to improve tolerance for daily activity.

Explaining Conditioning: Consider the following dialogues for analogies to improve understanding.

When will the pain go away?  Consider the analogy of a knee problem.

It makes no difference whether knee surgery is required or not.  Recovery only comes after conditioning the thigh muscles to the point of compensating for whatever knee problem remains.  With adequate conditioning of the protective muscles, some can again tolerate the rigors of professional athletics, not because the knee is normal but because there is adequate muscular compensation to tolerate the required activity.  The protective muscles must be conditioned well beyond what they were before the knee problem.  Until conditioned to that point, the knee continues to be painful, doesn’t tolerate activity, can be tweaked by any minor mishap and even reddens or swells after minor use until the muscles improve their efficiency.  It is similar with spine problems.

            Until our general and our protective muscle endurance is sufficient to tolerate our desired activity, we will experience the aches and pains (or worse) as do athletes beginning intense pre-season training or anyone gardening first time in spring after a prolonged winter’s resting.  It isn’t necessarily painful when we start, but after we tire or the muscles we are using begin to fatigue, our body can be more easily irritated.  We pay for the irritation that night, the next day or sometimes right away.  The pain is not due to dangerous activity or having a serious problem.  It is the result of the winter rest.  It usually takes weeks of working in the garden before muscles become conditioned well enough that the pain goes away.  If we are older or our muscles are already compensating for a aging problems or past sins, the irritation can cause much more intense symptoms.

Conditioning Suggestions:  These help patients realize how a lack of general stamina can prolong symptoms and how training of specific spine muscles provides protection from future problems. “Our best science indicates that conditioning involves addressing two weak links that can keep protective muscles from reacting fast and strong enough to protect our joints.  The most obvious is fatigue of the specific muscles.  When fatigued, they react slower and weaker, unable to do their protective job.  Also, if the owner of those muscles becomes tired, the spine muscles also react slower.  Fatigue robs us of our coordination and reactions.”

            2. Spine Considerations: Nothing, surgical or non-surgical, makes the back young again after a few weeks of limitation or significant radiculopathy.  For 1/3 of us by 30 and all by age 50 our back is no longer young.  The key to treatment is to improving spine muscle endurance to reduce the frequency and severity of future episodes of back problems.[40]

Treatment for Reduced Activity Tolerance (Spring Training for the Spine)¹⁵

If improving but not asymptomatic at 30 days or

After Appropriate Neuro (+) or Neuro (-) Work up begin:

            Conditioning to improve comfortable activity tolerance

                        Phase I Endurance for a few weeks, then add:

                        Phase II Back Muscle Stamina as needed for a few weeks then add:                

                        Phase III General leg and abdominal for a month before

                        Maintenance (Ph I 2 x per week, Ph II daily, Ph III 2-3 x per week)

                                    Optional non-back stretching Arms, legs

3. Phases of Conditioning: The conditioning process starts with a couple of weeks of general conditioning, perhaps 5 days per week for six weeks of keeping the pulse rate above 120-130 beats per minute. This is accomplished either with continuously walking or stationary cycling for 30 minutes, or jogging 15-20 minutes.  After 2-4 weeks of general conditioning add specific back muscle conditioning of erector spinae, gluteal and hamstring muscles to confer muscular protection with 4 minutes nightly (see figure 7).  Spine muscle conditioning has a proven protective impact that reduces symptoms and back limiting episodes in people with strenuous jobs.⁴⁸

Figure 7: Specific Erector Spinae Conditioning.  With back in neutral position¹⁵

Raise chest and limbs from position A to B holding lumbar curve in a neutral position similar to standing.

Begin holding 1 1/2 minutes and work up to 4 minutes over about 2 weeks.

[Do not go up and down - hold!]

Back muscles must burn 30 or more seconds each time to progress.

            A third Phase is not really treatment of the spine but an attempt to get back what we tend to lose when we are inactive for a time due to back symptoms.  Thus, this Phase is really simple but effective reconditioning of arm, legs and abdominal muscles.  Dips, for the arms, can be performed in an armchair.  Leg exercises include either squats at the sink or the old ski conditioning exercise of assuming the sitting position against a wall without a chair.  The abdominal muscle conditioning demands only mild exercises.  All of these can be performed in less than 5 minutes of effort and usually can be added after 4 weeks of specific spine muscle conditioning.

Review and Overview

This was the approach we experienced in a pilot study for a national retailer in 1999-2000 which showcased the combination of the Activity Paradigm introduced by Malmivaara et al., with back decisions based on the AHCPR Guide #14 and Industrial Medical Council of California.^2,6,13,[41]  The six stores in Las Vegas, Nevada receiving the care based upon reliable data through the activity paradigm had  1/6th time loss and similar reduction in costs of the care as provided by a large national occupational group for the other six stores for all injury claims at work.¹³  As expected the largest percentage thus greatest opportunity for success involves the adroit care of the patients with back problems.  Adherence to the activity paradigm provided quicker clinical and administrative decisions when predicated upon the patient’s response to clinician’s recommending as normal as possible activity.  If the patient was not convinced that there was nothing serious, the primary care clinician sought a second opinion, a colleague’s consultation or even a specialist only to address the potential for a serious problem.  If something serious was identified, care for it was expedited.  If nothing serious was found the patient was reassured and as normal as possible activity was recommended.  A specialist saw anyone on limited duty for more than one week and without something serious, the caveat against the debilitation of avoiding normal activity was reinforced.  Patients without serious pathology, but off work despite repeated debilitation caveats and offers of limited duty, quickly were assured by at least three opinions that nothing was serious.  Within a few weeks of demonstrated avoidance, non-physical issues usually surfaced and were dealt with administratively.  The early aggressive medical approach allows non-medical issues to be broached before falsely medicalized delays foster spurious and confusing hypothetical diagnoses.  Medicalization of non-physical problems can trigger the cascade of potential complications from invasive diagnostic and therapeutic procedures.

For back problems a simple reasonable history and quick physical examination addressed potentially dangerous conditions as either “red flags” or severe neurological involvement.  Thereafter, the timely use of other clinicians as needed to either identify serious conditions or help to convince the patient that “nothing serious” should limit activity. This persuasion allowed the primary clinician to apply a simple decision tree based upon the patient’s response to recommending “normal activity” as soon as possible.  Limited duty for a week was easily negotiated when needed.  Without concerns of serious pathology, and after hearing caveats about the risks of inactivity, the patient then had to decide, against clinical advice, to be off work.  Continuing with the activity paradigm either expedited diagnosis of a serious condition or hastened detection of non-physical issues.  Only physical issues are amenable to medical treatment and undetected non-physical issues may become an increased risk to the patient’s health by fostering the frustration that too commonly leads to invasive medicalization.  The simple three-decision algorithm as in figure Activity Algorithm, kept both the important questions and responses in front of the clinician working closely with an enlightened employer.

Figure: Activity Algorithm¹⁵

.

H&P –History and Physical Exam, Prim.Care – Primary Care Clinician, Risk Mgmt. – Risk Management representative for the employer, IME – Independent Medical Examination or opinion.

The pilot described above had the luxury of a well-coordinated store management and cooperative claims administration system as required to maximize this approach.  Less enlightened employers and their representatives markedly hamper the potential to reduce the time away from work, reduce the elective surgery rate, and limit the number who become chronically disabled or require an expensive legal contest.  There is little doubt that the health of the study group was maintained better than the control group who experienced more diagnostic procedures and a higher surgery rate, greater time off work and an increased risk of losing a job, which has been the results in other activity oriented studies.^6-12

Considerations Without Employer Cooperation

Work hardening should be reserved, for gradual return to work activities at work if at all possible.  If the patient is sufficiently comfortable to consider physical therapy, return to work or limited duty is a more ideal option.  The basic concept is to encourage the patient to perform as many repetitions of a specific limited task as possible.  If unable to tolerate a full circuit, then repetitions need to be built with a portion of the load (3/4 or 2/3 the requirement) until one circuit can be completed.   Then begin 2/3 to 3/4 of the persons accomplished load to build the repetitions beyond what is required.  Once the person accomplishes more repetitions than are needed, gradually increase the load to the normal level.  The speed of progression to the eventual goal can be predicated on many physical and non-physical factors.  A work hardening approach performed in the normal work milieu increases the chance of success, overcomes many more fears and reduces potential risk to the patient related to being away from work.

Slow Recovery Approach

This is what you are trying to avoid with the activity paradigm.  The slowest 10% have been proven to take up 90% of resources and similarly impact you.[42]  If you are here you or the patient probably did not maintain the Activity Paradigm or you do not have an enlightened employer or employer representatives.  Now you need to help inject reality into the patient’s decision making presently threatening his or her livelihood and future, while perhaps broaching some of the more sensitive issue that can be blocking progress through a concerned helpful approach.

Limited Physical Effort or Slow recovery with Conditioning

Concern – Might not keep job: CAUTION patient of job loss

            Gather information about Options just in case return to work doesn’t work out

            Be willing to support any patient livelihood decision

No Effort in the Information Gathering

Concern – back problems rarely interfere with making a few phone calls to gather information that can save your livelihood.  No attempt is insane behavior.

Insane behavior can be explained by: Insanity, Alcohol Addiction, Insanity,             Drug Addiction, Insanity, Illiteracy, Insanity, Depression and Insanity

Patient usually chooses to discuss reason other than Insanity.

Concerned Approach to Difficult Issues

            All clinicians are stymied by slow recovery or a parade of continuous obstacles to gaining reasonable activity tolerance through conditioning.  If return to work is the expected outcome, the patient may well be struggling to survive in a confusing contest where return to work seems to guarantee the patient’s failure.  Being trapped in the contest sometimes causes patients to embellish symptoms, display pain behavior or frustration with our ineptitude at solving the problem.  Don’t be too harsh in your judgment when you see survival behavior.  In the wild survival, is based upon confusing the enemy, whether a zebra’s disorienting stripes during a chase, a lion’s camouflaged fur or a hen faking a broken wing to lure a predator away from her nest.  Patients may fear that we seem more like a predator in the contest rather than someone who has their best interest in mind.  We may misinterpret our patients’ attempts to enlist our help.  Embellishments as in the Waddell criteria, may indicate that we have not persuaded the patient that we have his or her best interest in mind.  No species chooses failure to resolve such a contest.  The reasons why someone cannot overcome limitations can be due to innumerable combinations of physical, emotional, cognitive and social factors.  Patients benefit more from our honest help than our judgment.

Slow Recovery.  When recovery is slow, review the history, physical exam and special study findings to again assure the patient that no “RED FLAGS” have emerged.  Then, as a helpful partner in trying to build activity tolerance, show concern for slow progress or repeated difficulties in reaching an espoused activity goal. This always includes improving activity tolerance with an appreciation that it is not always easy.

Concern 1 “If it is this difficult now (to regain activity tolerance), what is the chance that as you get older it will be easier?  What will you do if, for any reason, you do not get back to your former job or activity?  If unsure about the future, gather some information about your options.  You may not need options immediately but they could be important for planning over the next few years or sometime before retirement age.”  The patient is provided with both assurance and your acceptance.

            Offer suggestions with your concern.  This can help the patient feel much more in control, knowing that he or she is not tied to a particular outcome if in a “return to work contest”. Offer to help the patient start a spiral notebook about calls and inquiries about potential career opportunities. You can quickly review the patient’s notebook on each visit to monitor efforts (Table 6).  This takes little clinician time and requires mostly a reminder.  Only gathering information and improving the patient’s understanding of the issues, seems to de-emotionalize decision-making.  About 1/4^th of patients, respond favorably without coaxing.  Half require a second reminder.  The remainder, require a second concern.

Table 6: Spiral Notebook approach to Options¹⁴

Start a Career Option Notebook

Record each phone-call on a separate page for future reorganization. Gather information in four phases.

1. Call agencies and educational institutions

            -Seek community colleges and training institutions for interview and guidance.

2. Call employers about careers that sound good to you in localities of interest.

            - Mostly to see if opportunities really exist and for names of employees in area of interest.

3.  Call employees to see up side and down side of the career and for recommendations about getting to where they are (best information available).

4. Review those that sound best for you with a college or training counselor, then work out a budget.

No Effort to Explore Options.  Some patients may require some coaxing to gather information about possible options.  A patient’s total lack of response to suggestions to gather information provides another opportunity to show concern, this time for apparent “insane behavior” to open the door to difficult issues.  The approach centers on the term “insane behavior.”

Concern 2. “It is quite unusual for spine symptoms alone to keep someone from making a few phone calls to figure out how to salvage a livelihood and perhaps a family’s future.  Usually other issues are involved.  You may need to see a counselor to sort out the reasons for such insane behavior.”

-If successful in earlier efforts to prove you have his or her best interest in mind or if the patient fears seeing a new person, the patient commonly asks, “Reasons like what?” 

-This provides you with a concerned opportunity to review common reasons.  “The common reasons for insane behavior are insanity, alcohol abuse, insanity, drug abuse, insanity, illiteracy or insanity, depression or insanity (if you get to this discussion both you and the patient may be somewhat depressed).

-The patient usually chooses something other than insanity to discuss either with you or a counselor.  Most gravitate to reasons other than insanity to explain your detection of “insane behavior”.

            Without noting “insane behavior,” approaching any of these emotional issues can result in sometimes volatile, defensive patient anger or avoidance.  Questioning “insane behavior” allows the patient to choose to defend his or her actions with admissions of either insanity, another problem or better yet, by proving capable of overcoming the limitation.  Fear of an insanity label seems a greater motivator than exposing a habit or weakness. 

            Though rare, if the patient chooses insanity, little further back care is required! Back care can accompany reading classes for the illiterate.  With addictions, back care can continue after abstinence or detoxification, but only while participating in Alcoholic Anonymous (AA) or Narcotics Anonymous (NA) meetings daily for at least 3 months.

Even patients without addictions may be candidates for a trial of antidepressants after weeks of trying to survive the injury contest without realizing any options to the real or apparent limitations that seem to assure failure.^14,15

Summary

Data driven care may well become a way of life as suggested by medicine and perhaps demanded of professionals by law.  This is but an overview of an activity approach to back problems that makes use of a reliable data reference like the AHCPR Guide # 14 for Back Problems or Cochrane Collaboration easier.^2,20  The authors had the opportunity in 1999-2000 to participate in application of the activity paradigm based upon reliable data.  The application was only a pilot plotting the care for work related problems for six of twelve stores for a national retailer in a major metropolitan area.  Back problems were the most frequent issue but the activity paradigm had a positive impact on throughout.  The results of the pilot found the disability and total costs for care reduced to 1/6^th for the activity group compared to an occupational care group reportedly using a pain oriented rather than activity guideline.13  Reliable data alone may not be the answer for treating back problems.  The change to an emphasis on activity treats the true problem (activity) while quickly detecting the presence of overwhelming non-physical issues.  The primary care clinicians and specialists have to deal with back problems.  It is prudent not to exclude work related non-physical issues – especially since these issues are often part of the patient’s problem even when work is not involved. 

As concerned, caring clinicians, we cannot ignore the decimating impact on our patients by being off work. Ross reported in 1995;

… that those who are off work for any reason (job loss, compensation, fired, etc,) have a higher mortality risk rate than any occupation--even the most dangerous ones.  In fact, so heightened is the risk of death from suicide, cirrhosis, and other stress-related diseases while not working, that being unemployed is equivalent to smoking 10 packs of cigarettes/day.[43]

Once familiar with the simpler format, an activity approach makes the use of the reliable data more logical.  We have tried in this chapter to provide a simple avenue to both better results for patients and added protection for the clinician dealing with back problems even when work.

Table: Summary of AHCPR Guide #14 “Finding and Recommendation Statements”¹⁵

	Recommend	Option	Recommend against
History and Physical Exam 34 studies	Basic history (B). History of cancer/infection (B). Cauda Equina Syndrome (C). History of significant trauma (C). Psychosocial history (C). Straight leg raising test (B). Focused neurological exam (B).	Pain drawing and   Visual Analog Scale (D).
Patient Education 14 studies	Patient education about back problems (B). Back school in occupational settings (C).	Back school in non-occupational settings(C).
Medication 23 studies	Acetaminophen (C). NSAIDs (B).	Muscle relaxants(C). Opioids, short course(C).		Opioids used >2 wks (C). Phenylbutazone (C). Oral steroids (C). Colchicine (B). Antidepressants (C).
Physical Treatment Methods 42 studies	Manipulation during first month of low back pain (B).	Manipulation for patients with radiculopathy(C). Manipulation for patients with symptoms>1 month(C). Self-application heat/cold to back (D) Shoe insoles(C). Corset for prevention   in occupational setting(C).		Manipulation for patients with undiagnosed neurologic deficits (D). Prolonged course of manipulation (D). Traction (B). Transcutaneous Electrical Nerve Stim. -TENS (C). Biofeedback (C). Shoe lifts (D). Corset for treatment (D).
Injections 26 studies		Epidural steroid injections for radicular pain to avoid surgery C).		Epidural injections for back pain without radiculopathy (D). Trigger point injections (C). Ligamentous injections (C). Facet joint injections (C). Needle acupuncture (D).
Bed Rest 4 studies		Bed rest of 2-4 days for severe radiculopathy (D).		Bed rest > 4 days (B).
Activities and Exercise 20 studies	Temporary avoidance of activities that increase mechanical stress on spine (D). Gradual return to normal activities (B). Low-stress aerobic exercise(C). Conditioning exercises for trunk   muscles after 2 weeks(C). Exercise quotas(C).			Back specific exercise machines (D). Therapeutic stretching of back muscles (D).
Detection of Physiologic Abnormalities 14 studies	Month of Not improving BP: Bone scan (C). Needle EMG and H-reflex tests to clarify 4 weeks of unclear nerve root dysfunction(C). SEP to plan spinal stenosis surgery (C).			EMG for clinically obvious radiculopathy (D). Surface EMG and F-wave tests (C). Thermography (C).
X-rays of L-S spine 18 studies	When “RED FLAGS” for fracture present(C). When “RED FLAGS” for cancer or infection present(C).			Routine use in first month of symptoms in absence of "red flags "(B). Routine oblique views (B).
Imaging 18 studies	CT or MRI when strongly suspect Cauda Equina, tumor, infection, or fracture C). MRI test of choice for patients with prior back surgery (D). Criteria for imaging tests (B).	Myelography or CT-Myelography for   preoperative planning (D).		Use of imaging test before one month in absence of "red Flags"(B). Discography or CT-discography (C).
Surgical Considerations 14 studies	Consider possible surgical options with persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B). Standard discectomy and micro-discectomy of similar efficacy in treatment of herniated disc (B). Chymopapain, after ruling out allergic sensitivity, acceptable but less efficacious than discectomy for herniated disc(C).			Disc surgery for back pain alone, no "red flags," and no nerve root compression (D). Percutaneous discectomy, less efficacious than chymopapain (C). Surgery for spinal stenosis within the first 3 months of symptoms (D). Stenosis surgery by imaging tests without Cauda Equina syndrome or Neuroclaudication (D). Fusion without motion & stenosis fracture, dislocation, tumor or infection complications(C).
Non-physical Factors	Social, economic, and non-physical factors can alter patient’s response to Symptoms (Sx) & Treatment (Tx) (D).			Before extensive Evaluation or Treatment Programs, first explore patient expectations & non-physical factors (D).

I. INITIAL ASSESSMENT

(Determine your patient’s Diagnosis)

Initial Patient Decisions

Serious                               If not è Activity Issue (Neuro+ & Neuro -)                  Non-Activity

Red Flags?                                                                                                          Pain Issue

Dx approach until                     1. Assure “Not dangerous”                           Pain Approach

  R/O or safe for                       2. Rec. “Normal Activity”

     activity

INITIAL CARE

(Monitor the patient’s response to recommending Normal As Possible Activity)

Activity Issue (Neuro (-) or Neuro (+)¹⁵

           (Assure no danger & Recommend Normal Activity)

RESPONSE ACTION

3. Normal Activity                              Support

4. Limited Choice                               Negotiate Activity

Level* and Normal

Activity ASAP

5.  Refuse Activity                                -2^nd Opinion + Warning against inactivity

   (concern for debilitation)

4.  Refuse Activity                                -Specialist (anything dangerous)

- Warning against inactivity

5. Refuses activity                                 -Rec. Insurer seek opinion ASAP                                                                                             if work related

III. Considerations for Limitations beyond 30 days       

 Expect reasonable activity -     Neuro (-) 90%   Neuro (+) 50% by 30 days

If not improving and limited – consider workup

Neuro (+) Sciatica below the knee

                        PE or EMG (include SSEP for elderly with neuro-claudication)

- to consider if imaging is worthwhile to seek concordant correctable lesion

         [CAUTION- ONLY STRONG CONCORDANT FINDING PREDICT A GOOD SURGICAL OUTCOME]

Neuro (-)

                        Medical review to consider

Labs - constitutional

                        Bone Scan – structural

                        - to consider if specific imaging is worthwhile

IV. Recommend Patient exercise as much as needed to be as comfortable with daily activity as the patient chooses.

Treatment for Reduced Activity Tolerance (Spring Training for the Spine)¹⁵

If improving but not asymptomatic at 30 days or

After Appropriate Neuro (+) or Neuro (-) Work up begin:

            Conditioning to improve comfortable activity tolerance

                        Phase I Endurance for a few weeks, then add:

                        Phase II Back Muscle Stamina as needed for a few weeks then add:                

                        Phase III General leg and abdominal for a month before

                        Maintenance (Ph I 2 x per week, Ph II daily, Ph III 2-3 x per week)

                                    Optional non-back stretching Arms, legs

V. Managing Patients where Employer Cooperation is Lacking

Limited Physical Effort or Slow recovery with Conditioning¹⁵

Concern – Might not keep job – CAUTION – loss of job

            Gather information about Options just in case RTW doesn’t work out

                        Be willing to support any patient livelihood decision

No Effort in the Information Gathering

Concern – back problems rarely interfere with making a few phone calls to gather information that can save your livelihood.  No attempt is insane behavior.

Insane behavior can be explained by: Insanity, ETOH Addiction, Insanity, Drug Addiction, Insanity, Illiteracy, Insanity, Depression and Insanity

Patient usually chooses to discuss reason other than Insanity.

First Step in Concern approach to failure: Spiral Notebook for Options²

Start a Career Option Notebook

            Staple Patient Discussion Handout # 4 inside the cover of a spiral notebook.

Record each phone-call on a separate page for future reorganization. Gather information in four phases.

1. Call agencies and educational institutions

            -Seek community colleges and training institutions for interview and guidance.

2. Call employers about careers that sound good to you in localities of interest.

            - Mostly to see if opportunities really exist and for names of employees in area of interest.

3.  Call employees to see up side and down side of the career and for recommendations about getting to where they are (best information available).

4. Review those that sound best for you with a college or training counselor, then work out a budget.

References

---

[1] Sackett DL, Haynes RB, Guyatt GH, Tigwell P. Clinical epidemiology: a basic science for clinical medicine. Boston: Little, Brown: 1991:59

[2] Bigos, S.J, Bowyer R.O., Braen GR., Brown K., Deyo R., Haldeman S., Hart J.L., Johnson E.W., Keller R., Kido D., Liang M.H., Nelson RM., Nordin M., Owen BD., Pope M.H., Schwartz R.K., Stewart DH., Susman J., Triano J.J., Tripp L.C., Turk D., Watts C., Weinstein J., Contributors: Battié M.C., Bombardier C., Hadler N., Nachemson A., Waddell G., Holland J., Webster J., Schriger D., Shekelle P. Clinical Practice Guideline #14: Acute Low Back Problems in Adults, Publication 95-0642 U.S. Department of Health and Human Services, Public Health Service AHCPR Rockville, MD.  December 9, 1994

[3] Shekelle P, Oritz E, et al, Validity of the AHRQ Clinical Practice Guidelines – How Quickly Outdated, JAMA, 9/26/01 Vol. 286, No.12, p.1461-67

[4] Daubert v. Merrell Dow Pharmaceutical, Inc. 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993)

[5] Black v. Food Lion, Inc., 171 F.3d 308 (5th Cir. 1999)

[6] Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, et al, The treatment of acute low back pain--bed rest, exercises, or ordinary activity? N Engl J Med 1995 Feb 9;332(6):351-5

[7] Atcheson SG, Brunner RL, Greenwald EJ, Rivera VG, Cox JC, Bigos SJ., Paying doctors more: use of musculoskeletal specialists and increased physician pay to decrease workers' compensation costs. J Occup Environ Med 2001 Aug;43(8):672-9 J Occup Environ Med 2001 Aug;43(8):672-9

[8] Buchbinder R, Jolley D, Wyatt M, Effect of Media Campaign on Back Pain Beliefs and Its Potential Influence on Management of Low Back Pain in General Practice SPINE 2001;26:2535-2542

[9] Hagen EM, Eriksen HR, Ursin H, Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000 Aug 1;25(15):1973-6

[10] Indahl A, Haldorsen EH, Holm S, Reikeras O, Ursin H. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 1998 Dec 1;23(23):2625-30

[11] Burton AK, Waddell G, Tillotson KM, Summerton N., Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine 1999 Dec 1;24(23):2484-91

[12] McGuirk B, King W, Govind J, Lowry J, Bogduk N., Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 2001 Dec 1;26(23):2615-22

[13] Personal Communication SpecialtyHealth Reno, NV 2000

[14] Bigos, SJ et al, Quick Reference Guide for Clinicians #14:  Acute Low Back Problems in Adults: Assessment and Treatment, Publication 95-0643 U.S. Department of Health and Human Services, Public Health Service  AHCPR Rockville, MD.  December 9, 1994.

[15] Bigos, S.J., Housestaff Handbook for Back Problems, SpineMATE Publications, Seattle 1996

[16] Fritzell P, Olle Hägg, Wessberg P, Nordwall A, Lumbar Fusion Versus Non-surgical Treatment for Chronic Low Back Pain, A Multi-center Randomized Controlled Trial, SPINE 2001;26:2521-2532

[17] Carragee EJ, Kim DH., A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Correlation of outcomes with disc fragment anc canal morphology. Spine 1997 Jul 15;22(14):1650-60

[18] Schade V, Semmer N, Main CJ, Hora J, Boos N., The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy. Pain 1999 Mar;80(1-2):239-49

[19] Borenstein DG, O'Mara JW Jr, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, Wiesel SW., The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am 2001 Sep;83-A(9):1306-11

[20] The Cochrane Collaboration 1989-2002

[21] Gresham JL, Miller R, Evaluation of lumbar spine by discography. CORR 67:29 1969

[22] Holt EP, The question of lumbar discography.  JBJS 50-A:720-726 1968

[23] Ritchie, JH, Fahrnie WH, Changes in lumbar intervertebral discs. Can. J. Surg. 13:65, 1970

[24] Carragee EJ; Tanner CM; Yang B; Brito JL; Truong T,  False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection. Spine - 1999 Dec 1; 24(23): 2542-7

[25] Carragee EJ; Tanner CM; Khurana S; Hayward C; Welsh J; Date E; Truong T; Rossi M; Hagle C, The rates of false-positive lumbar discography in select patients without low back symptoms. Spine - 2000 Jun 1; 25(11): 1373-80

[26] Carragee EJ; Chen Y; Tanner CM; Hayward C; Rossi M; Hagle C, Can discography cause long-term back symptoms in previously asymptomatic subjects? - Spine - 2000 Jul 15; 25(14): 1803-8 

[27] Carragee EJ, Paragioudakis SJ, Khurana S. 2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine 2000 Dec 1;25(23):2987-92

[28] Carragee EJ, Alamin TF, Grafe M, Miller J, Provocative discography in volunteer subjects with mild persistent low back pain. International Society for Study Lumbar Spine, Cleveland June 2002

[29] Weber H.  Lumbar disc herniation.  A controlled, prospective study with ten years of observation.  Spine 1983 Mar;8(2):131-40 Weber H.  Lumbar disc herniation.  A controlled, prospective study with ten years of observation.  Spine 1983 Mar;8(2):131-40

[30] Balderston, R.A., Gilyard, G.G., Jones, A.A., Wiesel S.W., Spengler, D.M., Bigos, S.J., and Rothman, R.H.:  The Treatment of Lumbar Disc Herniation:  Simple Fragment excision Versus Disc Space Curettage.  J Spinal Disord, 4(1):22-25, 1991

[31] van Tulder MW, Assendelft WJ, Koes BW, Bouter LM, Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies, Spine 1997 Feb 15;22(4):427-34

[32] Calin, A., Fries, J.F.: Striking prevalence of ankylosing spondylitis in "healthy" W27 positive males and females. A controlled study. N. Engl. J. Med. 293:835, 1975

[33] Bigos SJ, Mills EH, McKee JE, Holland JP, Spine Injury Model Impairment Rating: Lumbar Spine. ABIME vol.2 No.1 Jan.-March 2002

[34] Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT. 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997 Dec 15;22(24):2807-12

[35] Thomsen K, Christensen FB, Eiskjaer SP, Hansen ES, Fruensgaard S, Bunger CE. 1997 Volvo Award winner in clinical studies. The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospective, randomized clinical study. Spine 1997 Dec 15;22(24):2813-22

[36] France JC, Yaszemski MJ, Lauerman WC, Cain JE, Glover JM, Lawson KJ, Coe JD, Topper SM. A randomized prospective study of posterolateral lumbar fusion. Outcomes with and without pedicle screw instrumentation. Spine 1999 Mar 15;24(6):553-60

[37] Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am 1995 Jul;77(7):1036-41

[38] McGuire RA, Amundson GM. The use of primary internal fixation in spondylolisthesis. Spine 1993 Sep 15;18(12):1662-72

[39] Moller H, Hedlund R. Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis--a prospective randomized study: part 2. Spine 2000 Jul 1;25(13):1716-21

[40] Gundewall B, Liljeqvist M, Hansson T., Primary prevention of back symptoms and absence from work. A prospective randomized study among hospital employees. Spine 1993 Apr;18(5):587-94

[41] Industrial Medical Council of California 1996

[42] Spengler, D.M., Bigos, S.J., Martin, N., Fisher, L.D., Zeh, J., and Nachemson, A.:  Back Injuries in Industry:  A Retrospective Study:  I.  Overview and Cost Analysis.  Spine, 11(3):241-245, 1986

[43] Ross, JF. Where do real dangers lie? Smithsonian; Nov.,1995:42-53