Talk:Low back pain

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Some comments[edit]

I have listed some possible issues I found while reading through the article, some may be to minor to consider? I am happy to help remedy anything that is similarly viewed by other editors as an issue.

  1. Cause - Sentence #1 "Low back pain itself is not a specific health issue, but...". I understand this to mean that back pain is not a specific diagnosis or disease, it is a symptom of such. However, the sentence says it is not a health issue? I understand pain (particularly chronic pain) to be a significant health issue in the western world!! Perhaps this should be worded differently?
  2. Cause - The idea in the paragraph seems incorrect; it suggests that age-related degeneration causes less space in the spinal foramen....and "is the suspected cause of the increased susceptibility of middle-aged adults to nonspecific low back pain". However, age-related degeneration gets worse with age, so we should see the prevalence of low back pain increase with age if this is the mechanism - not afflict the middle-aged predominantly. The epidemiology of low back pain indicates that low back pain declines after the age of 65. Also, this reliable source (among others) says that "Imaging findings of the structural changes of osteoarthritis do not correlate with pain production", which is why health professionals are encouraged not to image their low back pain patients unless there are red flags. I see that our article's discussion is sourced to a recent [RS], so I am not sure where the problem is here, but there seem to be problems with the ideas expressed in this section - maybe I am just violating OR?
  3. Back Structures - The paragraph does not include any discussion of the sacrum or it's articulations with the rest of the spine and the ilium? Should the lumbosacral facets and the sacroiliac joints be included in the discussion? The lumbosacral facets can probably just be mentioned along with the other spinal joints, but we have more that one article discussing pain of sacroiliac origin - this may deserves some discussion here and a few wikilinks? sacroiliac joint dysfunction Sacroiliitis
  4. Management - The section is divided into sections (physical therapy, medications, Alt Med, Surgery). The first sentence of 'physical therapy' says "Physical therapy can include massage, ultrasound, and electrical stimulation." yet massage and the very common electrotherapy TENS are discussed in 'Alternative medicine' and not in 'physical therapy'. Personally, I associate electrotherapies and ultrasound with physical therapy, but not massage. Also, there is no source for ultrasound, here is a recent RS: Ultrasound and shock wave therapies for low back pain: a systematic review.

Puhlaa (talk) 03:43, 26 July 2013 (UTC)

I think you're making a good point, but there might be nothing in the literature actually hitting upon it. I have a fair amount of notes built up over the years. Researchers have not done a very good in this area, which is evidenced by the fact that the highly promising effect size shown in multicenter 2003 clinical trial by Kovacs et al on mattresses has not been substantively followed up on (Zad68 removed this from the prevention section, which you may notice is exceedingly sparse). Remarkably, research on therapies with relatively limited theoretical basis such as acupuncture, chiropractic, or shoe insoles exceed the attention paid to mattresses or daily posture habits (e.g. the Alexander technique). The article currently also doesn't discuss heritability at all, even though that is presumed to be an aspect (with PARK2 implicated in some cases; see Novel genetic variants associated with lumbar disc degeneration in northern Europeans: a meta-analysis of 4600 subjects) and also doesn't mention the multifidus once, despite it being one of the more commonly-implicated muscles (see The role of the lumbar multifidus in chronic low back pain: a review). I suffered from back pain for a while and still sometimes get it, but I largely fixed mine through purchasing an adjustable air-bed mattress and improving my lazy posture. I suspect that anyone who wakes up with lower back pain should get a new mattress. There have been a few small replications of Kovacs et al, such as Jacobsen et al in 2010, but it's easy to discount small studies. Even more unfortunate, my experience is that most primary care doctors, who tend be from an earlier generation, either don't pay much attention to mattresses or recommended firm mattresses, which are specifically not recommended (but was previously standard) per at least one guideline (tho I can't remember which). When I was on the board of an insuring organization (a health trust) I tried unsuccessfully to try to figure out how to help pay for mattresses as a conservative strategy rather than the enormous recurring chiropractic and massage therapy payments, but had no luck: no doctors were recommending them anyway. II | (t - c) 05:16, 26 July 2013 (UTC)
These comments here and above are good feedback, appreciate it, I plan on handling them over the next few days (busy with IRL stuff today). Thanks... Zad68 20:02, 26 July 2013 (UTC)

Regarding Puhlaa's points[edit]

1. "Low back pain itself is not a specific health issue, but rather is a general complaint..." changed to "Low back pain itself is not a specific diagnosis or disease, but rather is a general complaint..."
2. On re-reading, agree the content wasn't sufficiently in line with the source. Borczuk 2013 discusses the disk and vertebral changes, and the reduction in space, but doesn't go quite so far as to clearly implicate them as a suspected cause. Removed from Cause to Pathophysiology.
3. Back structures does mention "Small joints called facet joints prevent, as well as direct, motion of the spine." but a bit more could be added. Salzberg 2012 does describe the sacroilliac joint and talk about it as a source of pain, so I will expand it a bit to cover this. It's a tough balance to make sure everthing is covered without going into so much technical detail that it will overwhelm the average lay reader.
4. Will add ultrasound and move content around as suggested.
This one's done. Zad68 21:02, 2 August 2013 (UTC)

Good stuff, thanks for the notes. Zad68 20:30, 1 August 2013 (UTC)

They all look like good changes to me! Regards Puhlaa (talk) 06:15, 2 August 2013 (UTC)

Regarding ImperfectlyInformed's points[edit]

Yes, there's not much in the literature on prevention. The basic summary of the current state of the literature on that is Hoy 2012, which says "Further research is needed to identify risk factors and culturally appropriate interventions to prevent and treat low back pain." The NIH 2013 fact sheet mentions exercise and proper ergonomics/lifting techniques. Another review states exercise is helpful in preventing recurrence of LBP but not in preventing the initial onset of it. I can clarify that content in the article a bit. The only other things I found were that back belts and shoe insoles are not effective.

Regarding mattresses, I did not see anything in up-to-date literature about them so that's why I took it out. You mentioned Jacobsen 2010-- I did see it but as you noted it's a primary source. The only recent thing I have that does mention mattresses is Haldeman 2008 which simply lists "mattresses" as a "lifestyle therapy" available but otherwise does not talk about them at all. So overall I couldn't find sufficient coverage in up-to-date secondary sources to support content on mattresses. If you can find a good up-to-date secondary source on mattresses, it'd be great to have.

You're correct in that the sources available pay a lot more attention to things like acupuncture and chiropractic, so that's what the article content follows. In the overview sources I reviewed, heritability received almost zero mention. I looked at the meta-analysis implicating PARK2 you provided. As our article states, the large majority of LBP is considered to be caused by musculoskeletal sprain and strain, and also there's a lot of people walking around with disc problems that do not actually cause LBP. The conclusions of the PARK2 article are very tentative ("provides evidence of association ... suggests ... may influence"). And although it's a meta-analysis it comes across as a primary and not a secondary source: they're data-mining, not aggregating existing results. My thought is not to use it in this article but if you have a strong counter-argument I'm interested to hear.

Regarding the multifidus, Salzberg 2012's physiology overview does mention it, along with all of the other muscles and joints involved in the complex network of back structure, but does not call it out as a particular cause of LBP over all the other components. None of the other secondary sources I reviewed that cover cause or risks mention the multifidus in particular, they just talk about the network of back muscles and joints in general. I'd have WP:WEIGHT concerns if the article ends up covering the multifidus in detail but not the other components; likewise I'd be concerned about how big the pathophysiology section would end up being compared to the rest of the article if I tried to cover them all in detail.

Thanks for the careful review and feedback, it's very much appreciated. Zad68 20:30, 1 August 2013 (UTC)

Thanks for your response; it was very detailed and polite.
  • As far as prevention, I have no idea why the research community isn't picking up on some of what I see as low-hanging fruit like mattresses, but as I mentioned earlier this seems to be more of a real-world problem (researchers, like Wikipedia editors, are drawn like moths to the flame of controversy). With that said, I did find a guideline which mentioned mattresses which I added. I'm inclined to think that even if the reviewers aren't picking up on something clearly significant like Kovacs large trial, we should still cover it (perhaps through the mini-review in follow-up studies like the one by Bert Jacobson, who is a veteran back pain researcher) if it is something as basic and significant as mattresses. (MastCell had some interesting comments on the problems of review articles the other day.)
  • Does Kelly et al 2012 which reviews sleep really not mention mattresses? That is truly remarkable.
  • I also added Hendrick et al 2011 (physical activity) and Hendrick et al 2010 (walking intervention) as these are key areas. As a sidenote, RCTs on physical activity in regular life are not very practical, but Hendrick et al 2011 does discuss two in a more strict setting and while in both cases the subjects returned to work earlier, no stat. significant effect on pain or disability was found. Unfortunately, Hendrick et al 2011 just barely predates the Oct 2011 HUNT 3 study which found significant benefits for exercise.
  • Regarding heritability: I'm surprised you didn't see anything. I don't know about all the overview sources you're looking at, and I can't access Eron G. Manusov's paper which is used heavily. However, it appears from PubMed that Manusov is a generalist who has never published on back pain prior to 2012. So it's possible he's missing some things. To get back to the point, Park2 is indeed cutting-edge and not ready for primetime, but that article says that "LDD has been shown to be heritable, with estimates of 65%–80%" citing a couple refs. Our article doesn't much discuss lumbar disc degeneration (degenerative disc disease) and it's relationship to back pain, but it does acknowledge a relationship. Additional material on heritability includes the notable Twin Spine Study (Battie et al 2009) which has been running since 1991 or Battie's 2004 review. I don't have access to either of those but I do have access to Hartvigsen et al 2009.
  • Regarding the multifidus and Salzberg: again, like Eron Manusov, I wonder if the reviewer here should be accorded so much weight, as PubMed suggests that this is Salzberg's first article on back pain (with the his other two publications appearing a while back). Meanwhile, you've got a review article from 2010 which uses multifidus in the title and comes from Freeman et al, where Freeman is a veteran spine researcher with dozens of articles under his belt. The article doesn't use the word "core", "trunk", or "transversus" at all, even though the relationship between core muscles and chronic low back pain is huge in this topic. This is not to say it doesn't have its controversies: see for example Lederman's 2009 contrarian "The myth of core stability". Like heritability or disc degeneration, this is a tough topic to summarize but I'm concerned that the article is incomplete without more.
Hope you don't take this feedback the wrong way. Really impressed with all the work you've put in here. I've got a few other things in my notes but for now I need to get up and stretch my back. ;) Maybe I'll try another edit or two later. II | (t - c) 23:32, 20 August 2013 (UTC)
Sorry ImperfectlyInformed (and ping to Biosthmors), I had meant to get back to you on this, but after the GA started I stopped looking at this Talk page and started looking at the GA page. Thanks for the comments, and don't worry I'm not taking them the wrong way!

The first thing I want to mention is that I think we have to be careful to avoid letting our real-world experiences with these sorts of subjects drive the weight we give the topics in the article. It's great you found a particular mattress that you feel worked for your back pain, but we have to go by WP:DUEWEIGHT and let the reliable sources drive the weight.

It is kind of surprising how little there seems to be in the sourcing on the relationship between back pain and mattresses. To answer your question: Believe it or not, the word "mattress" does not appear at all in the full text of Kelly et al 2012 (PMID 20842008). And I saw you added a bit to the article sources to Chou 2007 (PMID 17909209). The addition of that content sourced to that source is not something I really agree with, honestly, as it's a bit old per WP:MEDDATE, and more importantly that's a guideline from only one medical organization. What's critical here is that we have a 2010 review of guidelines from many medical organizations worldwide (Koes 2010, PMID 20602122), and that source, surprisingly enough, does not mention mattresses at all either. I think it is a WP:WEIGHT problem to mention something from the 2007 guideline of only one medical organization when we have a 2010 review of guidelines worldwide that does not. I am not going to remove the content myself but I am pointing Biosthmors to it here for his review.

Regarding Manusov, that review is taken from this special series on LBP from 13 articles published together in The Clinics, a very well-respected publisher. I really like series like these, because they are organized by a single editing team to ensure complete and balanced coverage of a topic across all the articles. I think this is better than dipping a ladle into PubMed and seeing what you happen to pull up, because that way can get very unbalanced coverage: you might pull three review articles on some relatively obscure topic related to your subject just because three different journals by chance happened to publish on it recently, and it'll skew your article. So I've been using this series of The Clinics articles to drive the sourcing.

So I hope you understand here why I'm concerned about how you seem to be going about coming up with suggestions for what to weight in the article. You got benefit from focusing on your mattress and multifidus, but we don't want the experiences of one person to drive the weight. A better way to go about making sure we adhere to WP:WEIGHT is to use a balanced, recent series of review articles. Zad68 16:54, 6 September 2013 (UTC)

Hitting a few points separately:
  • Chou et al 2007 is actually a joint guideline from two American societies: the American College of Physicians and the American Pain Society. It is their current guideline and is not archived (see ACP guidelines and APS guidelines, altho for the American Pain Society there is a 2009 supplement by Chou et al). Guidelines don't always change that often, and possibly Chou et al should receive more weight than currently allowed, as it doesn't seem that American guidelines have been given much weight in this article.
  • I don't agree that trawling through PubMed to get a broader perspective on a topic is bad. I think the opposite: if you stick to one special issue or supplement focusing on something, you're very likely to get a systematic bias which will seriously skew the article. I've done it on occasion but not without double-checking a broader literature. I'm skeptical that the The Clinics is a high-quality publisher. I wouldn't view as a publisher: it's an Elsevier brand. I couldn't even find the editorial board for their Prim. Care journal. Elsevier is very aggressive so it wouldn't surprise me if there are brochures out there touting their quality, but the reality is they are being boycotted by academics in multiple fields, including medicine (see e.g. Academic publisher Elsevier hit with growing boycott. Out of curiosity, do you have a Web of Science subscription and access to the impact factors? Not that I think they're a reliable indication of quality, but it is something...
  • I actually didn't get any personal benefit from core stability, but it's a huge area of research in low back pain. If you stick to what's written in a single special issue written by amateurs in the particular research area (or research in general, like Manusov), then you'll miss things like that. II | (t - c) 21:05, 13 September 2013 (UTC)
I guess the question is are there any significant places where our article currently differs from the ACP or APS guidelines? If not that there's not a significant issue. This is only a GA not an FA. I am not a big fan of Elsevier either but they are still a leading medical publisher and I still use many of their sources.Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:34, 13 September 2013 (UTC)

GA Review[edit]

This review is transcluded from Talk:Low back pain/GA1. The edit link for this section can be used to add comments to the review.

Reviewer: Biosthmors (talk · contribs) 07:21, 5 August 2013 (UTC)

Be back later! Biosthmors (talk) 07:21, 5 August 2013 (UTC)

Yay! Thanks Biosthmors. Zad68 13:04, 5 August 2013 (UTC)
You're welcome. Thanks for your paitence. I didn't expect it would be 12 days before I was back. My apologies. Biosthmors (talk) 08:47, 17 August 2013 (UTC)
These are great notes, I don't have big chunks of time to focus on this during this week but will address them ASAP. Zad68 02:32, 20 August 2013 (UTC)

I'm caught up now on all your bullet points... looking forward to the next round of comments, hope we can finish this up soon. Thanks... Zad68 19:59, 30 August 2013 (UTC)

Starting to look today... Zad68 18:24, 2 September 2013 (UTC)

@Biosthmors: caught up to you! Zad68 04:10, 3 September 2013 (UTC)

@Biosthmors: Agreed Furlan 2012 is better than Casazza for acupuncture, made the change. What else is left? Zad68 17:42, 13 September 2013 (UTC)

Biosthmors and Jmh649, I did a little final reviewing and copyediting and added a bit about multifidus from Menezes 2010 per ImperfectlyInformed's suggestion on the Talk page. I think the mattress mention is OK. I think I'm all caught up on all the outstanding items now, and am pretty happy with it. Anything else? Zad68 04:23, 15 September 2013 (UTC)

Prose[edit]

Lead comments from Biosthmors
  • Is the sentence "The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain." necessary for the lead? It it followed by "For most episodes of low back pain, a specific underlying cause is never identified or even sought", which makes it sound kind of insignificant for it to be the third sentence.
    • I think it is needed, the article explains that most LBP episodes are mechanical in nature and although a specific cause isn't identified, the treatment and prognosis for most LBP episodes definitely revolve around the fact that the pain is mechanical in nature. OK with you? Zad68 03:20, 27 August 2013 (UTC)
  • "and expert groups recommend the use of acetaminophen as the first thing to try", --> "acetaminophen is recommended as the standard first treatment"? Expert groups are an assumed source of info.
    • simplified
  • "With conservative measures". Which measures? Readers might want to know.
    • specified
  • "is sensitive to this cause" --> "can identify this cause"? To make it more accessible?
    • it had gotten changed to "pick this up" which I didn't think was encyclopedic tone, so I changed it to "identify this cause"
  • "In most cases, imaging tools such as MRI are often not useful", can you pick out the unnecessary word I see towards the end?
    • someone already had removed "often"
  • We have the construction of "generally their use is not indicated ... Despite this ... is increasing in popularity." To me, this sounds like it's missing a bit of detail, or perhaps could be better reworded. Is it only increasing in popularity by 3% a year? (If that's the case then so what.) In which countries? To use the word "despite", I'd like to see a bit more context. Maybe I'm being a bit too nit-picky, but it caught my eye.
  • Could we have a more accessible word than "refractory"? Biosthmors (talk) 08:47, 17 August 2013 (UTC)
    • I was going to go with "obdurate" as a replacement but ended up replacing with simpler wording... Face-smile.svg
  • Is it worth an explicit mention, in addition to "Opioids ...are not recommended for general use due to side effects", of addictiveness?
    • Paragraph 3 of medications covers the side effects of opioids, including addictiveness. Because there are so many side effects, and because the sources I used didn't seem to make any bigger deal of addiction as compared to other potential problems, I didn't see a reason to choose any one specific side effect to highlight in the lead over the others. Is that OK?
  • Can we make "chronic radicular discogenic pain" more accessible?
    • Someone did this already
  • "alexander technique" --> "the Alexander technique".
    • done
  • Surgical options are probably not available globally. Reword this?
    • changed to "exist"
Cause
  • In "The majority of LBP is referred to as nonspecific low back pain and does not have a definitive cause" remove the classification details to "The majority of LBP does not have a definitive cause"?
    • This would remove the introduction and definition of the phrase "nonspecific low back pain", which is a very important phrase. If we were to remove it here, where else should we introduce it?
    • Wording simplified
  • We tend to avoid one sentence paragraphs. Move the sentence that starts with "Physical causes may include..." up into the preceeding paragraph?
    • done
Sensation
  • Can "damage or do damage" be shortened to "damage"?
    • Not without changing the content to not represent the source as well as it needs to, in my opinion... Sources that cover pain always include "potential to do damage" in their definition of pain because a stimulus does not have to actually cause damage to cause pain.
      • Currently we have "that have the potential to damage or do damage the body's tissues", which at a minimum is missing a "to". We still can't reword it to only use the word "damage" once?
        • Now it's "stimuli that have the potential to or do damage"
          • Now "an event that either damages or can potentially damage the body's tissues", even simpler
  • "The nerve cells that signal pain are individual structures with fibers that reach from the locations in the lower back where pain is sensed to the spinal cord. The body of each cell is located in the dorsal root ganglia. From a cell body, one fiber extends to the sensory location served by the nerve cell, and another fiber terminates in the spinal cord." The first and third sentences here appear largely repetitive. Condense, perhaps into one sentence?
    • condensed
  • Afferent should be piped to Afferent nerve fiber.
    • fixed
  • In general, it seems like at least some of this content would be happier at pain, and adopted here in more of a summary style.
    • These few paragraphs are a very brief summary of PMID 22958558, which is a 12-page document entitled The Physiology of Low Back Pain. It's an excellent secondary source focused specifically on pain and the lower back. I tried to trim it down to the basic pain transmission systems affected by the OTC drugs, and included detail about how the brain has the capacity to modify its own pain signaling system, which is an important factor in those with chronic pain. Are you sure it needs to be cut down even more?
  • A general question: is referred LBP consistent with this sentence?: "The process of pain sensation starts when the pain-causing event stimulates the endings of appropriate sensory nerve cells."
    • You're asking me to do a little OR, but... I think so. "Referred pain" doesn't have a precise definition, and it's a term mostly used to describe displaced feelings of pain in the arm related to a heart attack, and use less frequently related to low back pain. I actually think you can make a pretty good case for arguing that discogenic radicular pain is a kind of referred pain, but related to LBP, "referred pain" is talking about what feels like LBP but the origin is related to an organ.
Pathophysiology
  • In general, it seems like some of this background content is more appropriate at back. Biosthmors (talk) 10:57, 17 August 2013 (UTC)
    • Basically the same plea as I wrote above about the "happier at pain" content... I tried to include the very basic info needed to get the reader to understand why things like spondyloarthritis and herniated discs (covered in the very next section) are associated with low back pain. Are you sure it needs to be cut down even more?
Classification
  • I'm uncertain what "which are not specifically related to difficulties with the lower back" is trying to say. Is it trying to say "which are not typically associated with low back pain"? That would make more sense.
    • Hmmm... well, people who have fibromyalgia or somatoform disorders can complain of low back pain, it's not unusual for them to do so, so it would not be correct to say those conditions are not typically associated with low back pain. They are conditions that are not specifically targeting the low back but do result in complaints of low back pain. Is that OK?
Red flags
  • "arriving at a diagnosis of low back pain is not straightforward" appears to create tension with the above statement that "Low back pain itself is not a specific diagnosis". Can we say something like: "concluding that a person has low back pain can be a complicated clinical judgement."? Perhaps better solutions exist, or no solution is better. Not sure.
    • Fixed after a closer re-reading of Borczuk, I removed "diagnosis or"... from the earlier section, should work now.
  • "The diagnostic process must" --> "An evaluation should"?
    • Actually both "should" and "must" aren't preferred wording, as they're instructive instead of descriptive, fixed: changed to "A complete diagnostic process will uncover..."
  • "The presence of red flags indicates the need for further diagnostic testing for serious underlying problems that might require immediate or specialized treatment." and "Certain signs, termed 'red flags,' may indicate a more serious condition, and prompt a more extensive investigation using diagnostic imaging or laboratory testing" is repetitive. Copy-edit?
    • copy-edited, reworded to avoid redundancy
  • "successful finding" --> "identification"?
    • simplified by removing unnecessary "successful"
Tests
  • The sentence "Most other physical tests, such as evaluating for scoliosis, muscle weakness or wasting, and impaired reflexes, have poor diagnostic value" seems like it would more logically flow at the end of the paragraph.
    • agree, moved
  • I find the clause "many patients and doctors use them to try to find the cause of the pain" awkward. Patients can't use then the way doctors do, unless they have medical training, and who's to say the doctors aren't also (or primarily) using them to make money?
    • reworded a bit to better reflect point source is making
  • Should we use recommended instead of required in "Such tests are not required"?
    • fixed
  • The sentence "In most cases, the tests are not necessary, and most people will feel better after a month regardless of whether they undergo imaging" largely repeats previous material in the paragraph.
    • agreed redundant, removed
  • "more imaging is associated with higher expense". More imaging costs more money, so if that's what we're saying then "associated with" is too weak. Or, maybe we're talking over the long term.
    • sharper point put on it
  • "higher rates of surgery but no resultant benefit": Is that because the side effects cancel out the benefits? Or because there's no benefit but only side effects, which would be harm? Biosthmors (talk) 21:28, 20 August 2013 (UTC)
    • The source (Chou) says "routine imaging is not associated with clinically meaningful benefits but can lead to harms". Added Flynn to support.


Management
  • There is "Exercising to restore motion and strength to the lower back can be very helpful in relieving pain and preventing future episodes of low back pain" in management but "Exercise is probably effective in preventing the recurrence of non-acute pain" in prevention. These statements appear contradictory. Biosthmors (talk) 20:02, 29 August 2013 (UTC)
    • Someone added that recently, and appears not to have represented the source (Hendrick 2011) quite accurately enough. Hendrick's systematic review covered general increase in physical activity, and not exactly exercise. Hendrick actually mentions in his systematic review "the role of exercise in the management of LBP generally shows positive results" and distinguishes the subject of his review from exercise. I've adjusting the wording to clarify.
  • Is there a logic to why "Increasing levels of general physical activity" appears before the Physical therapy subsection but "Active physical therapies include stretching, strengthening and aerobic exercises" appears after? Might we lump physical activity/therapy together?
    • Sure, bad logic! Face-smile.svg I moved stuff around so things are in appropriate subsections now
Medications
  • Is "As pain medications are only somewhat effective" for chronic pain? If so, say "As pain medications are only somewhat effective for chronic pain"?
    • The source cited, Miller 2012, doesn't limit that statement to only chronic pain, so it should be OK as is?
Surgery
  • This sentence: "Adding the installation of spinal implant devices during spinal fusion increased the risk but provided no added improvement in pain or function." swtiched to past tense. Can we make it present?
    • done
  • Can we add links to instrumented posterior lumbar interbody fusion and instrumented posterolateral fusion? Red links (if that's what they would be) help the encyclopedia.
Alternative medicine
  • The first sentence of Chiropractic defines it as "complementary and alternative medicine". Should we name the title of the subsection that way in case Alternative medicine is a more pejorative characterization of the profession than the preponderance of reliable sources attribute to it?
    • Personally I don't think calling something "Alternative" or "CAM" is pejorative. Regardless, I think we should go with how the reliable sources categorize it. Our source Marlowe 2012 clearly characterizes it as CAM, and the NCCAM includes chiropractic in its database, check out its article there and look at how the refs categorize it. I'd like to leave it where it is unless/until someone brings a source-based reason to move it... if you could point to some sourcing that would clearly indicate it should get moved, perfectly happy with that too.
  • I don't think cognitive behavioral therapy is classified as alternative medicine. Should there be a "Psychological" subsection for the management section?
    • I've got 3 sources that cover these therapies, one is a Cochrane review and it just covers "Behavioral therapy" without trying to classify it, the other two definitely cover it as CAM, so its current classification is supported by sources, I think. So I think it's OK where it is but if you really don't like that classification, let me know and I'll move it.
  • Can we blend "Massage does not appear to provide substantial benefit for acute low back pain" (at the end) with the massage stuff that begins the section? Do "massage" and "massage therapy" have different intended meanings for the reader? They are both go to the same place so only one link is needed. Biosthmors (talk) 18:39, 1 September 2013 (UTC)
    • Yes good one, done
Prognosis
  • "As well, the studies" reads oddly to me. That's an undefined subset so can we generalize?
    • That wording appears to have gotten fixed by someone
  • Is "Determining a general prognosis from the available evidence for low back pain is difficult. Inconsistencies in the evidence are probably due to variations across the source studies in the definitions used for the characteristics of the condition. As well, the studies were not designed to produce the ideal kinds of evidence about the condition." really necessary? Does it help a reader learn anything about the prognosis of low back pain? If so, can we just state the heart of the matter?
    • Someone else already edited this out
  • We have "psychological and economic stresses ... can prolong an episode of low back pain". Is it causative or just an association? Biosthmors (talk) 19:02, 1 September 2013 (UTC)
    • Source is Miller 2012 which says "Physicians should assess patients for depression, unemployment, job dissatisfaction, somatization disorder, and psychological distress, as these conditions tend to delay recovery." so the source states it as causative, article wording implies the same, is that OK?
Epidemiology
  • "very common". Can we get a number on that? "very" isn't an encouraged word to use, typically. Maybe just remove "very"?
    • removed "very"... as for the numbers, this opening sentence just introduces the paragraph, and the hard numbers are indeed provided in the following sentences
  • Is "Within the United States, it is the most common type of pain in adults, and is responsible for a large number of missed work days.[4]" better off in the Society and culture section? I think so.
    • agree, merged into there
  • Is it necessary to say "Some analyses report a slightly higher rate among men[67] while others report a higher rate among women."? Why can't we just say "It is not clear whether men or women have higher rates of low back pain." and leave it at that? I don't think readers particularly care about the facts we may encounter when we research a topic, only the main points.
    • agree, trimmed wording
  • That's interesting about smoking. Is it an accepted risk factor? If so, then why not include it (with any other risk factors) in the Causes section? Biosthmors (talk) 19:09, 1 September 2013 (UTC)
    • yes, it is... I copied the whole risk factors sentence, which mentions smoking, from this NIH website into the article (the content is released as public domain)

Simple English[edit]

Also please do all you can to keep the language as simple as possible. Low back pain is one of our most important and most read articles. The translators will appreciated the easier English as we work to bring this content to other languages. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:34, 28 August 2013 (UTC)

Looks like you did a lot of work to simplify the language for translators, thanks Doc! Zad68 14:47, 12 September 2013 (UTC)

Epidemiology[edit]

The possible range often goes up to 80%. I suggest we change it to between 40 and 80% for lifetime prevalence [1]. The current ref mentions the issue of low income countries having a low rate. Data quality is often not as good in these areas. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:56, 28 August 2013 (UTC)

Clarified in the epidemiology section. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:59, 29 August 2013 (UTC)
thanks Doc! Zad68 03:04, 30 August 2013 (UTC)

Other Reviewers[edit]

Hello, I have had a look at this article and would support its nomination to GA status, this article is structured very well, every sentence has a clear purpose, and overall I find it very easy to read and full of content. If I have one comment it's about the introduction:

  • "Low back pain or lumbago /lʌmˈbeɪɡoʊ/ is a common musculoskeletal disorder affecting 40% of people worldwide at some point in their lives." I think this should say "about 40%", as 40% is rather specific and a minor variation (such as 39% or 41%) was surely within the original sample's margin of error. LT90001 (talk) 05:43, 31 August 2013 (UTC)
    • Thanks LT910001! I have added "about" to that sentence in the lead per your suggestion. Zad68 17:41, 1 September 2013 (UTC)

Verifiability[edit]

  • The first number out the random number generator was 18. Given that this source goes to "Red flags" in the table, but not on any of the specific red flags listed below, I'm not going to dive into the table because it would require me to check all the sources and I don't know what this is supposed to support. I wouldn't call this a violation of the good article criteria, but it doesn't facilitate fact-checking.
If you search for red flags in the document you will notice it supports the entire column of the table. These are standard "red flags". Hundreds of articles / books contain the exact same one. Doc James (talk · contribs · email) (if I write on your page reply on mine) 16:21, 8 September 2013 (UTC)
    • The three sources cited for the "Red flag" column in that table, Casazza 2012, Manusov 2012 and the ACR, all give lists of red flags. Everybody agrees that there are "red flags" and if they are present, imaging might be warranted. However, there is no perfect agreement across sources as to what the complete list of red flags actually is, but there is about 80% overlap/agreement. What I did was: I reviewed three authoritative sources and picked the ones common to all three lists. Only Casazza gave the suspected underlying causes. The sources are cited; I'm open to suggestions as to how to make it more clear how the sourcing is supposed to be applied to the table. Zad68 01:33, 6 September 2013 (UTC)
      • Perhaps, then, we should bundle the three for the red flags as one citation and explain the methodology. We could explain the methodology – "All red flags listed in the table can be found in the following three sources. Red flags not cited by all three sources were not included." – either as a preface to the cite bundle or it could be a footnote. Biosthmors (talk) 16:28, 6 September 2013 (UTC)
        • I've bundled the refs as requested with a note. I tied the content to the sources they came from, which is what WP:V requires and satisfies what the WP:GA process needs to check. However I don't think it should be explained in the article exactly how it was decided which flags were chosen to include. It's the job of Wikipedia editors to evaluate the sources and use Wikipedia's content rules and one's own judgment, there's no rule that one must use a certain number of sources and exactly choose the items that are common across, I don't think it would be correct to codify that process in the article content. Zad68 01:09, 8 September 2013 (UTC)
          • Thanks. And now the section has been edited. Generally speaking, it sounds like you're saying it's not good to clarify to readers how we're presenting content, as I've done with this note. I'm not suggesting we codify anything, I'm just suggesting an explanatory note could be helpful if we've used a specific methodology. Biosthmors (talk) 16:27, 8 September 2013 (UTC)
            • No, that's really not what I'm saying. Yes, include footnotes that explain the content when it's a bit of a tangent off the main line of the prose, but is still worth mentioning. What I don't agree is that we should include in article content (including footnotes) is "meta-comments" that explain how the content got there. The editorial process should be invisible to the article reader. But as noted, it's been edited out now, I agree with Doc providing just the one ref meets our needs and more or less makes this discussion moot. Zad68 17:07, 8 September 2013 (UTC)
              • Cool. Done with this.

  • I can check this for "Between 1990 and 2001 there was a 220% increase in spinal fusions in the United States, despite the fact that during that period there were no changes, clarifications, or improvements in the indications for surgery or new evidence of improved effectiveness". Biosthmors (talk) 19:02, 5 September 2013 (UTC)
    • This is supported, though I'd link and state efficacy. Efficiacy is used in terms of clincal data. Effectiveness is evidence about people in general medical practice. Biosthmors (talk) 19:52, 5 September 2013 (UTC)
      • some helpful gnome just went ahead and did this I guess Face-smile.svg Zad68 02:13, 8 September 2013 (UTC)



  • "Afferent nerve fibers carry nerve impulses from sensory nerve cells in the lower back towards the central nervous system." doesn't seem to need an inline citation, plus the one it had was to a book without a page number so I removed it.
    • Works for me!

  • I would like to verify "Epidural corticosteroid injections provide only slight improvement of sciatica with no long term benefit" from PMID 23362516. Same story about access.

  • I need to verify "Additionally, in degeneration, a disc can cause low back pain by losing height, which results in stress on the surrounding joints and tissues. Extruded disc material can also cause pain by impinging directly on a nerve root." from here.
    • The source says "that can potentially lead to LBP". Are we overstating it? Should we say "potentially cause"? Also, I found "Loss of disc height can contribute further to compression of the exiting nerve root, resulting in pain in the buttock and lower limb", but I'm not sure that matches what is stated. Biosthmors (talk) 19:44, 5 September 2013 (UTC)
      • Added "potentially", not sure why you don't think the content matches source... are you saying the content implies the pain caused by nerve root impingement is low back pain but the source is talking about radicular pain?? Zad68 01:19, 8 September 2013 (UTC)
        • Well, to be honest, I don't have a definition of radicular pain in my head. ;-) I'm trying to verify "Extruded disc material can also cause pain by impinging directly on a nerve root", and I don't see it stated in the source. Maybe it's common sense somehow, but it's not common sense to me. Biosthmors (talk) 18:40, 8 September 2013 (UTC)
          • Simplified / clarified it. Doc James (talk · contribs · email) (if I write on your page reply on mine) 04:54, 11 September 2013 (UTC)
            • Thanks.

  • I can get access to PMID 18843627 to check "but may benefit those with chronic pain, particularly when used as part of an integrated therapeutic program that also includes physical exercises and education".
    • I find "Our findings suggest that massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially if combined with exercise and delivered by a licensed therapist" in the source in the discussion portion. Should we add sub-acute and the licensed bit? In the Implications for practice section: there is :"Massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function. Massage therapy is costly, but it may save money [otherwise] ... [and combine with mentioned therapies for best use]. The beneficial effects of massage in patients with chronic LBP are long lasting (at least one year after end of sessions). It seems that acupuncture massage is better than classic massage, but this needs confirmation..." In general, I feel like the Cochrane source creates tension with the bits we have written later about massage and acupuncture. Cochrane seems to say massage and accupuncture massage can be part of a recommended therapy. Are the other sources just commenting on the clinical value of one thing, like massage alone? Then we can specify massage alone. I also don't know the difference between accupuncture and accupuncture massage. Biosthmors (talk) 16:20, 6 September 2013 (UTC)
      • Added mentions of licensed, added sentence about "acupuncture massage" (I don't know what it is either). There was a mention in the lead that massage cannot be recommended confidently, I removed this mention per Cochrane.
      • I'm not seeing the tension... sources are stating regular massage is not helpful for acute but it is helpful for non-acute. We have one source specifying that Thai and Swedish massage specifically are not helpful for chronic (although I don't know exactly how the massage that Cochrane researched is different from Thai and Swedish massage). Those are all the things the article says about massage. So, regular massage is helpful for non-acute but can't recommend Thai or Swedish massage chronic. That's it. I'm not sure why you're saying this source conflict with acupuncture... the only thing this source said was about "acupuncture massage", not (plain) acupuncture, and the article didn't have the sentence about acupuncture massage in it until I added it just now. Zad68 02:07, 8 September 2013 (UTC)
        • My concern is that "There is insufficient evidence to support a positive recommendation for either Thai or Swedish massage to treat chronic low back pain" might not be factual. If Thai or Swedish massage is done in the way Cochrane suggests for massage to be done (with licensing, education, and exercizes) is it still accurate? Biosthmors (talk) 18:45, 8 September 2013 (UTC)
          • Yes I agree, I see it now. Netchanok 2012 wasn't saying there wasn't enough evidence to say they were effective, but rather that there wasn't enough evidence to say one was more effective. Both this source and Cochrane agree massage is effective for non-acute pain, and as Netchanok 2012 wasn't conclusive the most straightfoward thing to do is remove it, updated. Zad68 20:36, 8 September 2013 (UTC)

  • I would like to verify "Therapeutic procedures such as nerve blocks can themselves be used as tests for diagnostic purposes to identify a specific source of pain." I can check for access in about 12 hours and report back if I don't have access.
    • I don't have access to Manusov, email? Thanks.
      • emailed!
      • This is sourced to Manusov Evaluation and diagnosis of low back pain, see pp. 478-479 where it says, "There is evidence for diagnostic procedures such as facet joint blocks and transforaminal epidural injections. There is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, and moderate evidence for transforaminal epidural injections. Sacroiliac injections can also be helpful for diagnosis. Pain reduction with anesthetic injection can support a specific anatomic source." Zad68 15:11, 12 September 2013 (UTC)
        • Thanks, =)

  • I would like to verify "Annually, low back pain disables a greater fraction of the work force populations in Canada, Great Britain, the Netherlands and Sweden as compared to the United States and Germany." from PMID 19461822. Will check on access. (Added free url link).
    • I thought I'd check Manchikanti for "Lumbar provocative discography may be a useful diagnostic tool to identify intervertebral disc disorders in those with chronically high levels of lumbar pain". I'm trying to verify the "useful ... to identify" portion but not finding it right away. How might it be useful, exactly? I see "The treatment of discogenic pain continues to be a challenging endeavor, with no treatment having been found that provides significant relief to a majority of presumed patients on a consistent basis." I think I'm missing something here. Biosthmors (talk) 18:10, 6 September 2013 (UTC)
      • Conclusions says "Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders." Did I not paraphrase it accurately?
        • I think I'm getting caught up on the word "useful". I'm wondering what is it useful for, exactly? Maybe I just need to look with some fresh eyes later. Biosthmors (talk) 18:23, 6 September 2013 (UTC)
        • Diagnosis isn't done for diagnosis' sake. I'm wondering how the treatment differs, I guess. Biosthmors (talk) 18:25, 6 September 2013 (UTC)
          • "Effective"?? "Productive"?? Basically they're saying that LPD actually does its intended job of identifying the root cause of the pain as discogenic in cases of chronic lumbar discogenic pain. Because one disk is tested at a time, LPD can identify the specific disc.
Hello. Biosthmors has invited me to comment on the references, particularly Manchikanti. The source states "lumbar provocation discography... may be a useful tool for evaluating chronic lumbar discogenic pain." Thus the statement here in Wikipedia's article is verified in the source. To answer Biosthmors' question, the reasoning is: "When performed appropriately, [provocation] discography can enhance sensitivity and specificity compared to non-provocative imaging. This in turn can improve clinical outcomes and prognostication through better selection of candidates and therapies. Equally important, it can reduce the likelihood that discs which are not contributing to pain are inappropriately treated." The implication is that MRI may find minor anomalies in a disc. However that is not sufficient evidence that those anomalies are the cause of the back pain, and that surgery will resolve the pain. Such anomalies are commonplace and often do not cause pain. Provocation discography will "prove" that the anomalous disc is the cause of the pain, implying that surgery is likely to be helpful. Axl ¤ [Talk] 09:03, 7 September 2013 (UTC)
Thanks Axl. Zad68 01:45, 8 September 2013 (UTC)
Yes, thanks Axl. Can we, instead of saying "useful diagnostic tool to identify intervertebral disc disorders" say something like "useful diagnostic tool to identify pain from specific discs"? Biosthmors (talk) 17:28, 8 September 2013 (UTC)
You're welcome. Biosthmors, your suggestion would be fine. Axl ¤ [Talk] 19:44, 8 September 2013 (UTC)
Done

  • I would like to verify "There is very little evidence that lumbar support lifting belts (corsets) are any more helpful in preventing low back pain than education about proper techniques for lifting." PMID 18425875 (cochrane) and PMID 22958560 support it.
    • Cochrane states "There was moderate evidence that lumbar supports are not more effective than no intervention or training in preventing low-back pain" which to me supports a different thing. The current wording implies there's a bit of evidence corsets are helpful. Cochrane seems to state there's evidence to support that they're not helpful. Biosthmors (talk) 18:39, 6 September 2013 (UTC)
      • That Cochrane review is from 2008. Not sure why you're not also looking at Guild 2012, the other source cited there? Guild 2012 says

        In a review of randomized controlled trials a total of 13,995 patients with lumbar supports, also known as corsets, were assessed for the effect on prevention of low back pain and treatment. Little to no evidence was found that lumbar support prevented back injury more than education on proper lifting technique. The review included 954 patients in a comparison of lumbar supports with no treatment for prevention of low back pain, with similar results. There was little to no evidence to support their use for prevention of low back injury.

        and this is cited to a 2011 Cochrane review, which I don't have, I'm using Guild's report on it. As we have a newer review which is pointing to a newer Cochrane review, I will age out the 2008 Cochrane review, which should resolve this. Zad68 01:40, 8 September 2013 (UTC)
        • Thanks

  • I can check on PMID 22958563 "For those with acute pain, acupuncture may provide short-term relief similar to over-the-counter pain medications, but the evidence for it is too weak to recommend it". also PMID 22335313 is cited to this.
    • To help this along: We're using Casazza 2012 writing in Am Fam Phys, and Marlowe 2012 in The Clinics (in Prim. Care). Casazza comes across as a skeptic regarding CAM. Cassaza says in his abstract "No substantial benefit has been shown with ... acupuncture" but in the discussion does say "Several low-quality trials show that acupuncture has minimal or no benefit over sham treatment, naproxen (Naprosyn), or the Chinese herbal therapy moxibustion. Although evidence to support its effectiveness is limited, acupuncture may be cost-effective in patients with pain lasting longer than four weeks." I am not sure how something that doesn't work at all can be cost-effective so I think he's saying it's a touch better than nothing, also he sources this to Lin 2011 (the review of guideline-endorsed treatments worldwide we use here), which also states acupuncture is a cost-effective thing to try. Meanwhile, Marlowe is accepting of CAM and acupuncture in particular, see his enthusiastic discussion of energy meridians and Qi, which aren't concepts exactly well-accepted by empiricists. In Marlowe states it does more than nothing but it's no more effective than basic meds. Casazza and Marlowe aren't in complete conflict but they don't dovetail nicely. So in the article I state that acupuncture may be helpful but the evidence is weak. Zad68 02:37, 8 September 2013 (UTC)
      • I don't think it's neutral to say "the evidence for it is too weak to recommend it use" and cite Casazza, who says, as you note, "Although the evidence to support its effectiveness is limited, acupuncture may be cost-effective in patients with pain lasting more than 4 weeks". I'd like to see Marlowe, thanks. Is that where the "short term relief" bit is verified? Biosthmors (talk) 21:27, 12 September 2013 (UTC)
      • How do you like my changes? Thanks for emailing Marlowe. Biosthmors (talk) 22:06, 12 September 2013 (UTC)
        • Well I didn't really like how the statement about acupuncture for acute pain was weakened in this change from "For those with acute pain, acupuncture may provide short-term relief similar to over-the-counter pain medications, but the evidence for it is too weak to recommend it use." to "...the evidence for it is limited." sourced to Casazza. Casazza says in his abstract "No substantial benefit has been shown with ... acupuncture" and in the body of the article clearly categorizes acupuncture as an "UNSUPPORTED" treatment for LBP. This is echoed by other sources, for example Borczuk says (referring to a Cochrane review) "The acute pain trials had small numbers of patients and were inconclusive.", Cohen 2008 says "The benefits of acupuncture for acute low back pain are unclear.". I think the current wording overstates the consensus view regarding its value. Would you agree to put back "too weak to recommend it use"? Zad68 01:57, 13 September 2013 (UTC)
          • Edit made and recommendation at Talk:Low_back_pain#Marlowe_vs._Casazza._Or.... Biosthmors (talk) 13:53, 13 September 2013 (UTC)
            • I tweaked the edit just a bit for flow, I don't believe I changed the meaning. Ok now? If you're good I'm good. Will look at Talk page. Zad68 14:06, 13 September 2013 (UTC)
            • After looking at Furlan 2012, agree it's better than Casazza on acupuncture, article updated to remove Casazza's negative punch, take a look. Zad68 17:44, 13 September 2013 (UTC)
                  • thanks

Neutral/broad in coverage/images[edit]

  • Is not not worth mentioning proper lifting technique in the prevention section, possibly with a picture if available? Biosthmors (talk) 19:06, 5 September 2013 (UTC)
  • Maybe someone else moved it but the mention of proper lifting techniques is in the Prevention section now. Will add image if I can find one.... image now added
  • If I had to say, I'd say this topic could be better illustrated. The four pictures are tagged with their copyright status, but there are only four. Biosthmors (talk) 19:09, 5 September 2013 (UTC)
    • More images now
  • The main picture caption: "The five vertebrae in the lumbar region of the back are the largest and strongest in the spinal column", sounds more like trivia than something relevant to LBP. Biosthmors (talk) 19:11, 5 September 2013 (UTC)
    • Improved now, more relevant to article content
  • "The lumbar region in regards to the rest of the spine" is a caption but couldn't we say something like "the lumbar region of the spine is towards the lower portion of the back"? Biosthmors (talk) 19:12, 5 September 2013 (UTC)
    • improved
  • You might like trying {{double image}} for the two that are side-by-side. Biosthmors (talk) 19:14, 5 September 2013 (UTC)
    • I didn't know about the {{double image}} template, thanks for the tip! I used it because it handles the longer captions better.
  • "The nerve and bone components of the vertebrae" isn't engaging prose. Maybe we could help the reader interpret the image a bit? Biosthmors (talk) 19:16, 5 September 2013 (UTC)
    • improved
  • The partial title is Overtreating chronic back pain for one paper cited. Shoudl we link overtreatment somewhere in the article? Biosthmors (talk) 19:56, 5 September 2013 (UTC)
    Yes! I love talking about overtreatment and treatment for low back pain is one of the most common types of unnecessary health care. This article already has an excellent section about not immediately seeking imaging on low back pain, but rather treating the pain for 6 weeks while waiting for pain to subside. Something interesting about this section is that there are several sources already talking about the overtreatment problem, and I myself just added four more. I think I would like to review all the sources, see what they have in common, and WP:BUNDLE them and rearrange the sentences for clarity and better association between assertions and sources. Cool stuff! Blue Rasberry (talk) 21:11, 5 September 2013 (UTC)
Wikilink to Unnecessary health care now in Tests
I am of the opinion that images must be directly related to the topic at hand. Have removed the one of morphine as it is just a random vial and this is not the treatment of choice. Also chiro does not have great evidence for it thus IMO an image of someone pushing on a back is not needed either. Okay with the other three imagesDoc James (talk · contribs · email) (if I write on your page reply on mine) 14:34, 6 September 2013 (UTC)
The caption from the infobox picture is "Low back pain is a common, widespread and costly complaint." What is the difference between "common" and "widespread"? Axl ¤ [Talk] 19:48, 8 September 2013 (UTC)
"Widespread" removed Zad68 20:10, 8 September 2013 (UTC)
Thanks. Axl ¤ [Talk] 20:48, 8 September 2013 (UTC)
In "Pathophysiology", subsection "Back structures", a caption reads "The lowest five bones of the spinal column are the lumbar vertebrae, and define the lower back region." That's just not true. Axl ¤ [Talk] 19:52, 8 September 2013 (UTC)
Does the change from "lowest five bones" to "lowest five articulating vertebrae" fix it? Zad68 20:05, 8 September 2013 (UTC)
Hmm, I'm not sure. It is possible to quibble over the definition of "articulation". Axl ¤ [Talk] 20:50, 8 September 2013 (UTC)
Removed the phrase altogether, now it is "The five lumbar vertebrae define the lower back region" Zad68 13:10, 9 September 2013 (UTC)
Thanks, that's fine. Axl ¤ [Talk] 15:50, 9 September 2013 (UTC)
thanks

Passing[edit]

After all the recent edits/copyedits, I think we now have ourselves a good article. My thanks to all involved! Biosthmors (talk) 09:05, 15 September 2013 (UTC)

ImperfectlyInformed after reviewing the sourcing again, I agree we can have the mattress mention you added. I also did a bit more reading on the multifidus and it does seem important. Salzberg gave it a whole paragraph and also devoted half a page to a diagram of them. That, plus the review you found, justifies a bit of specialized content on them. I added a new paragraph to Pathophysiology on it using Salzberg and Menezes that you found, please take a look and comment, if you would. Zad68 04:16, 15 September 2013 (UTC)

Comments from Anthony[edit]

Pain sensation[edit]

  • "Pain is generally an unpleasant feeling in response to a force that either damages or can damage the body's tissues."
  • "Force" ignores chemical, thermal, ischemic and neural pathology (e.g., neuroma) as classes of cause.
In physics forces are not just mechanical. Check out the Wikipedia article "any influence that causes an object to undergo a certain change". What wording do you propose? Stimulus is too complicated. We need a simplification. Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:54, 11 September 2013 (UTC)
"Force" is most likely to be read as "pressure" and I can't imagine anyone reading it as including heat or chemical action. So "force" is too ambiguous. --Anthonyhcole (talk · contribs · email) 18:17, 11 September 2013 (UTC)
The term is still correct and is better than using a term few people know. Most pain is caused by mechanical forces anyway. Yes some is cased by electromagnetic forces among others. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:36, 11 September 2013 (UTC)
  • Pain is often elicited by stimuli that approach but don't reach damaging intensity, so I'm not sure "damages or can damage" is precise enough.
Sure what wording do you suggest? "can potentially damage"? Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:54, 11 September 2013 (UTC)
  • Possibly, "Pain is an unpleasant feeling usually caused by intense stimulation of the receptors of dedicated pain-signalling sensory nerve fibers (nociceptors), called nociceptive pain, or by pathology affecting sensory nerves themselves (neuropathic pain)"?
To complicated we need to make sure our text is generally accessible. Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:54, 11 September 2013 (UTC)
I'm assuming the following neurophysiology section or something like it will remain. If so, it's worth pointing out that the pain process usually begins with either the stimulation of the peripheral end of a nociceptor or with damage or disease affecting a nerve. If the neurophysiology explanation is excised, that won't be necessary and we can stick with the more everyday definition of pain above (though without "force" IMO ... maybe replace "force" with "event or process"?). --Anthonyhcole (talk · contribs · email) 18:19, 11 September 2013 (UTC)
I am happy with event :-) Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:41, 11 September 2013 (UTC)
  • "There are four main steps in the process of feeling pain: transduction, transmission, perception, and modulation. <p> Each nerve cell that signals pain has its body located in the dorsal root ganglia and fibers that reach from the locations in the lower back where pain is sensed to the spinal cord. The process of pain sensation starts when the pain-causing event stimulates the endings of appropriate sensory nerve cells. This type of cell converts a stimulus into an electrical signal by transduction. Several different types of nerve fibers carry out the transmission of the electrical signal from the transducing cell to the posterior horn of spinal cord, from there to the brain stem, and then from the brain stem to the various parts of the brain such as the thalamus and the limbic system. In the brain, the pain signals are processed and given context in the process of pain perception. Through modulation, the brain can modify the sending of further nerve impulses by signaling the release of neurotransmitters that inhibit the signals (for example, serotonin and endorphins) or stimulate them. <p>Ingoing nerve fiberss carry nerve impulses from sensory nerve cells in the lower back towards the central nervous system. Signals travel to the dorsal root ganglia (the connections between the peripheral nerves and the central spinal nerves) along three types of afferent nerve fibers: A beta fibers, A delta fibers, and C fibers. The fibers of the A group are coated to differing degrees with myelin, an electrical insulator that prevents signal loss and increases transmission speed. The A beta fibers transmit light touch but not pain messages, and as they are heavily myelinated, they transfer their signals quickly. The A delta and C fibers handle pain messages, and as they are less myelinated, they transfer their signals more slowly. These nerve cells release certain chemicals (peptides) in response to painful stimuli. Common analgesics generally treat back pain by interfering with these neurochemical processes involved in the initiation and transmission of pain signals."
  • I've scanned the subsequent text - and may have missed it - but haven't seen anything that needs to be supported by this degree of detail. Perhaps the above could change to "The pain signal travels from the receptor, along the fiber, through the nociceptor's cell body in the dorsal root ganglion to the posterior horn of the spinal cord, where it stimulates activity in spinal cord fibers that carry the signal to the brain. There, the signal travels to various brain regions where intensity, location, quality, unpleasantness and other features are registered, and from which "modulating" signals are sent back down the spinal cord to either dampen or amplify output from the posterior horn."
  • "Parts of the pain sensation and processing system may not function properly; creating the feeling of pain when no outside cause exists, signaling too much pain from a particular cause, or signaling pain from a normally non-painful event. Additionally, the pain modulation mechanisms may not function properly and not decrease the amount of pain felt. These phenomena are involved in chronic pain."
  • Possibly delete "...and not decrease the amount of pain felt." as redundant? --Anthonyhcole (talk · contribs · email) 06:06, 11 September 2013 (UTC)
Done Doc James (talk · contribs · email) (if I write on your page reply on mine) 16:08, 11 September 2013 (UTC)

Agree that this bit was overly complicated and thus moved here. It may do well on a subpage or the pain article. "Ingoing nerve fibers carry nerve impulses from sensory nerve cells in the lower back towards thecentral nervous system. Signals travel to the dorsal root ganglia (the connections between the peripheral nerves and the central spinal nerves) along three types of afferent nerve fibers: A beta fibers, A delta fibers, andC fibers.[1] The fibers of the A group are coated to differing degrees with myelin,[1] an electrical insulator that prevents signal loss and increases transmission speed.[2] The A beta fibers transmit light touch but not pain messages, and as they are heavily myelinated, they transfer their signals quickly. The A delta and C fibers handle pain messages, and as they are less myelinated, they transfer their signals more slowly.[1] These nerve cells release certain chemicals (peptides) in response to painful event.[1] Common analgesics generally treat back pain by interfering with these neurochemical processes involved in the initiation and transmission of pain signals.[3]"Doc James (talk · contribs · email) (if I write on your page reply on mine) 23:32, 13 September 2013 (UTC)

Diagnosis - Classification[edit]

  • "Rarely, complaints of low back pain result from systemic or psychological problems, such as fibromyalgia and somatoform disorders."
  • The etiology of fibromyalgia is contested and highly controversial. Personally, I'd avoid making a categorical claim that it is "systemic or psychological". Though contestants often make confident claims, we should probably avoid it for now.
Systemic or psychological takes in the two main camps of the cause of fibromyalgia. No one says it is a localized problem. Some say it is a systemic rheumatologic condition. Others say it is psychological. So we are not taking sides so not sure what the issue is? Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:59, 11 September 2013 (UTC)
Fair enough. --Anthonyhcole (talk · contribs · email) 18:17, 11 September 2013 (UTC)

Prognosis[edit]

I just noticed this: "...following an episode of low back pain it is likely that a patient will have further episodes..." in this 2010 review: How do we define the condition ‘recurrent low back pain’? A systematic review. Worth mentioning?

Great find. Have added it to the prognosis section. Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:22, 13 September 2013 (UTC)

Sub-chronic/sub-acute[edit]

I'm confused by the use of these terms in the literature, and by their use here. If they're generally interchangeable, can we stick to using just one of them? --Anthonyhcole (talk · contribs · email) 06:38, 11 September 2013 (UTC)

Yes we should. Have switched over to sub-chronic Doc James (talk · contribs · email) (if I write on your page reply on mine) 16:00, 11 September 2013 (UTC)

"It affects about 40% of people at some point in their lives." - is this a worldwide figure?[edit]

Are there cultural variations, say? Or does all this info pertain worldwide, like Africa, India, Malaysia, etc? Soranoch (talk) 21:42, 12 October 2013 (UTC)

Yes. This is answered in the "Epidemiology" section: "Globally, about 40% of people have LBP at some point in their lives", with citation. According to the WHO, lower back pain is present in similar proportions in different cultures (link). The article does not seem especially US-oriented; why the tag? Ewulp (talk) 23:16, 12 October 2013 (UTC)
Well, you can remove the tag if you want.
My reasons for the tag: I think one reference for such a global statement (a total of 165 studies from 54 countries were identified between 1980 and 2009) is not a convincing methodology - 54 countries covering a span of 20 years - is a small number considering there's something like 350 countries. There is an abnormal reliance, in my view on a particular American source, with the others being "Western world" i.e. American, Canadian, European. Also, the treatments focus on those available to a small part of the world's population and are very middle-class Western e.g. mindfulness-based stress reduction, behavioral therapy, surgery, antidepressants, etc., not available to most in the world. I couldn't find the WHO reference, but I don't think the WHO is the best of sources in any case. Just my opinion, so it doesn't really matter.
I read the article because I have low back pain. Interestingly, though acupuncture is dismissed as a possible treatment, my low-budget insurance plan will pay for it as well as chiropractic care. And they won't pay for anything that there is no evidence of effectiveness. The article treats chiropractic care as if there's only one school, when there are many differing methods. etc. etc. Oh, well. Excuse the ramble. I do think the "Prevention" section is skimpy and that although back pain has been with us since "at least the Bronze age", it doesn't mean the prevalence and causes are the same now as they were then. e.g. obesity is linked to back pain now, which probably wasn't the case then. Thanks for answering! Soranoch (talk) 00:11, 13 October 2013 (UTC)
I'm sorry to hear that you have low back pain, and am glad to hear you found something that works for you. The article uses global prevalence data, international journals, and a European review of guidelines worldwide. We can only use the sources that are available. I don't think the global tag is needed either, and as you say you're OK with its removal, I'll do that. If you find more WP:MEDRS-quality sources that provide more global information, please bring them so we can consider using them. Zad68 00:41, 13 October 2013 (UTC)

Manual therapy and acupuncture for LBP[edit]

This article could be improved by adequately represent the effectiveness of manual therapies and acupuncture. The evidence is of clear benefit for SM and c-LBP and mixed for acute. There also needs to be a discussion why osteopathic physicians, chiropractors and physical therapists manipulate the spine. That is is to help reduce pain, improve mobility to mechanical dysfunctions of the spinal segments. These mechanical dysfunctions are in the WHO and are most reliable with painful palpation of a spinal segments as this review suggest [2]. The JAMA has also recommended chiropractic care for LBP [3]. So, it seems like we may be minimizing the appropriateness of chiropractic management of low back pain. Massage has also been shown to be of short term benefit in this new review [4]. There is also good evidence of acupuncture for low back pain, maybe even moreso than medication, "The current evidence is encouraging in that acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP" [5] in this new review. The lede is rather ambiguous with spinal manipulation when the research is much more succinct, there is no mention of acupuncture whatsoever despite the evidence which suggests comparable effectiveness. Hoping we can have a good discussion and help make this article better by offering a complementary POV. Regards, DVMt (talk) 03:49, 16 May 2014 (UTC)

Re PMID 15454722, this 2004 review is very out-of-date; re the article in JAMA by Goodman et al., "JAMA" is not the one doing any recommending, and the authors of the article are not in any way recommending chiro; re PMID 24043951 I think you're overstating the findings (although the review is useful), same with PMID 23269281 which absolutely does not state that the evidence for acupuncture "good" as you're characterizing it. The sources you have offered and your interpretations of them send up red warning flags, I think we will need to review suggested edits to the article very carefully for source quality and accurate representation of the findings. Recommend we use RFCs and drop notifications at WT:MED for any significant suggested changes. Zad68 15:11, 16 May 2014 (UTC)
That's a rather interesting characterization. It would be red flags if I entered this into the article instead of discussing it. The representation of the findings are accurate, and this domain is my wheelhouse. "The current evidence is encouraging in that acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP. " http://www.ncbi.nlm.nih.gov/pubmed/23269281. When the AMA makes a recommendation for something 'non medicinal' like manipulation or acu, and there's a RS, well, it's worth consideration for inclusion in the article. Is the systematic review 'poor' evidence? I was using the term colloquially, but nonetheless, my point remains. DVMt (talk) 15:37, 16 May 2014 (UTC)
Agree with Zad68; I am concerned about the insistence that PMID 23269281 is being characterized as "good" evidence for acupuncture. The article states several limitations about the evidence, which should suggest that the evidence is not "good" - and suggests further suggestions by this editor needs to be careful scrutinized. Characterizing a one line mention in a short JAMA patient handout as a "recommendation" by the entire American Medical Association is beyond bizarre. Yobol (talk) 18:43, 16 May 2014 (UTC)
Did you not read my comment above? I said the paper itself was good. If JAMA recommends a trial of care for LBP, isn't that worthy of a mention considering the AMA once called chiropractic an unscientific cult? How about we discuss the paper itself which is why I posted here on talk instead of casting aspersions. DVMt (talk) 19:00, 16 May 2014 (UTC)
No, you said there is "good evidence" for low back pain, citing PMID 23269281. That would seem to be an incorrect reading of PMID 23269281. If you want to talk about a source, suggest a specific wording change citing the specific source. Short patient handouts are generally inferior to other sources such as systematic reviews so I see no reason why we should include that. Any insinuation that this is an endorsement or recommendation by the AMA is pure hogwash. Yobol (talk) 19:12, 16 May 2014 (UTC)
Look at the conclusions of the source, Yobol, and quote it back to me to prove that you've read it. If I made a claim that said "JAMA has recommended chiropractic care for LBP" you would ask me for a source. Then I provided you one. Is it a reliable source? Prove to me, using a reliable source, that JAMA did not endorse chiropractic therapy for LBP"many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed." Are you suggesting that the AMA's own medical journal is not a mainstream, reliable source? DVMt (talk) 19:21, 16 May 2014 (UTC)
I am suggesting that everything published in JAMA is not necessarily endorsed by the AMA, as you implied. I am also suggesting patient handouts are of lower quality than review articles, specifically systematic reviews, which there are plenty of in the medical literature. I have found that the main reasons editors try to use a lower quality source is to push a specific POV. Either present a specific statement by the AMA endorsing chiropractic, or let's drop the subject because it is going nowhere fast. Using a JAMA patient handout to backdoor a mention of the AMA will not work. Yobol (talk) 19:30, 16 May 2014 (UTC)
So, things that gets published in the journal of the AMA isn't endorsed by the AMA. That's speculative. Do you have a source for this? I never once said that the AMA endorsed chiropractic, I simply stated that the JAMA recommends chiropractic therapy (along with acu) for LBP. You seem to getting rather defensive. LBP, is after, all, a specialization of chiropractic as demonstrated by the World Spine Care [6] initiate. Looks like MDs and collaborating with DCs there too. Interesting. DVMt (talk) 19:37, 16 May 2014 (UTC)
The article cited does not "recommend" chiro in the first place. What it actually says is, "Some people benefit from chiropractic therapy or acupuncture." This is an observation about what some people with LBP have done, it is not a recommendation that people with LBP go get chiro, and certainly not ahead of exercise, physical therapy or medication. To see what an actual recommendation looks like, see for example this article on dietary salt, which has a definitive recommendation "Eat salt in moderation." The chiro reference in the LBP article is not most accurately characterized as a "recommendation." Zad68 20:01, 16 May 2014 (UTC)
(e/c)Of course, it's not "speculative", that's a fact. Besides being well known that publishers (AMA) do not necessarily endorse every statement written that they publish (JAMA), there is this statement, written in every single journal of JAMA, which reads, "All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do not reflect the policy of the American Medical Association, the Editorial Board, or the institution with which the author is affiliated, unless this is clearly specified." You did state the AMA endorsed chiropractic, when you said "When the AMA makes a recommendation for something 'non medicinal' like manipulation or acu, and there's a RS, well, it's worth consideration for inclusion in the article" in this edit. As it appears you do not even know what you yourself are writing, I'm taking leave of this discussion as a waste of my time. Cheers. Yobol (talk) 20:05, 16 May 2014 (UTC)
You're conflating things, Zad. Also, most chiro's are multi-modal so your insinuation that exercise or pt (whatever that means nowadays since they're jumping on the manipulation and acupuncture bandwagon) aren't part of chiropractic management is incorrect. Also, the quote is "ome people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed"'. The JAMA article is clear on this point, it suggests some people benefit. If you're getting hung up on a word, by all means, 'suggests' is the actual quote, but Yobol's assertion that the the JAMA isn't necessarily endorsed by the AMA is grasping at straws. How do you suggest we deal with this? It is factual, JAMA is a reliable source. DVMt (talk) 20:14, 16 May 2014 (UTC)

I have asked for wider input from the editors at WT:MED here. Zad68 20:31, 16 May 2014 (UTC)

Sounds good. DVMt (talk) 20:35, 16 May 2014 (UTC)
JAMA publishes all kinds of things. Practically none of what they publish is an official position of the AMA. A good analogy would be the conversations or casual publications of the pope and the pope's infallible ex cathedra statements - one is much more weighty than the other. Journal publications are like conversations unless they are position papers. Blue Rasberry (talk) 20:38, 16 May 2014 (UTC)
Speaking as an interested reader, not a medical practitioner, I think that:
1) - this discussion has become highly focused on the extent to which an article in the JAMA represents an AMA "position", so much so that
2) - the initial concern raised by editor DVMt is getting lost.
For example, here are two sentences from the beginning of the Alternative medicine section of the article: "It is not clear if chiropractic care or spinal manipulation therapy (SMT) improves outcomes in those with low back pain more or less than other treatments. Some reviews find that SMT results in equal or better improvements in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up; other reviews find it to be no more effective in reducing pain than either inert interventions, sham manipulation, or other treatments, and conclude that adding SMT to other treatments does improve outcomes."
What the second sentence seems to say to me is "Some reviews find that SMT results in equal or better improvements in pain and function ...; other reviews ... conclude that adding SMT to other treatments does improve outcomes." In other words, "some reviews" are neutral or positive and "other reviews" are positive. I don't know if this is what it was meant to say. I fear the meaning is buried in too many words. Wanderer57 (talk) 22:26, 16 May 2014 (UTC)
Thanks Wanderer57. We could be more concise with respect to acute LBP, chronic LBP and maintenance SMT for LBP. We have editors here who 'don't believe' in manipulative therapy instead of understanding manipulative therapy. Also the article doesn't really address that 'alt med' such as manipulation is combined with exercise (mainstream) which seems to yield better outcomes. DVMt (talk) 22:58, 16 May 2014 (UTC)

Leading cause of disability?[edit]

Low back is currently the leading cause of disability globally. -- Buchbinder R, Blyth FM, March LM, Brooks P, Woolf AD, Hoy DG. (Oct 2013). "Placing the global burden of low back pain in context.". Best Pract Res Clin Rheumatol. 27 (5): 575–589. doi:10.1016/j.berh.2013.10.007. 

A new edit citing Buchbinder says that according to the 2012 Global Burden of Disease study that LBP is now the #1 cause of disability. However, the WHO's site here: http://www.who.int/features/factfiles/global_burden/facts/en/index7.html which is tagged as updated 2013 says that "Hearing loss, vision problems and mental disorders are the most common causes of disability". I am not sure how to reconcile the two. Zad68 15:28, 16 May 2014 (UTC)

That would be because Buchbinder is probably using a different metric than the WHO (reading the Buchbinder article, they are using "years living with disability" as the metric for cause of disability, which would probably not be the one WHO is using. Since they are purportedly using WHO data, and the WHO disputes their interpretation, I would remove mention of it from this article. Yobol (talk) 19:32, 16 May 2014 (UTC)
We don't 'remove' mention of systematic review, we present both sides. DVMt (talk) 19:39, 16 May 2014 (UTC)
Agree w/Yobol, based on this I am removing the recent addition from the article and bringing it here for discussion, to see if there's consensus for including it, and if so, how. There's no rush on this. Zad68 20:04, 16 May 2014 (UTC)
Why wouldn't you include it? And feel free to discuss, but it's rather odd that you selectively take out a reliable source rather than including the WHO source until we find something better. DVMt (talk) 20:18, 16 May 2014 (UTC)

It is definitely a top cause of disability globally. Let me look at the GBD report. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:57, 17 May 2014 (UTC)

  • Okay we have [7] which gives "116 704" for the DALYs for LBP. Ischemic heart disease comes in at "129 820" so I agree strange. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:04, 17 May 2014 (UTC)
That review however is from 2012 and the Buchbinder is from 2013. This site suggests it did compare it again heart disease and other conditions [8] We might have to dig deeper. DVMt (talk) 16:01, 17 May 2014 (UTC)
Yes am also trying to figure out the definition they are using. Was 6th for overall disease burden based on DALYs in 2010
Ah they are using years lived with disability (YLDs). It was also highest in 1990. Because it doesn't kill you and it develops fairly early thus many people have LBP much of their life. Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:11, 18 May 2014 (UTC)
Agreed. It is a recurrent issue and a big drain on health system. Speaking of having LBP for much of their life, this recent review discusses the topic [9] and might be useful to the article. DVMt (talk) 15:54, 18 May 2014 (UTC)
User:Zad68, User:Jmh649, have you found any more research that states whether or not LBP is the leading cause of global disability? Regards, DVMt (talk) 16:33, 4 June 2014 (UTC)

McKenzei method[edit]

This was added to the lead "There is growing recognition of the role of physiotherapy McKenzie method in treating lower back pain and evidence appears to support the directional preference exercises in lower back pain, particulalry with the first attack.[4]" Already discussed in the body of the article. Removed as IMO undue weight for the lead. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:01, 1 October 2014 (UTC)

  1. ^ Cite error: The named reference salzberg_2012 was invoked but never defined (see the help page).
  2. ^ Hartline DK (May 2008). "What is myelin?". Neuron Glia Biol. 4 (2): 153–63. doi:10.1017/S1740925X09990263. PMID 19737435. 
  3. ^ Cite error: The named reference miller_2012 was invoked but never defined (see the help page).
  4. ^ Dunsford A, Kumar S, Clarke S (November 2011). "Integrating evidence into practice: use of McKenzie-based treatment for mechanical back pain". Multidisciplinary Healthcare 4: 393–402. doi:10.2147/JMDH.S24733.