DEGENERATIVE DISCOGENIC SYNDROME

Amazing Data

International Publicized Data

GMCD Instructional  Course Lecture

Author :  

Dr. med. Guy M.C. Declerck MD (GMCD)

Medical FRCS-, FRCS Ed Orth-, M Ch Orth-, PhD-studies

Spinal Surgical and Research Fellow, Perth, Western Australia

Spinal Orthopaedic Surgeon and Surgical Instructor

Consultant R&D Innovative & Restorative Spinal Technologies

President International Association of Andullation Technology (IAAT)

Translation:   Filip Vanhaecke PhD

Illustrative expertise and page layout:   Lennart Benoot, Mincko, Halle, Flanders, Belgium

Review scientific literature:   Medical Consulting Advice, Ostend, Flanders, Belgium

Support:   International Association of Andullation Therapy (IAAT)

Legal advice:   Anthony De Zutter, kornukopia.be

Dedication to the Colombian Family Gloria Rúa Meneses and her sons Andres David and Juan Camilo Hinestroza, both representing Colombia’s National Waterpolo Team. For their friendship and hospitality. April 2014.

        

Acknowledgements

Relying on the work of giants is the lifeblood of scientific research. Indeed, if I have seen further, it is by standing on the shoulders of giants. One might even say that I have always depended

on the kindness of strangers in this regard (*).

The continuous support by professor BA Kakulas (Neuropathology), professor JR Taylor (Spinal Anatomy and Human Biology), and Sir George M Bedbrook (Spinal Orthopaedic and Rehabilitation Surgeon) made it possible to analyse 27539 post-mortem human spines, normal and pathological, in the Department of Neuropathology, Royal Perth Hospital/University Western Australia, Perth.

Note: in order not to disturb easy reading of the underneath scientifically based chapters, only a few authors are mentioned in the text where dr. Guy considered it essential. Their names are placed between brackets. Further information on their individual research can be read in the last chapter ‘Literature Encyclopedia’.

(*) Mirsky Steve. Technology is making it harder for word thieves to earn outrageous fortunes. Scientific American, February 2014, p. 64

Contents

1. Only 20 % of low back pain (LBP) patients demonstrate a serious underlying disease

2. Intervertebral disc degeneration. Degenerative discogenic syndrome is not a disease

3. No clear explanation for benign LBP

4. Mismatch of opinions

5. Intermittent and undulating low back pain

6. Benign LBP is temporarily disabling

7. Benign LBP during World War I, WWII and in 2000

8. Prevalence and incidence of benign LBP complaints

9. Something is going wrong

10. Benign LBP is the major reason for enormous economic losses

11. Benign LBP causes enormous personal and societal costs

12. Benign LBP is an exceptional therapeutic challenge

13. Literature Encyclopaedia

1. Low back pain: a serious disease in only 20 %

Following thorough clinical, laboratory and radiological investigations, an evident, clear-cut and undeniable pathology will only be found in maximum 20 % of patients suffering from low back pain. Spinal infections, poliomyelitis, tumors, metastases, thoracolumbar fractures, metabolic and rheumatoid diseases, abdominal pathologies etc ... are disabling conditions. Their diagnosis should not be missed because the causing mechanisms are crippling. For each of these serious conditions, therapeutic approaches are available.

2. Intervertebral disc degeneration. Degenerative discogenic syndrome is not a disease

Scientific medical research is only at the beginning of understanding that the synergetic degenerative mechanisms between the nucleus pulposus (NP), the endplates (EP) and the annulus fibrosus (AF) of the intervertebral disc (IVD) [see: ‘Structure of the Intervertebral Disc’] are responsible for an important public health issue. Surgical investigations by Kuslich (1991) and Barrick (2000) showed clear evidence that the intervertebral disc is the culprit for a very large portion of LBP. Indeed, approximately 80 % of all chronic LBP patients show nothing but investigational evidence of IVD degeneration. The author defines symptoms and signs of chronic low back pain linked to the - benign - degenerative changes in the IVD as degenerative discogenic syndrome.

Benign acute (ALBP) and benign chronic low back pain (CLBP) are not diseases. Both conditions simply are symptomatic manifestations related to an underlying condition which is difficult to comprehend because of an unique interrelation of various aetiological factors. Benign LBP results from an extraordinary - and as yet still not understood - interplay between genetic background, declining nutrition of the IVD, biochemical aging and degenerating processes in the IVD and disturbed daily biomechanical loading patterns on the IVD.

Fig. 2. Typical illustration of the normally evolving degenerative processes in the lumbar intervertebral discs.

The information is based on a review and analysis of 23,539 postmortem lumbar spines by dr. med. Guy Declerck at the Department of NeuroMuscular Pathology at the University of Perth.

The Colombian sculptor Alonso Ríos Vanagas (www.alonsoriosescultor.com) depicted the typical details in the nucleus pulposus, the endplates, and the annulus fibrosus at the L4-L4 IVD level.

3. No clear explanation for benign LBP

There exists no relationship at all between symptoms of low back pain and potential ‘abnormal’ radiological features. All human beings will age and may develop degenerative changes in their lumbar intervertebral discs without any associated pain at all. Then something special must happen to cause pain!

The complex ongoings and synergetic degenerative mechanisms in the IVDs are as yet not understood. But chronic LBP remains an area of deep concern. The effect of LBP on the quality of life has far reaching consequences. LBP is the most common cause of disability and loss of mobility. Some LBP sufferers even become suicidal. As most of us already experienced, the medical professionals as well are awaiting a logic and universally acceptable explanation. Socioeconomic factors are not at all the reasons why structural defects occur in the annulus fibrosus and the endplates of a degenerating IVD but are known to be important risk factors for intensifying the pain and the related disability.

Animal and in vitro cell culture study models still remain the basis for analyzing the degenerative processes in the intervertebral disc. It has overwhelmingly been shown that there exists a close relationship between biology and biomechanics of the IVD in the bipedal humans. It’s called ‘the mechanobiology of the IVD’ (Adams). To paraphrase the politician Winston Churchill, it is quite possible that in a few years’ time the reasons for chronic low back pain no longer will be ‘a riddle, wrapped in a mystery, inside an enigma’

4. A mismatch of opinions

As long as the exact pain causing mechanisms are not known, the human brain will be left open to all kind of explanatory fantasies. It all depends where the medical and paramedical staff received part or all of their clinical (and surgical) training. During his lifetime, the author has heard as many explanations as institutes he visited and worked in! Because only a few experts start understanding the important relationship between biomechanics and biochemistry in the pathogenesis of chronic LBP, the mismatch of opinions will remain fantastic, extremely confusing and contradictory.

5. Intermittent and undulating low back pain

Low back pain is not something which simply passes by as a meaningless event. Once a first episode of LBP has occurred, new episodes of LBP always must be anticipated. LBP is the manifestation of an underlying phenomenon which will never spontaneously nor definitely disappear.

A first episode of LBP may settle in approximately 30 % of patients at three months from its origin. When a period of LBP continues for more than 3 months, it is defined as chronic LBP. Overall, up to 75 % of LBP sufferers still experience some (slight) symptoms at one year following an acute LBP attack.

LBP may continue as a fluctuating condition over time with frequent relapses or exacerbations. Intermittent CLBP is the term used when pain free periods of varying duration alternate with short acute LBP attacks (Fig. 5a). Undulating CLBP means that the ever present LBP is accompanied by up and down going symptoms (Fig. 5b). Strangely enough and irrespective of the type of treatment, as many as 90 % of recurrent acute episodes of LBP will improve spontaneously in about 6 weeks. LBP suites the definition of ‘perpetuum mobile’.

Fig. 5a. The course of chronic intermittent low back pain. Each time, the recurring attacks of LBP are followed by pain free periods. (Illustration by Natacha Monstrey)

 

Fig. 5b. The course of chronic undulating low back pain. The LBP complaints present an up and down going pattern. There are no pain free periods. (Illustration by Natacha Monstrey)

6. Benign LBP is temporarily disabling

Disability is defined as restricted functioning, limitation of activities and decreased participation in life situations. The degenerative discogenic syndrome (DDS) related to the degenerative processes in the intervertebral disc is not crippling. It represents the most common cause of restrictions on activity in individuals between 20 and 50 years of age, especially in men. Benign acute LBP and benign chronic LBP are only temporarily disabling.

7. Benign LBP during World War I, WW II and in 2000

Disability related to LBP in soldiers during World War I counted for 0,23 %. They returned to duties after two weeks. Disability increased 400 % during World War II (1,07 %) and sick leave was two months. Disability due to LBP varies enormously but continues to grow exponentially. Both disability and sick leave depend on the country of origin, the social background and the daytime. By the end of the 20th century up to 12 % of the population in the high income countries was temporarily disabled by LBP (Cassidy).

8. Prevalence and incidence of benign LBP complaints

Prevalence is the percentage of individuals in a given population who have the complaints related to an underlying condition during a specified period of time. The incidence is the percentage of individuals in a given population who will develop a disease during a specified period of time.

Epidemiological studies since the 1970s repeatedly recognized that benign low back pain (LBP) is one of the most prevalent conditions of the human race. LBP is widespread, temporarily disabling, but not invalidating nor crippling, costly and responsible for exorbitant levels of work absenteeism and significant productivity losses. An overall evaluation of the huge amount of published figures points out that the prevalence of benign LBP is similar in low-income, middle-income, and high-income countries. The prevalence of LBP in schoolchildren and adolescents approaches that seen in adults. Eight out of ten (80 %!) individuals will - at some stage in their lives - have suffered at least one episode of significant benign LBP. As many as 40 % in a normal population have experienced some degree of LBP in the past year.

In the younger populations benign LBP seems to be the only major source of pain. However, the prevalence peaks between the ages 35 and 55 years. In industrialised countries, approximately 25 % of these adults report LBP occurring in the past 3 months. In a small part of the world, Flanders in Belgium, this figure corresponds to over 1,5 million individuals and in the USA to approximately 54 million individuals. The prevalence of LBP in the elderly older than 65 years of age is not known with certainty but is lower than in the younger population groups.

9. Something is going wrong

How long will patients worldwide continue to tell that they are not taken seriously, that the medical personnel doesn’t believe them, and answer that they are simply faking their signs and symptoms?

I do not at all agree that chronic LBP sufferers seek compensation on purpose. The patients are ignorant of what’s going on and seek assistance. Therefore,  LBP was and always will be a reason for seeking sick leave. LBP suffers are fearful that ‘something’ may go wrong. This feeling is accentuated because most doctors simply have no idea and no clue about the reasons for this benign type but sometimes very intense pain. Is it really possible that a ‘torn spinal muscle’ can cause that amount of pain and for so long? Why do torn (stronger and larger) muscles in the arm or tight do not cause similar pains? Of course, there is that famous ‘disc herniation’ explanation! For most doctors the ‘disc herniation theory’ simply is an excuse and a synonym for ‘a riddle, wrapped in a mystery, inside an enigma’. Doctors are not allowed to say ‘I don’t know!’.

Most caretakers prefer to take no risks. The oath to Hippocrates means that at all times they have to seek the best for their patients. Regarding benign low back pain, this means avoiding a worst outcome by simply doing nothing. This is the attitude by which LBP sufferers are driven. Of course, compensation doctors do exist. They like to get rid of these LBP sufferers as they present unexplainable complaints. There exist no imaging techniques to identify potential cellular and molecular indicators of pain. Electrochemical technology CLARITY visualizing projections, already tested on mouse brains, may present solutions in the future (Chung and Deisseroth).

10. Benign LBP: major reason for economic losses

Although the percentage of individuals who have benign LBP is similar in low-income, middle-income, and high-income countries, chronic low back pain (CLBP) only is epidemic and only has a major societal impact in the developed and industrialised world. No doubt this situation is influenced by the well-structured social security systems with their compensational mechanisms. In countries which as yet are not fully developed, there simply is nothing to gain by staying at home for a benign condition.

In the developed countries CLBP related to intervertebral disc degeneration affects the majority of the population. CLBP is the leading cause of limitation of activities in both sexes. In a given year, up to 15 % of the entire working population will be (temporarily) disabled by LBP. The ensuing economic losses for society are enormous. In the USA and as for 1981, LBP was responsible for 93 million lost working days. Recently it has been calculated that LBP now accounts for 149 million days lost from work.

In all high and middle-income countries, LBP is the second most common reason for sick leave, behind only a common cold. In Belgium 12 % of work absenteeism exceeding 28 days is due to by LBP. Lost working days due to LBP mostly are registered in the work force of companies or industries dealing with housekeeping, cleaning, textile, food and building. Employees in sports clubs, insurance companies, and sectors concentrating on gardening, farming, and agriculture record the least days lost to work. Nobody can rationally explain these figures. In the industrialized countries it seems that the social security systems do not concentrate on reactivating people but simply encourage the LBP sufferers ‘to rest a while’. At least this was the author’s experience while practising in Belgium! He even received letters from these security systems urging not to send the patients back to work. Unfortunately, the author never cooperated with the authorities of these politically driven systems (at least in Belgium).

The economic burden due to LBP is similar to that of the more serious coronary heart diseases. The economic losses due to LBP are higher than those of other major health problems, such as diabetes, Alzheimer disease, and kidney diseases.

11. Benign LBP: enormous personal and societal costs

Statistics on the impact of low back pain provide figures which repetitively indicate that CLBP of degenerative origin is extremely expensive, costs billions of dollars or euros, and continues to rise. The direct and indirect costs to the individual and to the society may count for 12 % of gross domestic product in a country.

The direct costs which are related to diagnosis and treatment include fees of medical visits, medication, hospitalization, radiology, blood analyses, all kind of devices, the whole gamma of medical and alternative therapies, etc … . Two-thirds of all costs are indirect. These include charges due to reduced or loss of productivity, inactivity, absence from work, loss of work, lost wages, costs of transportation to and from medical and paramedical care providers, all kind of societal supports for the affected individuals, their family and professionals .

In the USA the total cost of LBP to the individuals and the society reached 100 billion $ per year in 1991 and were estimated to value up to 200 billion $ per year in 2005. In 2006, the socialist mutuality in Belgium published amazing figures for this small country. Direct costs per LBP individual in 2006 accounted for 922 euros per year. The total direct medical costs for the whole country were estimated somewhere between 81 and 167 million euros. The sum of direct and indirect costs was between 270 and 1600 million euros (Federaal Kenniscentrum voor de Gezondheidszorg).

The whole society has to compensate for its LBP-members!

12. Benign LBP: exceptional therapeutic challenge

Elucidating the molecular mechanisms how intervertebral disc (IVD) cells and their pericellular matrix communicate with each other and how they react on the daily mechanical forces exerted on the lumbar IVDs remains fundamental for developing a cause-directed biological therapy to settle the degenerative changes. Till that moment (in another 10 to 15 years), patients suffering (the attacks of) benign low back pain have no choice but to accept their fate or decide to undergo one of the various physiotherapeutic, injecting or surgical treatments. Finally developing an efficient and universally accepted therapy curing the degenerative disc syndrome remains one of the most exceptional therapeutic challenges in the 21ste century.

13. Literature Encyclopaedia

A

Anderson JA

Epidemiological aspects of back pain

J Soc Occup Med, 1986, 36:90

Andersson GB

Epidemiological features of chronic low-back pain

The Lancet, 1999, 354:581

Andersson GBJ

The epidemiology of spinal disorders

In: The Adult Spine: Principles and Practice

Frymoyer JW (editor-in-chief)

Raven Press, Ltd., New York, 1991:107

Andersson GBJ, Pope MH, Frymoyer JW, Snook S

Epidemiology and cost

In: Pope MH, Andersson GBJ, Frymoyer JW, Chaffin DB (eds)

Occupational low back pain. Assessment, treatment and prevention

Mosby Year Book, St. Louis, 1991:95

Andersson HI, Ejlertsson G, Leden I, Rosenberg C

Chronic pain in a geographically defined general population. Studies of differences in age, gender, social class, and pain localization

Clin J Pain, 1993, 9:174

Asche CV, Kirkness CS, McAdam-Marx C, Fritz JM

The societal costs of low back pain: data published between 2001 and 2007

J Pain Palliat Care Pharmacother, 2007, 21:25

Atlas SJ, Chang Y, Kammann E, Keller RB, Deyo RA, Singer DE

Long-term disability and return to work among patients who have a herniated lumbar disc. The effect of disability compensation

J Bone Joint Surg, 2000, 82A:4

B

Balague F, Troussier B, Salminen JJ

Non-specific low back pain in children and adolescents. Risk factors

Eur Spine J, 1999, 8:429

Barrick WT, Schofferman JA, Reynolds JB, Goldthwaite ND, McKeehen M, Keaney D, White AH

Anterior lumbar fusion improves discogenic pain at levels of prior posterolateral fusion

Spine, 2000, 25:853

Battié MC, Videman T

Lumbar disc degeneration. Epidemiology and genetics

J Bone Joint Surg, 2006, 88A (Suppl 2):3

Battié MC, Videman T, Parent E

Lumbar disc degeneration. Epidemiology and genetic influences

Spine, 2004, 29:2679

Bigos SJ, Battié MC, Spengler DM, Fisher LD, Fordyce WE, Hansson TH, Nachemson AL, Wortley MD

A prospective study of work perceptions and psychosocial factors affecting the report of back injury

Spine, 1991, 16:1

Bolten W, Kempel-Waibel A, Pförringer W

Analyse der Krankheitskosten bei Rückenschmerzen

Medizinische Klinik - Intensivmedizin und Notfallmedizin, 1998, 93:388

Bracken MB

Risk, Chance, and Causation. Investigation the origins and treatment of disease

Yale University Press, 2013        

Bressler HB, Keyes WJ, Rochon PA, Badley E

The prevalence of low back pain in the elderly. A systematic review of the literature

Spine, 1999, 24:1813

Buckwalter JA

Aging and degeneration of the human intervertebral disc

Spine, 1995, 20:1307

Burton K, Adams M, Dolan P, Greenough Ch, Findlay G, Main Ch, Coles C, Balagué F,  Bjarke ChF, James FB, Teli M

Spine Course 2006. Chronic Low Back Pain. Spine Society of Europe

Barcelona, Spain, September 2006

C

Cassidy JD, Carroll LJ, Cote P

The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults

Spine, 1998, 23:1860

Chung K, Deisseroth K

CLARITY for mapping the nervous system

Nat Methods, 2013, 10:1035

Chung K, Wallace J, Kim SY, Kalyanasundaram S, Andalman AS, Davidson TJ, Mirzabekov JJ, Zalocusky KA, Mattis J, Denisin AK, Pak S,

Bernstein H, Ramakrishnan C, Grosenick L, Gradinaru V, Deisseroth K

Structural and molecular interrogation of intact biological systems

Nature, 2013, 497:332

Clinical Standards Advisory Group

Epidemiology review. The epidemiology and cost of back pain

The annex to the Clinical Standards Advisory Group’s report on back pain (by Rozen M – see below)

London, HMSO, May 1994

Cressey D        

Images of the year

Mind reader: one of the first ‘transparent brains’ to be made with CLARITY

Nature, 2013, 504:350

Crow WT, Willis DR

Estimating cost of care for patients with acute low back pain. A retrospective review of patient records

J Am Osteopath Assoc, 2009, 109:229

D

Dagenais S, Caro J, Haldeman S

A systematic review of low back pain cost of illness studies in the United States and internationally

Spine J, 2008, 8:8

Deyo RA        

Measuring the functional status of patients with low back pain

Arch Phys Med Rehabil, 1988, 69:1044

Deyo RA, Mirza SK, Martin BI

Back pain prevalence and visit rates. Estimates from U.S. national surveys, 2002

Spine, 2006, 31:2724

Deyo RA, Tsui-Wu YJ

Descriptive epidemiology of low-back pain and its related medical care in the United States

Spine, 1987, 12:264

E

Ebbehoj NE, Hansen FR, Harreby MS, Lassen CF

[Low back pain in children and adolescents. Prevalence, risk factors and prevention]

Ugeskr Laeger, 2002, 164:755

Ekman M, Johnell O, Lidgren L

The economic cost of low back pain in Sweden in 2001

Acta Orthop, 2005, 76:275

F

Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS 

The rising prevalence of chronic low back pain

Arch Intern Med, 2009, 169:251

Frymoyer JW

Back pain and sciatica

N Engl J Med, 1988, 318:291

Frymoyer JW

Magnitude of the problem

In: The lumbar spine (2nd ed)

Wiesel SW, Weinstein JN, Herkowitz H, Dvorak J, Bell G (eds)

WB Saunders, Philadelphia, 1996, vol 1:8

Frymoyer JW, Cats-Baril WL

An overview of the incidences and costs of low back pain

Orthop Clin North Am, 1991, 22:263

Frymoyer JW, Durett CL

The economics of spinal disorders

In: The adult spine: principles and practice (2nd ed)

Frymoyer JW (ed)

Lippincott-Raven, Philadelphia, 1997, vol 1:143

Frymoyer JW, Pope MH, Clements JH, Wilder DG, MacPherson B, Ashikaga T

Risk factors in low-back pain. An epidemiological survey

J Bone Joint Surg, 1983, 65A:213

G

Gou HR, Tanaka S, Halperin WE, Cameron LL

Back pain prevalence in US industry and estimates of lost workdays

Am J Public Health, 1999, 89:1029

H

Hadler NM

Legal ramifications of the medical definition of back disease

Ann Intern Med, 1978, 89:992

Hansson EK, Hansson TH

The costs for persons sick-listed more than one month because of low back or neck problems. A two-year prospective study

of Swedish patients

Eur Spine J, 2005, 14:337

Hestbaek L, Leboeuf-Yde C, Manniche C

Low back pain. What is the long-term course? A review of studies of general patient populations

Eur Spine J, 2003, 12:149

I

IJzelenberg W, Burdorf A

Risk factors for musculoskeletal symptoms and ensuing health care use and sick leave

Spine, 2005, 30:1550

K

Katz JN        

Lumbar disc disorders and low-back pain. Socioeconomic factors and consequences

J Bone Joint Surg, 2006, 88B (Suppl 2):21

KCE        

Chronische Lage Rugpijn (Chronic low back pain)

Federaal Kenniscentrum voor de Gezondheidszorg (KCE)

2006, KBC Reports, Vol 48 A

Kelsey JL, Githens PB, O'Conner T, Weil U, Calogero JA, Holford TR, White AA 3rd, Walter SD, Ostfeld AM, Southwick WO

Acute prolapsed lumbar intervertebral disc. An epidemiologic study with special reference to driving automobiles and cigarette smoking

Spine, 1984, 9:608

Kelsey JL, White AA 3rd

Epidemiology and impact of low-back pain

Spine, 1980, 5:133

Kuslich SD, Ulstrom CL, Michael CJ

The tissue origin of low back pain and sciatica. A report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia

Orthop Clin North Am, 1991, 22:181

M

Maetzel A, Li L

The economic burden of low back pain. A review of studies published between 1996 and 2001

Best Pract Res Clin Rheumatol, 2002, 16:23

Manchikanti L

Epidemiology of low back pain

Pain Physician, 2000, 3:167

Manek NJ, MacGregor AJ

Epidemiology of back disorders. Prevalence, risk factors, and prognosis

Curr Opin Rheumatol, 2005, 17:134

Maniadakis N, Gray A

The economic burden of back pain in the UK

Pain, 2000, 84:95

McIntosh G, Frank J, Hogg-Johnson S, Bombardier C, Hall H

Prognostic factors for time receiving workers' compensation benefits in a cohort of patients with low back pain

Spine, 2000, 25:147

Modic MT, Ross JS

Lumbar degenerative disk disease

Radiology, 2007, 245:43

Moffett JK, Richardson G, Sheldon TA, Maynard A

Back pain. Its management and cost to society

The University of York, 1995, discussion paper 129

N

Nordby EJ Epidemiology and diagnosis in low back injury

Occup Health Saf, 1981, 50:38

P

Papageorgiou AC, Croft PR, Ferry S, Jayson MI, Silman AJ

Estimating the prevalence of low back pain in the general population. Evidence from the South Manchester Back Pain Survey

Spine, 1995,20:1889

Pengel LH, Herbert RD, Maher CG, Refshauge KM

Acute low back pain: systematic review of its prognosis

Brit Med J, 2003, 327:323

Praemer A, Furner S, Rice DP

Musculoskeletal conditions in the United States

American Academy of Orthopaedic Surgeons, 1992

R

Rizzo JA, Abbott TA 3rd, Berger ML 

The labor productivity effects of chronic backache in the United States

Med Care, 1998, 36:1471

Rozen M        Epidemiological evidence on back pain

In: Back pain

Report of a CSAG (Clinical Standards Advisory Group) Committee on back pain

London, HMSO, May 1994:9

Rubin DI        Epidemiology and risk factors for spine pain

Neurol Clin, 2007, 25:353

S

Seitz R, Schweikert B, Jacobi E, Tschirdewahn B, Leidl R

Economic rehabilitation management among patients with chronic low back pain. Article in German

Schermz, 2001, 15:448

Shekelle PG, Delitto AM

Treating Low back pain

The Lancet, 2005, 365:1987

Shvartzman L, Weingarten E, Sherry H, Levin S, Persaud A

Cost-effectiveness analysis of extended conservative therapy versus surgical intervention in the management of herniated lumbar intervertebral disc

Spine, 1992,17:176

T

Taimela S, Kujala UM, Salminen JJ, Viljanen T

The prevalence of low back pain among children and adolescents. A nationwide, cohort-based questionnaire survey in Finland

Spine, 1997, 22:1132

U

Urban JPG, Roberts S

Degeneration of the intervertebral disc

Arthritis Res Ther, 2003, 5:120

V

van Tulder MW, Koes BW, Bouter LM

A cost-of-illness study of back pain in The Netherlands

Pain, 1995, 62:233

Volinn E        The epidemiology of low back pain in the rest of the world. A review of surveys in low- and middle-income countries

Spine, 1997, 22:1747

W

Waddell G        

A new clinical model for the treatment of low-back pain. 1987 Volvo award in clinical sciences

Spine, 1987, 12:632

Waddell G        

Low back disability. A syndrome of Western civilization

Neurosurg Clin N Am, 1991, 2:719

Waddell G        

Low back pain. A twentieth century health care enigma

Spine, 1996, 21:2820

Waddell G        

The back pain revolution

Churchill Livingstone, 2004, 2nd edition

Waddell G, Morris EW, Di Paola MP, Bircher M, Finlayson D

A concept of illness tested as an improved basis for surgical decisions in low-back disorders

Spine, 1986,11:712

Walker BF        

The prevalence of low back pain. A systematic review of the literature from 1966 to 1998

J Spinal Disord, 2000, 13:205

Watson KD, Papageorgiou AC, Jones GT, Taylor S, Symmons DP, Silman AJ, Macfarlane GJ

Low back pain in schoolchildren. Occurrence and characteristics

Pain, 2002, 97:87

Y

Yelin E        Cost of musculoskeletal diseases. Impact of work disability and functional decline

J Rheumatol Suppl, 2003, 68:8