title: Prognostic factors for time receiving workers' compensation benefits in a cohort of patients with low back pain. Evaluation of the Quality of Prognosis Studies in Systematic Reviews Can It Be Predicted Which Patients With Chronic Low Back Pain Should Be Offered Tertiary Rehabilitation in a Functional Restoration Program?: A Search for Demographic, Socioeconomic, and Physical Predictors Relationship between spinal stiffness and outcome in patients with chronic low back pain. The Centralization Phenomenon: Its Usefulness as a Predictor of Outcome in Conservative Treatment of Chronic Low Back Pain (A Pilot Study) Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Predicting the outcome of sciatica at short-term follow-up. Prediction of Success From a Multidisciplinary Treatment Program for Chronic Low Back Pain Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Psychosocial Predictors of Outcome in Acute and Subchronic Low Back Trouble Centralization: Its Prognostic Value in Patients With Referred Symptoms and Sciatica The Prognosis of Low Back Pain in General Practice Factors predicting radical treatment after in-hospital conservative management of disk-related sciatica. The correlation of selected physical examination findings and the efficacy of physiotherapy for chronic lumbosacral pain. Predictive tests for non-return to work in patients with chronic low back pain Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain: An Update of the Cochrane Review The nordic back pain subpopulation program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low back pain. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation Is There a Subgroup of Patients With Low Back Pain Likely to Benefit From Mechanical Traction?: Results of a Randomized Clinical Trial and Subgrouping Analysis Clinical effectiveness of behavioral signs for screening chronic low-back pain patients in a work-oriented physical rehabilitation program. Pain response classification does not predict long-term outcome in patients with low back pain who are sick-listed. Factors Predicting Pain Reduction in Chronic Back and Neck Pain After Multimodal Treatment Five‐Year Follow‐Up Study of a Controlled Clinical Trial Using Light Mobilization and an Informative Approach to Low Back Pain Predictors of a favorable response to transforaminal injection of steroids in patients with lumbar radicular pain due to disc herniation. Long-term prognosis of acute low back pain in patients seen in general practice: a 1-year prospective follow-up study. Course of back pain in primary care: a prospective study of physical measures. Prediction of the Clinical Course of Low-Back Trouble Using Multivariable Models
abstract: STUDY DESIGN Prospect i ve inception cohort study . OBJECTIVE To develop a prognostic model that predicts time receiving  workers ' compensation benefits for low back pain cl aim ants . SUMMARY OF BACKGROUND DATA As the cost and difficulty of managing low back pain escalate , any predictor of outcome is advantageous . METHODS To obtain the outcome and predictor variables , patient data from two separate data bases were linked : a clinical data base and an administrative ( Ontario workers ' compensation ) data base . Cl aim ants injured between January 1 and December 31 , 1994 , were included and observed for 1 year from the date of accident . The outcome variable was cumulative number of calendar days receiving benefits . RESULTS Multivariable Cox proportional hazards regression ( forward stepwise ) showed eight significant predictors ; five were associated with increased time receiving benefits compared with their reference groups : 1 ) working in the construction industry , 2 ) older age , 3 ) lag time from injury to treatment , 4 )  pain referred into the leg  , and 5 ) three or more positive Waddell nonorganic signs . Three predictors were associated with reduced time receiving benefits : 1 ) higher values of question naire score , 2 ) intermittent pain , and 3 ) a previous episode of back pain . A predictive score was calculated to categorize cl aim ants as at high or low risk for chronicity . When an arbitrary cutoff point was set at the 75th percentile of predictive score , negative predictive value was 94 % . CONCLUSION This research identified eight factors for time receiving workers ' compensation benefits among cl aim ants with low back pain . This model discriminates between high- and low-risk cl aim ants . Few low-risk cl aim ants continued to receive benefits for more than 3 months Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items Study Design . A prospect i ve clinical trial was conducted that involved six groups of patients with chronic low back pain selected from a large cohort ( N = 816 ) . Objectives . To correlate pretreatment baseline variables with outcome parameters after treatment in a functional restoration program or in control programs , to identify possible factors predictive of the need for functional restoration . Summary of Background Data . Since the functional restoration program was first described , research has focused on identifying patients who will or will not benefit from such a program . The value of previous studies is limited , however , because predictive factors from a control group were not " subtracted . " Methods . Eight hundred sixteen patients with chronic low back disability were included . All had a structured medical examination , including various physical tests before participation in either a functional restoration program ( n = 621 ) or shorter " control " outpatient programs ( n = 144 ) . A smaller group of the cohort ( n = 51 ) had no treatment and served as a pure control group . Six groups were selected from the cohort : Three underwent an identical functional restoration program and three underwent different outpatient control programs . Several baseline demographic , physical , and socioeconomic variables were correlated to 1‐year outcome parameters . Results . Age , days of sick leave , connection to the work force , and back pain intensity , were significantly correlated to success 1 year after entry into the study in all groups , no matter what kind of treatment was administered . Back muscle endurance , sports activity , activity of daily living scores , and vibrations were of importance in some outcome parameters for success after functional restoration . Smoking was positively correlated to disability pension . Days of sick leave and , in functional restoration , ability to work were the only factors that were correlative with statistics for people who withdrew . Conclusions . Different factors can be identified as predictive of outcome in a functional restoration program , but most of these factors were also shown to predict success for shorter control outpatient programs or of no treatment Many manual therapists assess and treat spinal stiffness of people with low back pain . The objectives of this study were to investigate : ( i ) whether spinal stiffness changes after treatment ; ( ii ) the relationship between pre-treatment spinal stiffness and change in stiffness with treatment ; ( iii ) the relationship between spinal stiffness , pain , disability and global perceived effect of treatment ; ( iv ) whether spinal stiffness predicts outcome of treatment or response to treatment in chronic low back pain patients . One hundred and ninety-one subjects with chronic low back pain were r and omly allocated to groups that received either spinal manipulative therapy , motor control exercise , or a general exercise program . Spinal stiffness  was assessed before and after intervention . All three groups showed a significant decrease in stiffness following treatment ( p<0.001 ) . No difference between groups was observed . There was a significant negative correlation between pre-treatment stiffness and change in stiffness ( r=-0.61 ; p<0.001 ) . There was a significant but weak correlation ( r=0.18 ; p=0.02 ) between change in stiffness and change in global perceived effect of treatment , and a significant but weak correlation between change in stiffness and change in function for subjects in the spinal manipulative therapy group ( r=-0.28 ; p=0.02 ) . No significant association was observed between initial stiffness score and any of the final outcome measures following treatment . Initial stiffness did not predict response to any treatment . In conclusion , spinal stiffness decreases over the course of an episode of treatment , more so in those with the stiffest spines , but the decrease is not dependent on treatment and is not generally related to outcome Study Design Two-hundred-forty-three patients with chronic low back pain were studied in a prospect i ve comparative survey to determine whether the “ central ization phenomenon ” was associated with outcome after an interdisciplinary work-hardning program . Objective The hypothesis was that patients who demonstrated central ization during initial mechanical assessment would have better outcomes than non central izers . Summary of Background Data Overall subjects had decreased pain intensity ratings ( mean 10 % ) , increased lifting ability ( 6–8 kg ) , and a 59.2 % return-to-work rate at a mean of 9.7 months follow-up . Methods . Patients were classified as either central izers or non central izer  , based on results of their initial assessment , changes in pain ratings , one-time maximal weights lifted , Oswestry scores , and returen-to-work status were compared between groups . Results The central izers reported significant decreases in their maximum pain ratings ( central izers , 16 % non central izers , 6 % ) and had higher return-to-work rate ( central izers , 68 % ; non central izers , 52 % ) than the non central izers . Conclusion . Centrelization can help identify subgroups within the population with chronic low back pain and could be a useful goal setting and case management toll in the rehabilitation of low back pain OBJECTIVE To develop a clinical prediction rule to predict treatment response to a stabilization exercise program for patients with low back pain ( LBP ) . DESIGN A prospect i ve , cohort study of patients with nonradicular LBP referred to physical therapy ( PT ) . SETTING Outpatient PT clinics . PARTICIPANTS Fifty-four patients with nonradicular LBP . INTERVENTION A st and ardized stabilization exercise program . MAIN OUTCOME MEASURE Treatment response ( success or failure ) was categorized based on changes in the Oswestry Disability Question naire scores after 8 weeks . RESULTS Eighteen subjects were categorized as treatment successes , 15 as treatment failures , and 21 as somewhat improved . After using regression analyses to determine the association between st and ardized examination variables and treatment response status , preliminary clinical prediction rules were developed for predicting success ( positive likelihood ratio [ LR ] , 4.0 ) and failure ( negative LR , .18 ) . The most important variables were age , straight-leg raise , prone instability test , aberrant motions , lumbar hypermobility , and fear-avoidance beliefs . CONCLUSIONS It appears that the response to a stabilization exercise program in patients with LBP can be predicted from variables collected from the clinical examination . The prediction rules could be used to determine whether patients with LBP are likely to benefit from stabilization exercises Aim To determine the frequency of different patterns of central ization and their association with outcomes and MRI findings in patients experiencing sciatica . Methods A prospect i ve longitudinal cohort study of 176 patients with radicular pain below the knee , who all had an MDT clinical assessment . Based on their pain response , patients were divided into five groups : abolition central ization , reduction central ization , unstable central ization , peripheralization , and “ no effect ” . Patients had an  MRI .  Results Overall , 84.8 % of patients reported experiencing central ization , 7.3 % peripheralized and 7.9 % reported “ no effect ” . The median reduction in RMQ scores across all the three central ization groups was 9.5 points at 3 months , and 12.0 points at 12 months . The peripheralization group improved similarly . The ‘ no effect ’ group improved significantly lower ( p < 0.001 ) , by 3.0 at both time points . Patients who central ized , and peripheralized had a significantly reduction in leg pain , the “ no effect ” group demonstrated a less favorable outcome ( p < 0.02 ) . There was no association between pain responses and the type of disc lesion . Conclusion In patients with sciatica , central ization was common and associated with improvement in activity limitation and leg pain . Central ization was very common in ruptured disc therefore the study does not support the theory , that central ization only occurs if the intra-discal hydrostatic mechanism is functional BACKGROUND The prognostic value of the clinical findings elicited in the patient presenting with sciatica is unknown . AIM To investigate whether history and physical examination findings can predict outcome . DESIGN OF STUDY Prospect i ve study of prognostic factors . SETTING A sample of primary care patients with sciatica . METHOD Short-term favourable outcome was registered as improvement perceived by the patient after two weeks . Long-term failure was defined as eventual surgery or lack of improvement after three months . RESULTS The signs and symptoms that most consistently predicted an unfavourable outcome were : a disease duration of more than 30 days ; increased pain on sitting ; and more pain on coughing , sneezing or straining . The straight leg raising test and , to a lesser degree the reversed straight leg raising test , were the most consistent examination findings associated with poor outcome . Chances of short-term improvement were also related to the body weight relative to the length . CONCLUSION The predictors in this study can indicate the prognosis of patients with sciatica at an early stage . Knowledge of these prognostic factors may help to fine tune treatment decisions and improve patient selection in trials of conservative therapy strategies Study Design . The study included 90 disabled patients with chronic low back pain recruited from a pain clinic who were admitted to an 8-week program of functional restoration and behavioral support .  Initial evaluations included a medical examination , rating of the physical impairment , a personal interview , a visual analogue scale to record pain intensity , an assessment of limitations for daily activities , a pain disability index , a depression and psychovegetative scale , and a scale to evaluate general living st and ards . The physical assessment included different flexibility measurements , measurement of power and endurance through st and ardized exercises , and measurements of isokinetic trunk and lifting strength and general endurance . The measurements were repeated at the end of the 8-week program and thereafter at intervals of 6 and 12 months . Final analyses were carried out on 82 patients . Objectives . To determine whether objective or subjective signs most influence the outcome of rehabilitation . Summary of Background Data . In recent years , several studies have shown that active and intensive multimodal treatment of chronic low back pain is successful . Until now there has been lack of information about which patients will respond to the therapy and what is the most effective part of treatment . Methods . Prognostic factors ( return to work , pain intensity , self- assessment of treatment success by patients ) were tested by study ing variance and regression analyses for their ability to predict treatment outcome . Results . Certain factors were identified that had a significant impact on determining the probability of a patient 's return to work and the reduction of pain intensity . These factors included self-evaluation for predicting a return to work , the length of absence from work , application for pension , and a decrease in disability after treatment . Overall satisfaction with treatment was best determined by the number of medical consultations before treatment , the extent of disability , previous measures taken for coping with the disease , and reduction of disability during treatment . Medical background , medical diagnosis , and physical impairment had no predictive value . Physical variables ( i.e. , mobility , strength , endurance , and physical performance ) also demonstrated only limited predictive value . Conclusion . This study has demonstrated that the most important variable in determining a successful treatment of chronic low back pain is the reduction of subjective feelings of disability in patients STUDY DESIGN A cohort of 100 patients with symptomatic lumbar spinal stenosis , characterized in a previous article , were given surgical or conservative treatment and followed for 10 years . OBJECTIVES To identify the short- and long-term results after surgical and conservative treatment , and to determine whether clinical or radiologic predictors for the treatment result can be defined . SUMMARY OF BACKGROUND DATA Surgical decompression has been considered the rational treatment . However , clinical experience indicates that many patients do well with conservative treatment . METHODS In this study , 19 patients with severe symptoms were selected for surgical treatment and 50 patients with moderate symptoms for conservative treatment , whereas 31 patients were r and omized between the conservative ( n = 18 ) and surgical ( n = 13 ) treatment groups .  Pain was decisive for the choice of treatment group . All patients were observed for 10 years by clinical evaluation and question naires . The results , evaluated by patient and physician , were rated as excellent , fair , unchanged , or worse . RESULTS After a period of 3 months , relief of pain had occurred in most patients . Some had relief earlier , whereas for others it took 1 year . After a period of 4 years , excellent or fair results were found in half of the patients selected for conservative treatment , and in four fifths of the patients selected for surgery . Patients with an unsatisfactory result from conservative treatment were offered delayed  surgery  after 3 to 27 months ( median , 3.5 months ) . The treatment result of  delayed surgery  was essentially similar to that of the initial group . The treatment result for the patients r and omized for surgical treatment was considerably better than for the patients r and omized for conservative treatment . Clinical ly significant deterioration of symptoms during the final 6 years of the follow-up period was not observed . Patients with multilevel afflictions , surgically treated or not , did not have a poorer outcome than those with single-level afflictions . Clinical or radiologic predictors for the final outcome were not found . There were no dropouts , except for 14 deaths . CONCLUSIONS The outcome was most favorable for surgical treatment . However , an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome Study Design A prospect i ve survey of patients seeking primary care for low back pain . Clinical and psychosocial data , available at presentation , were explored for predictors of outcome at 1 year . Objectives To determine the relative value of clinical and psychosocial variables for early identification of patients with a poor prognosis . Summary of Background Data Current treatment strategies for low back pain have failed to stem the rising levels of disability . Psychosocial factors have been shown to be important determinants of response to therapy in chronic patients , but the contribution from similar data in acute or subchronic patients has not been comprehensively investigated . Methods Two hundred fifty-two patients with low back pain , presenting to primary care , underwent a structured clinical interview and completed a battery of psychosocial instruments . Follow-up was done by mail at 1 year ; outcome was measured using a back pain disability question naire . Predictive relationships were sought between the data at presentation and disability at follow-up . Results Most patients showed improved disability and pain scores , although more than half had persisting symptoms . Eighteen percent showed significant psychological distress at presentation . Multiple regression analysis showed the level of persisting disability to depend principally on measures in the psychosocial domain ; for acute cases outcome is also dependent on the absence or presence of a previous history of low back trouble . Discriminant models successfully allocated typically 76 % of cases to recovered/not-recovered groups , largely on the basis of psychosocial factors evident at presentation . Conclusions Early identification of psychosocial problems is important in underst and ing , and hopefully preventing , the progression to chronicity in low back trouble Study Design . Prospect i ve , comparative cohort study . Objective . To investigate the prognostic significance of central ization in patients with subacute sciatica and referred symptoms . Summary of Background Data . Previous studies have shown that central ization occurs commonly in the nonspecific low back population , and its occurrence is associated with a good prognosis . The phenomenon has never been evaluated in a population with sciatica and referred symptoms . Methods . The sample pool was 104 consecutive patients referred for investigation of possible disc herniation . Of these patients , 60 were recruited into the study and underwent a st and ardized mechanical evaluation using repeated end-range movements , while symptom response was monitored to expose 2 groups : central ization group ( CG ) and non central ization group ( NCG ) . All patients were treated in the same way and were followed for one year . If patients did not have improvement surgery was considered . Outcomes included back and leg pain , disability , Nottingham Health Profile , and surgical outcome . Results . There were 25 patients who were classified in the CG , 35 in the NCG , and other baseline characteristics were similar between groups . At 1 , 2 , and 3 months , the CG had significantly better outcomes than the NCG . At 2 months , the CG had more improvements in leg pain ( P = 0.007 ) , disability ( P = < 0.001 ) , and Nottingham Health Profile ( P = 0.001 ) . After 1 year , disability was less in the CG ( P = 0.029 ) . In the CG , 3 patients underwent surgery , in the NCG , 16 ( P = 0.01 ) . The odds ratio for surgery in the NCG was 6.2 . Conclusion . Patients with sciatica and suspected disc herniation who have a central ization response to a mechanical evaluation will have significantly better outcomes . Patients who do not have central ization will be 6 times more likely to undergo surgery Study Design . A prospect i ve cohort study on low back pain in consecutive patients in general practice , in which potential prognostic indicators at baseline and at the 1-year follow-up examination were assessed by means of four weekly question naires . Objectives . To identify prognostic indicators of the duration of low back pain in general practice and the occurrence of a relapse . Background . Little is known about the prognosis of low back pain in general practice . Different design s and different results of preceding studies make drawing conclusions about the prognostic indicators , if any , of the course of low back pain in general practice difficult . Methods . For a period of 2 years , 15 general practitioners from Amsterdam and surrounding areas studied consecutive patients with chronic low back pain and those with a recent onset of low back pain . A large number of potential prognostic indicators were assessed at the initial visit . After the initial visit , each patient was monitored for a period of 12 months . The follow-up assessment was conducted with four weekly postal question naires . The associations among the potential prognostic indicators , the duration of the index episode , and the occurrence of a relapse were analyzed using multivariate Cox regression and logistic regression analysis , respectively . Results . Of the 605 patients identified , 443 were included in the follow-up period of assessment ; the question naires were completed by 269 patients . In general , patients with less severe low back pain participated less often or did not complete the follow-up study . Thirty-five percent of the population still experienced low back pain after 12 weeks , and 10 % still experienced it after 1 year . Approximately three of every four patients whose index episode ended before the end of the follow-up period had one or more relapses within a year . The analysis result ed in a model with four variables predicting the duration of the low back pain , including " the duration of the low back pain preceding the initial visit , " " receiving physical therapy , " " pain intensity , " and " history of back surgery . " Daily functioning appeared to be the only variable that was significantly associated with the occurrence of a relapse . Conclusions . Only a few variables appear to be related to the clinical course of low back pain seen in general practice . In particular , the duration preceding the initial visit and , unexpectedly , receiving physical therapy were both associated with a longer duration of low back pain OBJECTIVE To determine predictive factors for radical treatment ( nucleolysis or surgery ) after in-hospital conservative management of low back pain with sciatica ( LBPS ) . PATIENTS AND METHODS A st and ardized form was used to collect data on 134 patients admitted for conservative treatment of LBPS . Subsequent radical procedures were recorded 11 to 24 months after discharge . RESULTS Forty-seven patients required radical treatment after discharge . Significant risk factors for radical treatment in the univariate analysis were taller stature , use of a lumbar support , more preadmission epidural injections , a positive straight leg-raising test , and a disk herniation diameter of at least 50 % of the spinal canal diameter . Protective factors were onset within the month preceding admission and normal range of motion of the lumbar spine . In the multivariate analysis , symptom duration longer than one month , use of a lumbar support prior to admission , and a positive straight leg-raising test were associated with radical treatment . A positive straight leg-raising test was the only significant clinical risk factor in the subset of patients investigated by computed tomography ( CT ) . When CT findings were added to the model , only size of the herniation was significant . CONCLUSION Sixty-five percent of patients admitted for conservative treatment of LBPS do not receive radical treatment during a mean follow-up of 18 months . Several factors are associated with the likelihood of radical treatment BACKGROUND Lumbosacral pain is a significant social problem . Effective treatment of this ailment should be based on thorough diagnostic work-up . The goal of the present study was to determine which physical examination findings can help predict a positive outcome of physiotherapy , including kinesitherapy and physical therapy , aim ed at symptomatic improvement . MATERIAL AND METHODS The study group consisted of 50 patients with lumbosacral pain syndromes presenting as lumbalgia and ischialgia . RESULTS Statistically significant correlations were ascertained between certain physical examination findings before the therapy and after the therapy . CONCLUSION The crossed Lasegue sign was the only component of the physical examination that correlated with the dynamic efficacy of the rehabilitation treatment Abstract . Return to work ( RTW ) is the primary goal in the rehabilitation of patients with chronic low back pain . In spite of expensive rehabilitative efforts , many patients do not RTW . To increase cost effectiveness , predictive tests for non-RTW are needed to select patients for rehabilitation . The reliability of these tests must be high , to prevent exclusion of patients who might improve . This study evaluates the reliability and predictive validity of four tests and the following psychosocial factors for non-RTW : nationality , off-work duration , unemployment and work load . It was design ed as a prospect i ve cohort study of 99 patients with chronic low back pain . Upon entry , physical work load , time off work , unemployment and nationality were recorded . The study investigated four tests with an anticipated prognostic value for non-RTW : the  Numeric Pain Rating Scale ( NRS , 9–10 of a maximum of 10 ) , the  Step Test and Pseudo Strength Test ( precipitous cessation ) and  Behavioural Signs .  After 12 months , the RTW rate was obtained from the physicians responsible for sick-listing by postal survey . The response rate regarding RTW was 91 % at 1 year . The RTW rate at 1 year was 20 % . All investigated tests significantly correlated with non-RTW . Regression analysis showed that the best prediction of non-RTW was obtained when at least two out of the four tests were positive ( positive predictive value 0.97 , sensitivity 0.45 ) . Unemployment , time off work , nationality and physical work load were less predictive . The results show that the combination of the four prognostic tests allows a very reliable prognosis of non-RTW . The cost effectiveness of rehabilitation aim ing at RTW will , therefore , be increased by excluding patients with two or more positive tests OBJECTIVE To examine the predictive validity of posterior-anterior ( PA ) mobility testing in a group of patients with low back pain ( LBP ) . DESIGN R and omized controlled trial . SETTING Outpatient physical therapy clinics . PARTICIPANTS Patients with LBP ( N=131 ; mean age + /- st and ard deviation , 33.9+/-10.9 y ; range , 19 - 59 y ) , and a median symptom duration of 27 days ( range , 1 - 5941 d ) . Patients completed a baseline examination , including PA mobility testing , and were categorized with respect to both hypomobility and hypermobility ( present or absent ) , and treated for 4 weeks . INTERVENTION Seventy patients were r and omized to an intervention involving manipulation and 61 to a stabilization exercise intervention . MAIN OUTCOME MEASURES Oswestry Disability Question naire ( ODQ ) scores were collected at baseline and after 4 weeks . Three-way repeated measures analyses of variance ( ANOVAs ) were performed to assess the effect of mobility categorization and intervention group on the change on the ODQ with time . Number-needed-to-treat ( NNT ) statistics were calculated . RESULTS Ninety-three ( 71.0 % ) patients were judged to have hypomobility present and 15 ( 11.5 % ) were judged with hypermobility present . The ANOVAs result ed in significant interaction effects . Pairwise comparisons showed greater improvements among patients receiving manipulation categorized with hypomobility present versus absent ( mean difference , 23.7 % ; 95 % confidence interval [ CI ] , 5.1%-42.4 % ) , and among patients receiving stabilization categorized with hypermobility present versus absent ( mean difference , 36.4 % ; 95 % CI , 10.3%-69.3 % ) . For patients with hypomobility , failure rates were 26 % with manipulation and 74.4 % with stabilization ( NNT=2.1 ; 95 % CI , 1.6 - 3.5 ) . For patients with hypermobility , failure rates were 83.3 % and 22.2 % for manipulation and stabilization , respectively ( NNT=1.6 ; 95 % CI , 1.2 - 10.2 ) . CONCLUSIONS Patients with LBP judged to have lumbar hypomobility experienced greater benefit from an intervention including manipulation ; those judged to have hypermobility were more likely to benefit from a stabilization exercise program Study Design . Systematic review and meta- analysis . Objective . To assess the efficacy of opioids in adults with chronic low back pain ( CLBP ) . Summary of Background Data . Opioids for CLBP has increased dramatically . However , the benefits and risks remain unclear . Methods . We up date d a 2007 Cochrane Review through October 2012 of r and omized controlled trials from multiple data bases . Use of noninjectable opioids in CLBP for at least 4 weeks was compared with placebo or other treatments ; comparisons with different opioids were excluded . Outcomes included pain and function using st and ardized mean difference ( SMD ) or risk ratios with 95 % confidence intervals ( CIs ) , and absolute risk difference with 95 % CI for adverse effects . Study quality was evaluated using Grading of Recommendations Assessment , Development , and Evaluation criteria . Results . Fifteen trials ( 5540 participants ) , including twelve new , met the criteria . Tramadol was better than placebo for pain ( SMD , −0.55 ; 95 % CI , −0.66 to −0.44 ) and function ( SMD , −0.18 ; 95 % CI , −0.29 to −0.07 ) . Compared with placebo , transdermal buprenorphine  decreased pain ( SMD , −2.47 ; 95 % CI , −2.69 to −2.25 ) , but not function ( SMD , −0.14 ; 95 % CI , −0.53 to 0.25 ) . Strong opioids ( morphine , hydromorphone , oxycodone , oxymorphone , and tapentadol ) , were better than placebo for pain ( SMD , −0.43 ; 95 % CI , −0.52 to −0.33 ) and function ( SMD , −0.26 ; 95 % CI , −0.37 to −0.15 ) . One trial demonstrated little difference with tramadol compared with  celecoxib for pain relief .  Two trials ( 272 participants ) found no difference between opioids and antidepressants for pain or function . Review ed trials had low to moderate quality , high drop-out rates , short duration , and limited interpretability of functional improvement . No serious adverse effects , risks ( addiction or overdose ) , or complications ( sleep apnea , opioid-induced hyperalgesia , hypogonadism ) were reported . Conclusion . There is evidence of short-term efficacy ( moderate for pain and small for function ) of opioids to treat CLBP compared with placebo . The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven . Level of Evidence : OBJECTIVE To identify demographic and clinic-related predictors for successful outcome in patients with persistent low-back pain who received chiropractic treatment .  DESIGN Prospect i ve uncontrolled multicenter study with internal control groups . SUBJECTS Each of 115 Norwegian chiropractors , out of 205 invited , were asked to recruit 10 consecutive patients who had low-back pain for at least 2 weeks at the time of consultation and a minimum of 30 days altogether within the preceding year . In all , 875 patients were included at baseline . The response rates at the fourth visit and at 3 and 12 months were 799 , 598 , and 512 , respectively . METHODS Baseline data were obtained through question naires administered to chiropractic patients and to their treating chiropractors ; clinical information was obtained through question naires at the fourth visit from patients and chiropractors . Outcome was obtained from patients at the fourth visit . Mail surveys of patients were conducted after 3 and 12 months , and additional information was obtained from chiropractors at 12 months in relation to treatment history . POTENTIAL PREDICTORS : Demography and information on past and present history , clinical findings , and prognosis . OUTCOME VARIABLE Number of low-back pain"free patients  ( defined as those with a maximum pain score of 1/10 and a maximum Oswestry score of 15/100 ) . DATA ANALYSIS Positive predictive values and relative risks were calculated for each categorized predictor variable singly and in combination in relation to being low-back pain free at the 3 follow-up surveys . RESULTS Treatment outcome at the fourth visit was best predicted by a model containing the following 5 variables : sex , social benefit , severity of pain , duration of continuous pain at first consultation , and additional neck pain ( odds ratios between 2.2 and 4.3 ) . A similar profile was found at 3 months , but 2 different variables ( relating to disability ) were the final variables in relation to the 12-month status . These final models were best at predicting absence of treatment success . Being low-back pain free at the fourth visit was a strong predictor for being low-back pain free both at 3 months and 12 months , with relative risks of 3.0 ( 2.2 - 4.8 ) and 3.1 ( 1.5 - 6.5 ) , respectively . CONCLUSION In patients with persistent low-back pain , it is possible to exclude from treatment those who are unlikely to become low-back pain free after chiropractic care and to do this before they have been examined clinical ly . Early recovery is a strong predictor for outcome up to 1 year later Study Design . A prospect i ve , cohort study of patients with nonradicular low back pain referred to physical therapy . Objective . Develop a clinical prediction rule for identifying patients with low back pain who improve with spinal manipulation .  Summary of Background Data . Development of clinical prediction rules for classifying patients with low back pain who are likely to respond to a particular intervention , such as manipulation  , would improve clinical decision-making and research . Methods . Patients with nonradicular low back pain underwent a st and ardized examination and then underwent a st and ardized spinal manipulation treatment program . Success with treatment was determined using percent change in disability scores over three sessions and served as the reference st and ard for determining the accuracy of examination variables . Examination variables were first analyzed for univariate accuracy in predicting success and then combined into a multivariate clinical prediction rule . Results . Seventy-one patients participated . Thirty-two had success with the manipulation intervention . A clinical prediction rule with five variables ( symptom duration , fear – avoidance beliefs , lumbar hypomobility , hip internal rotation range of motion , and no symptoms distal to the knee ) was identified . The presence of four of five of these variables ( positive likelihood ratio = 24.38 ) increased the probability of success with  manipulation  from 45 % to 95 % . Conclusion . It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment Study Design . R and omized Clinical Trial . Objective . To identify a subgroup of patients with low back pain who are likely to respond favorably to an intervention including mechanical traction . Summary of Background Data . Previous research has failed to find evidence supporting traction for patients with low back pain . Previous studies have used heterogeneous sample s , although clinical experts tend to recommend traction for a more limited subgroup of patients with low back pain . Methods . Sixty-four subjects ( mean age 41.1 year , 56.3 % female ) with low back and leg pain and signs of nerve root compression were r and omized to receive a 6-week extension-oriented intervention with or without mechanical traction during the first 2 weeks . Between-group comparisons were conducted for changes in pain , disability , and fear-avoidance beliefs . Baseline variables were explored for potential as subgrouping criteria defining a subgroup of subjects likely to benefit from traction . Results . The group receiving traction showed greater improvements in disability ( adjusted mean difference in Oswestry change 7.2 points ) and fear-avoidance beliefs ( adjusted mean difference in FABQPA change 2.6 points ) after 2 weeks . There were no between-group differences after 6 weeks . Two baseline variables were associated with greater improvements with traction treatment ; peripheralization with extension movements and a crossed straight leg raise . Conclusion . A subgroup of patients likely to benefit from mechanical traction may exist . The results of this study suggest this subgroup is characterized by the presence of leg symptoms , signs of nerve root compression , and either peripheralization with extension movements or a crossed straight leg raise . Further research is needed to vali date this finding This prospect i ve study investigated the relationship between behavioral sign scores ( from Waddell ) and the return to work status of chronic low-back pain patients who completed a work-oriented physical rehabilitation program without formal facility-related psychologic or social services . Further , the authors monitored the effect of this program on changing these scores . The program consisted of physical reconditioning through resistive exercises , flexibility and aerobic training , posture and body mechanics education , and progressive work simulation tasks and activities of daily living .  One hundred eighty-three nonworking or partially disabled low-back pain patients with an average duration of 8.7 months ' disability were included in the study . The presence of each of eight behavioral signs was tested for on entry and again on completion of the program . Analysis showed a significant drop in behavioral sign scores for patients who successfully returned to work . There was no significant reduction in scores for patients who did not return to work . The results suggest these signs may predict the effectiveness of treating chronic low-back pain patients in a return-to-work physical rehabilitation program . Conversely , screening for behavioral signs may identify low-back pain patients who would benefit from intensive behavioral and psychiatric testing and intervention efforts STUDY DESIGN Prospect i ve cohort study nested in a r and omized clinical trial . OBJECTIVE To investigate the prognostic value of pain response classification at initial physiotherapy examination in patients with low back pain ( LBP ) who are sick-listed . BACKGROUND Recurrent and chronic LBP accounts for a substantial proportion of all absence from work . In predicting outcome in patients with LBP , psychosocial factors are thought to play an important role , while findings from clinical examination seem to be of more limited value . Mechanical evaluation , using repeated end range spinal movements that result in specific pain responses , has been shown to be of some value . METHODS The study included 351 patients sick-listed because of LBP with or without sciatica . Prior to clinical examination , the patients completed a comprehensive question naire including questions on pain , function , and psychosocial factors . The physiotherapy examination included a st and ardized mechanical evaluation . Patients were classified into 3 groups according to their pain response : central ization , peripheralization , or no response . Outcomes were obtained by national register data , medical records , and a postal question naire at 1 year . RESULTS At 1-year follow-up , 65 % of the patients had returned to work . All pain response groups showed significant and clinical ly important improvements in both pain and disability . No significant differences were found between pain response groups in any outcome measure . Results remained unchanged after adjustment for potential confounders . CONCLUSION The prognostic value of pain response classification seems limited in patients sick-listed from work because of LBP Objectives : To determine whether treatment related pain reduction  on the short- and long-term is predicted by different baseline variables , and with different accuracy , in patients with chronic low back pain as compared with those with chronic neck pain . Design and Methods : A single blinded prospect i ve cohort study based on patients with chronic musculoskeletal pain in the lower back ( N = 167 ) or the neck ( N = 136 ) who completed a 4-week multimodal rehabilitation program .  At admission , each patient was evaluated on 17 potential predictors , including pain characteristics and physical , sociodemographic , and psychosocial-behavioral variables . Changes in self-reported pain intensity in the lower back or the neck between the pretreatment evaluation and those performed immediately after , and 12 months after the rehabilitation program , were assessed . Results : Logistic regression models revealed that change in pain intensity could be predicted with good specificity but with poor sensitivity both for patients with chronic low back pain and chronic neck pain . Significant predictors among the neck pain patients were high endurance , low age , high pain intensity , few other symptoms , low need of being social , to do things with others , and to be helped , along with optimistic attitudes on how the pain will interfere with daily life . Among the low back pain patients , high pain intensity , low levels of pain severity , and high affective distress were important predictors . Variables such as sex , sick leave history , working status , accident , pain duration , and depressive symptoms demonstrated no predictive value . Short- and long-term pain outcome was equally predictable and predicted by almost the same variables . Conclusions : Patients who reported unchanged or increased pain after multimodal treatment could be predicted with good accuracy , whereas those who reported decreased pain were more difficult to identify . Treatment-related pain alteration in chronic low back pain seems to be predicted by partly different variables than in chronic neck pain Study Design . A controlled clinical trial . Objectives . To examine the long‐term effect of an informative approach to low back pain . Summary of Background Data . In management and prevention of low back pain , back school based on an ergonomic approach have played an important role . The effect of such informative interventions is not clear . Methods . A 5‐year follow‐up study was done on patients included in a previous study . The outcome was measured by return to work or still on sick leave . The patients were allocated to an intervention group ( n = 245 ) and a control group ( n = 244 ) . Only the intervention group was called in for examination and intervention and answered a battery of tests for psychological and health factors . The intervention apart from the clinical examination consisted of education in a " mini back school . " The program was based on a new medical model for low back pain . Results . Forty‐seven ( 19 % ) of the patients in the intervention group , compared with 84 patients ( 34 % ) in the control group , were still on sick leave after 5 years ( P < 0.001 ) . There were fewer recurrences of sick leave ( P < 0.03 ) in the intervention group than in the control group . Based on Internal Health Locus of Control , number of children , and income , 75 % were correctly classified as nonreturners in the intervention group . Conclusions . This study indicates that subchronic low back pain may be managed successfully with an approach that includes clinical examination combined with information for patients about the nature of the problem , provided in a manner design ed to reduce fear and give them reason to resume light activity BACKGROUND Transforaminal injection of steroids ( TFIS ) is effective for some patients with lumbar radicular pain caused by disc herniation . Factors associated with better outcomes are unknown . OBJECTIVE To identify clinical and radiological features predictive of a favorable response to TFIS . METHODS Seventy-one patients with lumbar radicular pain caused by disc herniation were treated with TFIS as part of a previously reported , r and omized , clinical trial . The clinical features analyzed were the presence of neurologic symptom , neurologic signs , and the duration of sciatica . Radiological features evaluated using magnetic resonance imaging ( MRI ) were the segmental level of the pathology , the location and morphological features of the disc herniation , the cross-sectional area of the disc herniation and its ratio to the cross-sectional area of the spinal canal , and the grade of nerve root compression . RESULTS None of the clinical features was associated with successful outcome from treatment . The only radiological feature associated with successful outcome was the grade of nerve root compression . Of patients with low- grade root compression , 75 % responded favorably to TFIS . Only 26 % of patients with high- grade nerve root compression responded . DISCUSSION These results indicate that  TFIS  is more often successful in patients without significant compression of the nerve root and , therefore , in whom an inflammatory basis for radicular pain is most likely . In such patients , a success rate of 75 % renders TFIS an attractive alternative to surgery . In patients with significant compression of the nerve root , the likelihood of benefiting from TFIS is low . The success rate may be no more than that of a placebo effect , and surgery may be a more appropriate consideration OBJECTIVES We aim ed to examine the prognosis of acute low back pain ( LBP ) in patients in general practice and to identify prognostic factors associated with the long-term prognosis based on information immediately available to the GP . METHOD We conducted a prospect i ve cohort study in general practice in Denmark . The patients were those aged 18 - 60 years consulting their GP due to an episode of LBP lasting less than 2 weeks . The GPs collected data regarding 34 exposure variables , including their global assessment of the likelihood of chronic LBP . Outcome variables were collected from the patients after 1 , 6 and 12 months . The outcome measures were days on sick leave , and functional or complete recovery from LBP . RESULTS In total , 503 ( 96 % ) patients were followed during the whole study period . Fifty per cent of the patients on sick leave returned to work within 8 days ; after 1 year , only 2 % remained on sick leave . At the 1-year follow-up , 45 % of the patients continued to complain of LBP . Logistic regression analyses showed that the factors most significantly associated with poor long-term LBP outcome were ( i ) severity of LBP at inclusion , ( ii ) assessment s by the GP of susceptibility to develop chronic LBP and ( iii ) a history of LBP having caused previous sick leave . CONCLUSIONS LBP in general practice has a good prognosis with regard to sick leave , but a high proportion of patients continue to complain of LBP . We were not able to identify objective measures that strongly predict the prognosis of the individual LBP patient . The overall assessment by the GPs seems to be the most important predictor associated with the long-term outcome OBJECTIVE To describe physical measures used in patients with back pain when no specific treatment is given , to examine associations between change over time in these measures and changes in pain and back-related disability , and to study the value of physical measures at baseline and at a 4-week follow-up to predict outcome at 12 months . DESIGN A prospect i ve consecutive study . SUBJECTS Forty-four patients presenting with low back pain in primary care . METHODS The patients underwent a physical examination at baseline and at 4 weeks . Follow-up was carried out using question naires until 12 months . Linear regression was used to identify predictors . RESULTS Most measures had improved significantly at the 4-week follow-up . Thoracolumbar rotation , isometric endurance back extensors , and fingertip-to-floor distance at 4 weeks were significant predictors for pain intensity and back-related disability at the 12-month follow-up . Eighteen out of 44 patients reported an increase in pain after the assessment of the physical measures at baseline . This group of patients improved more in physical measures between baseline and the 4-week follow-up . CONCLUSION Physical measures assessed at the 4-week follow-up , but not at baseline , could provide important additional information for identifying those patients at risk for worse outcome in pain or back-related disability at 12 months The inability to predict outcome in patients with low-back pain seriously impedes clinical trials and leads to inappropriate or unnecessary treatment . This prospect i ve study investigated the value of multivariable mathematical models to predict the 1-year clinical course of 109 patients with low-back trouble ( LBT ) . Discriminant analysis was used to determine predictive models for outcome groups at 1 month , 3 months and 1 year . The variables selected in the analyses were subsets of 29 items from a clinical interview at presentation . These included anamnestic features of the first episode as well as symptomatic details and results from clinical tests for the current spell . The derived models successfully discriminated outcome groups with estimates of sensitivity and specificity ranging from 63 to 99 % . When models from one set of patients were tested for predictive accuracy by the application of them to a different set , nonrecovery and satisfactory improvement were predicted with a 76–100 % success rate . The results affirmed the importance of considering combinations of interrelated variables for prediction and discrimination in LBT . This work has demonstrated that outcome can be predicted successfully by the use of mathematic models based just on presentation data . The ability to determine homogenous groups in respect to outcome is seen as an important aid to therapeutic research ; further work will enable refinement of these models for general clinical use and for incorporation into computer-based interview systems
target: Conclusions For most clinical tests in LBP there is not consistent evidence for an association with outcome .
  Central ization and non-organic signs are exceptions from that .
background: Background There is a strong tradition of performing a clinical examination of low back pain ( LBP ) patients and this is generally recommended in guidelines .
  However , establishing a pathoanatomic diagnosis does not seem possible in most LBP patients and clinical tests may potentially be more relevant as prognostic factors .
  The aim of this review of the literature was to systematic ally assess the association between low-tech clinical tests commonly used in adult patients with acute , recurrent or chronic LBP and short- and long-term outcome .