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AUTORES Acute Low Back Problems Guideline Panel Stanley J. Bigos, MD, Chair Orthopedic Surgery Dr. Bigos is Professor of Orthopedic Surgery and Environmental Health at the University of Washington School of Medicine and founder and director of the Spine Resource Clinic in Seattle. He is the author of numerous articles and book chapters focusing on back problems in industry and the management of back pain. He has contributed to a new method of spine evaluation included in the American Medical Association's "Guidelines to Evaluate Permanent Impairment, 4th edition, 1993" and also serves as Consultant to the Clinical Standards Advisory Group of the British Department of Health. Among his many honors, Dr. Bigos received from the American Academy of Orthopaedic Surgeons in 1991 the Kappa Delta Award for Orthopedic Excellence for his sentinel work on industrial back problems. Rev. O. Richard Bowyer Consumer Rev. Bowyer has experienced low back pain for many years. He is campus minister at Fairmont State College, West Virginia, and also serves on the Board of Directors and Quality Assurance Committee of the Monongahela Valley Association of Health Centers. From 1981-1993 he was a consumer member of the West Virginia Board of Medicine and served as chairperson of the Board's Complaints Committee. G. Richard Braen, MD Emergency Medicine Dr. Braen is a practicing emergency physician at Buffalo General Hospital and Professor and Chairman of the Department of Emergency Medicine at State University of New York, Buffalo. Certified by both the American Board of Emergency Medicine and the American Board of Internal Medicine, he has served on several guideline panels established by the American College of Emergency Physicians. He is currently President of the American Board of Emergency Medicine. Kathleen Brown, PhD, RN Occupational Health Nursing Dr. Brown is Professor in the School of Nursing of the University of Alabama at Birmingham and director of Occupational Health Nursing for the NIOSH-funded Educational Resource Center for Occupational Health and Safety. Her research and publications have focused on the cst-effectiveness of back school interventions and the effect of back school education and exercise on back-injured municipal workers. She is principal investigator of an NIH-funded study of worksite education and exercise to prevent back injuries. Richard Deyo, MD, MPH Internal Medicine Dr. Deyo, a general internist, is Professor in the Departments of Medicine and Health Services at the University of Washington School of Medicine, and staff physician at the Seattle Veterans Affairs Medical Center. He is principal investigator of the low back pain Patient Outcome Research Team (PORT) and has published widely on the diagnosis and treatment of low back problems in primary care and on the measurement of quality-of-life and outcomes of surgery for patients with back pain. Scott Haldeman, DC, MD, PhD Neurology/Chiropractic Dr. Haldeman is trained in chiropractic and is board certified in neurology, neurophysiology and electrodiagnosis. He is an Associate Clinical Professor of Neurology at the University of California, Irvine, and an Adjunct Professor at Los Angeles Chiropractic College. He is past president of the North American Spine Society and the North American Academy of Manipulative Medicine and has published widely in the fields of electrodiagnosis, spinal manipulation, and back pain. John L. Hart, DO Rehabilitation Medicine Dr. Hart serves as Director of Outpatient Physical Medicine and Rehabilitation at Still Regional Medical Center in Columbia, Missouri. His research interests include nonoperative treatment of herniated discs and the relationship of employee/employer interactions to the symptoms of low back pain. Ernest W. Johnson, MD Physical Medicine/Rehabilitation Dr. Johnson served for 25 years as Chair of the Department of Physical Medicine and Rehabilitation at the Ohio State University College of Medicine before assuming his present position as Professor and Associate Dean for External Affairs. He is past president of the American Academy of Physical Medicine and Rehabilitation, the Association of Academic Physiatrists, and the American Association of Electrodiagnostic Medicine. The author of numerous articles on electromyography, he serves as Chair of the American Board of Electrodiagnostic Medicine. Robert Keller, MD Orthopedic Surgery Dr. Keller serves as Executive Director of the Maine Medical Assessment Foundation and is a member of the Council on Health Policy and Practice of the American Academy of Orthopaedic Surgeons. He is co-investigator of the Patient Outcomes Research Team (PORT) evaluating low back pain and surgical outcomes and has published on the subject of small area analysis and physician behavior change. A past president of the Maine Medical Association, he is an Adjunct Professor of Community and Family Medicine and Surgery in the Dartmouth Medical School. Daniel Kido, MD, FACR Radiology Dr. Kido is a Professor of Radiology and Director of the Neuroradiology Section of the Mallinckrodt Institute of Washington University School of Medicine in St. Louis, Missouri. His research and publications have focused on the assessment of imaging techniques to evaluate low back pain, including MRI, CT, and myelography. He has also compared invasive and noninvasive imaging procedures of the low back, documenting frequency of complications. Matthew H. Liang, MD, MPH Internal Medicine/Rheumatology Dr. Liang is an Associate Professor in the Departments of Medicine and Rheumatology at Harvard Medical School. He also serves as medical director of rehabilitation services at the Brigham and Women's Hospital in Boston. His major research interests include outcome assessment of low back problems, cost-effectiveness of diagnostic procedures, and outcomes of spinal stenosis surgery. Roger M. Nelson, PT, PhD Physical Therapy Dr. Nelson is Professor and Chairman of the Department of Physical Therapy at the Thomas Jefferson University College of Allied Health Sciences. His clinical interests include electromyography and measurements of outcome and satisfaction of low back pain patients. He is a contributor to the National Institute of Occupational Safety and Health (NIOSH) Low Back Atlas on the subject of tests and measures for the assessment of low back pain. Margareta Nordin, RPT, DrSci Orthopedic Research Dr. Nordin is Research Associate Professor and Director of the Occupational and Industrial Orthopaedic Center of the Hospital for Joint Diseases in New York City. Her primary research interest is the prevention of chronicity among patients with low back pain. She has published extensively on the biomechanics, ergonomics, and early care of low back pain. Bernice D. Owen, PhD, RN Community Health Nursing Dr. Owen is a Professor in the School of Nursing of the Center for Health Sciences, University of Wisconsin, Madison. Her work as a teacher and researcher has focused on back stress among health care personnel and the reduction of physical demands on the back in occupational settings. She currently serves as a consultant on back injury reduction programs to hospitals, long-term care facilities, and home care agencies. Malcolm H. Pope, DrMedSc, PhD Orthopedic Research/Biomedical Engineering Dr. Pope is Professor of Biomedical Engineering at the University of Iowa and serves as Director of the Iowa Spine Research Center. Before coming to Iowa, he was Director of Orthopaedic Research at the University of Vermont. His research and numerous publications have focused on the biomechanics of low back pain, ergonomics, and the primary and secondary prevention of low back problems. Richard K. Schwartz, MS, OTR, FSR Occupational Therapy Mr. Schwartz has treated work-related injuries since 1972. He is currently in private practice as an occupational therapy consultant on injury prevention, ergonomics, and early return-to-work programs. Before 1992 he was Associate Professor and Chairman of Occupational Therapy at the University of Texas Health Science Center at San Antonio. Donald H. Stewart, Jr., MD Neurosurgery Until his retirement in 1993, Dr. Stewart was in private practice as a neurosurgeon in Syracuse, New York. He also served as Clinical Assistant Professor of Neurosurgery at the State University of New York, Syracuse. He has published widely on medical economics and medical liability. Jeff Susman, MD Family Practice Dr. Susman is Associate Professor, Director of Primary Care, and Vice Chairperson of the Department of Family Practice at the University of Nebraska Medical Center. A member of the American Academy of Family Physicians' Task Force on Clinical Policies, he is interested in clinical decisionmaking by physicians and the effects of guidelines on health provider behavior. John J. Triano, MA, DC Chiropractic Dr. Triano is a staff chiropractic physician and a clinical research scientist at the Texas Back Institute in Plano, Texas. He coordinates the work of interdisciplinary teams in the rehabilitation of patients with spinal pain and conducts research on spine biomechanics and the outcomes of patients treated for spinal problems. He has served as a consultant to the U.S. Department of Labor and NIOSH training programs and is a Professor at the National College of Chiropractic, Lombard, Illinois. Lucius C. Tripp, MD, MPH, FACPM Industrial Medicine/Neurosurgery Dr. Tripp, a neurosurgeon, is board certified in Occupational Medicine and Addiction Medicine. He serves as Medical Director of the General Motors-Henry Ford Hospital Rehabilitation Center in Warren, Michigan, and is actively involved in research on the prevention of back injury and restoration of function in patients with back pain. He is a member of the Board of Directors of the American College of Occupational and Environmental Medicine. Dennis C. Turk, PhD Psychology Dr. Turk is a Professor in the Departments of Psychiatry and Anesthesiology at the University of Pittsburgh School of Medicine. He serves as Director of the University's Pain Evaluation and Treatment Institute, a large interdisciplinary facility that annually evaluates and treats over 1,500 new patients, the majority of whom have back pain. His current research is directed toward examination of the role of psychological factors in back pain and the accompanying disability. Clark Watts, MD, JD Neurosurgery Dr. Watts is a Professor of Neurosurgery at the University of Texas Health Science Center at San Antonio. As editor of Neurosurgery from 1982-1987, he was responsible for evaluating and publishing research on the care of low back problems. His own research has focused on the nature of discogenic pain and the clinical management (operative and nonoperative) of low back problems. James N. Weinstein, DO Orthopedic Surgery Dr. Weinstein is a Professor in the Departments of Orthopaedic Surgery and Biomedical Engineering and is Director of the Spine Diagnostic and Treatment Center at the University of Iowa Hospitals and Clinics. His research has focused on the basic mechanisms of pain and aging, the diagnosis and treatment of spinal tumors, and the evaluation of outcomes for patients with low back pain. He is currently Editor-in-Chief of the journal Spine. Other Contributors Project Directors John P. Holland, MD, MPH University of Washington Seattle, Washington John S. Webster, MD Naval Regional Medical Center San Diego, California Consultants Michele C. Battie, PhD, PT Orthopedic Research University of Washington Seattle, Washington Claire Bombardier, MD, FRCP Rheumatology/Clinical Epidemiology University of Toronto Toronto, Ontario, Canada Nortin M. Hadler, MD Rheumatology University of North Carolina Chapel Hill, North Carolina Alf L. Nachemson, MD, PhD Orthopaedic Surgery Göteborg University Göteborg, Sweden Gordon Waddell, MD Orthopaedic Surgery Western Infirmary Glasgow, Scotland Methodologists David L. Schriger, MD, MPH UCLA Medical School Los Angeles, California Paul G. Shekelle, MD, MPH Department of Veterans Affairs Medical Center West Los Angeles, California Panel Staff Mary M. Webster, MA Seattle, Washington Laura Novell St. Louis, Missouri Keld Vaegter, MD Ralix, Sweden AHCPR Staff David Lanier, MD, MFA Project Officer Randie A. Siegel Managing Editor Harriet V. Bennett Karen Carp Public Affairs Specialists Peer Reviewers [1] Lucien Abenhaim, MD, MSc, ScD McGill University Montreal, Quebec, Canada Gad Alon, PhD, PT University of Maryland Department of Physical Therapy Baltimore, Maryland Michael Andary, MD Michigan State University College of Osteopathic Medicine East Lansing, Michigan Gunnar B.J. Andersson, MD, PhD Rush-Presbyterian-St. Luke's Medical Center Chicago, Illinois Howard A. Balduc, DC American Chiropractic Association Arlington, Virginia Judith C. Bautch, PhD, RN, CS University of Wisconsin School of Nursing Madison, Wisconsin James R. Bean, MD Neurosurgical Associates Lexington, Kentucky Alfred O. Berg, MD, MPH University of Washington Seattle, Washington Stephen Blood, DO American Academy of Osteopathy Indianapolis, Indiana Wilbur J. Boike, MD Center for Comprehensive Back Care Flint, Michigan Richard H. Borman, MD University of California San Diego, California Albert M. Brady, MD Harris Methodist Health System Fort Worth, Texas Phillip O. Bridenbaugh, MD University of Cincinnati Medical Center Cincinnati, Ohio Jerry M. Calkins, PhD, MD University of Arizona Department of Anesthesiology Phoenix, Arizona J. David Cassidy, DC, PhD Royal University Hospital Department of Orthopaedics Saskatoon, Saskatchewan, Canada C. Richard Chapman, PhD University of Washington Department of Anesthesiology Seattle, Washington Steven G. Charapata, MD Pain Management Associates Kansas City, Missouri Joy White Danches, MOT, OTR Visionary Management, Inc. Dallas, Texas Marsha Courville Davis, MSN, RN, CRRN Association of Rehabilitation Nurses Jackson, Mississippi Douglas E. DeGood, PhD University of Virginia Health Sciences Center Charlottesville, Virginia Anthony Delitto, PT, PhD University of Pittsburgh Pittsburgh, Pennsylvania Mark A. Doyne, MD, FACPE Texas Back Institute Dallas, Texas Daniel A. Dyrek, MS, PT Massachusetts General Hospital Boston, Massachusetts Frank Eismont, MD University of Miami School of Medicine Miami, Florida Maury R. Ellenberg, MD, FACP Wayne State University School of Medicine Detroit, Michigan Julia Faucett, RN, PhD University of California San Francisco, California Morris A. Fisher, MD Loyola University Stritch School of Medicine Chicago, Illinois Gary M. Franklin, MD, MPH University of Washington Occupational Epidemiology Seattle, Washington Todd D. Gastaldo, DC Private Chiropractic Research Sunnyvale, California Sharon J. Gates The Graduate Hospital Philadelphia, Pennsylvania Michael Goertz, MD, MPH Airport Medical Clinic Minneapolis, Minnesota Michael K. Greenberg, MD Uniformed Services University of the Health Sciences Bethesda, Maryland J. Eric Griffiths, DC Wheat Ridge Chiropractic Center Denver, Colorado Daniel T. Hansen, DC, FICC Private Practice of Chiropractic Olympia, Washington Dennis L. Hart, PhD, PT Rehability Corporation Falls Church, Virginia Jodie K. Haselkorn, MD, MPH Veterans Affairs Medical Center Seattle, Washington Stanley A. Herring, MD Puget Sound Sports and Spine Physicians Seattle, Washington Paul D. Howard, PhD, PT Thomas Jefferson University Philadelphia, Pennsylvania Thomas E. Hyde, DC, CCSP American Chiropractic Association Sports Council North Miami Beach, Florida Susan J. Isernhagen, PT Isernhagen & Associates, Inc. Duluth, Minnesota Manucher J. Javid, MD University of Wisconsin Department of Neurosurgery Madison, Wisconsin John H. Juhl, DO American Academy of Osteopathy New York, New York Neil Kahanovitz, MD Anderson Clinic Arlington, Virginia Robert D. Kerns, PhD West Haven VA Medical Center Yale University West Haven, Connecticut Myron M. LaBan, MD, FACP William Beaumont Hospital Department of Physical Medicine and Rehabilitation Royal Oak, Michigan Ruth A. Larkin, RN North Colorado Medical Center Greeley, Colorado Casey K. Lee, MD New Jersey Medical School Department of Orthopaedics Newark, New Jersey Daniel Lessard Back Health Medical Centers Seattle, Washington Stephen M. Levin, MD American Academy of Orthopaedic Medicine Vienna, Virginia Philipp M. Lippe, MD, FACS, FACPM American Academy of Pain Medicine Skokie, Illinois Michael D. Lockshin, MD National Institute of Arthritis and Musculoskeletal and Skin Diseases National Institutes of Health Bethesda, Maryland John D. Loeser, MD University of Washington Seattle, Washington Don M. Long, MD, PhD Johns Hopkins University School of Medicine Baltimore, Maryland Sally L. Lusk, PhD, RN, FAAN University of Michigan School of Nursing Ann Arbor, Michigan Norman J. Marcus, MD New York Pain Treatment Program Lenox Hill Hospital New York, New York Stephen C. Marini, MS, DC, PhD Pennsylvania College of Chiropractic Philadelphia, Pennsylvania Tom G. Mayer, MD Southwestern Medical School Department of Orthopedics Dallas, Texas George B. McClelland, DC Foundation for Chiropractic Education and Research Arlington, Virginia William A. McIlwain, MD, FACS Bristol Regional Medical Center Bristol, Tennessee William C. Meeker, DC, MPH Palmer College of Chiropractic-West San Jose, California Christine Miaskowski, RN, PhD University of California San Francisco, California Edward H. Mills, MD U.S. Department of Labor Seattle, Washington Michael Mittelmann, MD Aetna Life and Casualty Hartford, Connecticut Vert Mooney, MD University of California San Diego, California Mary T. Muffroid, PhD, PT University of Vermont Burlington, Vermont Albert M. Murtland, MD Guthrie Clinic Sayre, Pennsylvania David E. Nestor, MS, PT, ECS U.S. Public Health Service Rochester, Minnesota E.J. Nordby, MD University of Wisconsin Medical School Madison, Wisconsin Jane E. Parker-Conrad, PhD, RN Walters State College Morristown, Tennessee Richard Payne, MD University of Texas M.D. Anderson Cancer Center Houston, Texas Reed B. Phillips, DC, PhD Los Angeles College of Chiropractic Whittier, California William R. Phillips, MD, MPH University of Washington Seattle, Washington Vern Putz-Anderson, PhD National Institute for Occupational Safety and Health Cincinnati, Ohio Jan K. Richardson, PT, PhD Slippery Rock University School of Physical Therapy Pittsburgh, Pennsylvania Hubert L. Rosomoff, MD, DMedSc University of Miami School of Medicine Department of Neurological Surgery Miami, Florida Renee Steele Rosomoff, RN, MBA, CRC University of Miami Comprehensive Pain and Rehabilitation Center Miami Beach, Florida Michel Rossignol, MD, FRCPC McGill University Montreal, Quebec, Canada Donald Sheffel, MD Memorial Hospital Division of Neurosurgery Hollywood, Florida Dennis Shubert, MD, PhD Neurosurgical Associates Bangor, Maine Stover H. Snook, PhD Liberty Mutual Insurance Company Hopkinton, Massachusetts Jody L. Snow, PT Sacred Heart Medical Center The Rehabilitation Center Spokane, Washington Dan M. Spengler, MD Vanderbilt University Medical Center Department of Orthopaedics and Rehabilitation Nashville, Tennessee Richard L. Stieg, MD University of Colorado Health Sciences Center Department of Neurology Denver, Colorado Rand S. Swenson, DC, MD, PhD Dartmouth Medical School Hanover, New Hampshire Robert L. Swezey, MD, FACP, FACR Arthritis & Back Pain Center Santa Monica, California Peter J. Vicente, PhD Good Samaritan Hospital Pain Rehabilitation Center Cincinnati, Ohio Nicholas E. Walsh, MD University of Texas Health Science Center San Antonio, Texas Barbara S. Webster, RPT, PA-C American Academy of Physician Assistants Alexandria, Virginia Debra Weiner, MD Duke University Medical Center Durham, North Carolina Arthur H. White, MD San Francisco Spine Institute San Francisco, California John W. Wickenden, MD Penobscot Bay Medical Center Rockport, Maine Sam W. Wiesel, MD Georgetown University Medical Center Department of Orthopaedics Washington, DC Arthur Winter, MD, FICS University of Medicine and Dentistry of New Jersey New Jersey Neurological Institute Livingston, New Jersey Hansen A. Yuan, MD State University of New York Syracuse, New York Pilot Reviewers Douglas A. Benner, MD Kaiser Permanente Oakland, California James E. Blessman, Jr., MD, MPH Wayne State University Detroit, Michigan Michael Erdil, MD Industrial Medical Care Center Hartford, Connecticut Don C. Fisher, MD, MS Presbyterian Occupational Health Network Albuquerque, New Mexico Garry A. Goldstein, MD General Motors Corporation Wilmington, Delaware Robert J. Gorman, MD, MPH Park Nicollet Medical Center Minneapolis, Minnesota Rowland G. Hazard, MD University of Vermont Burlington, Vermont Timothy J. Key, MD, MPH University of Alabama School of Medicine Birmingham, Alabama Ron R. Loeppke, MD, MPH Corporate Health and Medical Programs, Inc. Greeley, Colorado Christel Mottur-Pilson, PhD Internal Medicine Center to Advance Research & Education (IMCARE) Washington, DC Julie Graves Moy, MD, MPH Baylor College of Medicine Houston, Texas Dennis A. Plante, MD University of Vermont Burlington, Vermont Louis Sportelli, DC Private Practice Palmerton, Pennsylvania