Chronischer Rückenschmerz

Background

The aim of the study was to replicate the different reaction groups: “Fröhlicher Durchhalter (FD)” who are characterised by a positive mood and endurance strategies, “Depressiver Durchhalter (DD)” with depressive mood and cognitions to hold on and “Depressiver Vermeider (DV)” who are depressed with social and physical avoidance strategies. The replication was conducted with more feasible methods than the Kiel Pain Inventory (KPI), which had been frequently used in former research. This might effectuate a superior intervention outcome.

Patients/methods

The sample (n=290) consisted of patients after their first nucleotomy at the beginning of the inpatient medical rehabilitation. Selection of the scales was based on cognitive-emotional and behavioural pain characteristics. Therefore 14 scales of generic standardised questionnaires were investigated

Results

The cluster analysis revealed two heterogeneous groups: the FD (n=203, 75.7%) and DV (n=65, 24.3%). MANOVA showed significant differences between both groups (Wilks’ lambda: F (14,253)=30.97; p<.001); especially the emotional pain characteristics were relevant.

Conclusion

The study contributes to the methodological stability of two postulated groups. Thus further research should foster the development of risk-based interventions to evaluate if these groups offer an appropriate differentiation in rehabilitation.     

Körperbild und Rückenschmerz

Background

Many factors seem to be causal for non-specific low back pain and are sometimes controversially discussed. Some years ago the concept of subjective body image attracted attention but due to the inconsistent use of terms and concepts it is difficult to classify publications in the literature. Studies confirmed a difference between the body images of patients with low back pain and healthy controls so that an inclusion of body image concepts could be relevant for causation and therapy.

Objective

This article presents an overview of the current state of research on the association between body image and low back pain and with respect to the allocation of body image in psychosocial concepts of low back pain.

Material and methods

Relevant studies on body image and low back pain were reviewed and are discussed with respect to the different use of terms and concepts of body image. Moreover, an approach for integration of the body image into current psychosocial concepts and therapy of low back pain is presented. Finally, it is discussed whether consideration of the body image could be of value in the therapy of low back pain.

Results

Studies have shown that low back pain patients have a more negative body image compared to healthy controls. There is a lack of studies on clinical evidence for the application and effectiveness of interventions that influence the body image in low back pain.

Conclusion

Further studies are necessary which include body image concepts as a possible psychosocial risk factor, in particular studies on the mechanism of body image procedures.

     

Diskogener Rückenschmerz und degenerative Spinalstenose

Surgery in acute and/or chronic low back pain is still a matter of intensive and controversial discussions. A vast number of minimally invasive or so called semi-invasive procedures have been published in the last 3 decades, but evidence-based data on efficacy and benefit of most of these techniques are still lacking. However, empirical data suggest good or at least satisfactory clinical results for a limited number of procedures if they are applied under restrictive indication criteria. Discogenic low back pain and lumbar spinal stenosis belong to the most frequent diagnoses associated with low back pain. This article gives a survey on definitions, indication criteria and modern surgical or semi- invasive techniques used for the treatment of these two pathologic entities. Discogenic low back pain: This clinical and morphological entity is defined as low back pain arising mainly from disc degeneration. Pain generators are usually nociceptors in the cartilaginous endplates, in the outer anulus fibrosus as well as in the periosteum of the vertebral bodies. Clinical symptoms correlate with morphologic changes detected with MR-imaging (modic type I) or with contained disc protrusions mainly without neurological symptoms. Surgery is rarely indicated, spontaneous remissions occur in more than 60% of all cases. Spinal fusion has been the only surgical option in cases which did not respond to conservative therapy. Recently, electro-thermal modulation of the posterior anulus fibrosus has been published as a semi- invasive technique to relieve low back pain generated by fissures in the outer anulus and ingrowing nociceptors (intradiscal electro-thermal therapy, IDET(TM)). First results are promising, however, prospective randomised studies comparing this technique with conservative therapy are still lacking. The same is true for artificial nucleus pulposus replacement using hydrogel cushions implanted in the intervertebral space after removal of the nucleus pulposus from posterior or through an anterior approach (PDN, prosthetic disc nucleus(TM)). In cases with severe disc degeneration total disc replacement is another innovative option (ProDisc(TM)). Two metal endplates with titanium surface coating are implanted through a minimal invasive anterior approach (mini-laparotomy). A polyethylene inlay anchored in the caudal endplate holds the distance between the endplates and preserves the physiological range of motion between the two vertebral bodies. Degenerative lumbar spinal stenosis: Narrowing of the spinal canal due to degenerative changes of the disc, the facet joints and thickening of the yellow ligament is a geriatric disease which is diagnosed in increasing numbers within the last 10 years. More than 80% of the patients present with low back pain in association with neurogenic claudication. Neurological symptoms at rest are less frequently found. The spontaneous course shows progressive symptoms in more than 50% of all patients. More than 35% of the patients have associated diseases which might influence the perioperative course, complication rates and outcomes of surgery. Surgery is indicated in patients with progressive neurological symptoms, unacceptable decrease of quality of life or progressive intractable pain. In patients with mainly "leg symptoms" microsurgical mono- or multisegmental decompression is the procedure of choice. If low back pain is predominant and associated with degenerative instability such as degenerative spondylolisthesis or lumbar scoliosis, decompression must be combined with instrumented spinal fusion. In general a restrictive indication for surgery must be recommended especially for spinal fusion procedures. Non-fusion techniques such as intradiscal electro thermal therapy or spine arthroplasty with replacement of nucleus pulposus or total disc show promising early results; however, little is known about the long-term effect. It should be a principle to apply surgery in the least invasive way.     

Der anatomische Hintergrund von Rückenschmerz

The central and lateral lumbar canals constitute complex osteofibrous neurovascular tunnels, allowing movement and deformation of the spine without loss of their main configuration. Intervertebral discs play an important role in determining their configuration. Disc degeneration may alter or even threat the functional anatomical relationships between successive adjacent "juncturae" of the vertebral column. Shape and morphometric aspects of the bony neural canals reveal level dependency [39], inter-individual variation [11], and are particularly susceptible for changes with aging [49]. Articular tropism and other left-right differences may influence their morphology. In the epidural compartments behind the vertebral bodies, a sagittal membrane may totally or partly connect the deeper layer of the posterior longitudinal ligament (PLL) with the posterior midline of the vertebral body. This membrane is considered clinically significant in the prevention of movement of disc material from one side to the other at the level of the vertebral bodies [44]. Meningovertebral ligaments represent a heterogenous group of membranous formations, connecting the dura with the PPL and other elements of the spinal canal. They prevent the dura from moving away from the bony container. These ligaments may vary from loose areolar tissue to clearly individualised ligaments and from pure midsagittal septa to more laterally oriented attachments. A double cross vault structure between the PPL and the dura mater often extends from L3 to the end of the dural envelope [3]. A retrospective study of medial and paramedial attachments in CT- and MRT-scans confirmed the presence of a mediosagittal structure below L3 in 35% of the cases 7). It was hypothesized that meningovertebral ligaments may play a [7] role as a barrier to transverse displacement of extruded disc material [43]. The surrounding morphology renders the lateral neural canal its typical inverted teardrop shape [39]. The subpedicular notch of the upper vertebra provides the widest part and represents the neural foramen strictu sensu. The posterolateral aspect of two articulating vertebrae and the interposed intervertebral disc constitute the anterior wall. The morphology of the anteroinferior aspect of the intervertebral foramen strongly depends on the condition of the apophyseal rings and the intervertebral disc. The latter may show a slight physiological posterior bulging at lower lumbar levels. The posterior wall of the nerve root canal is represented by the ligamentum flavum, the pars interarticularis of the upper vertebra, and the superior articular facet of the vertebra below. Thickening of the ligamentum flavum must be considered in relationship to alterations of anterior components: trabecular reorganization and spreading of vertebrae in aging [49], and disc degeneration [38, 49]. Nerve root sleeves display a level dependent, variable oblique course from their emanation from the thecal sac towards the outer third of the neural canal [39]. The presence of anamalous lumbosacral nerve roots may result in considerable course alterations, originating from an abnormal high or low level emanation, conjoined nerve roots, a double set of nerve roots or anastomosis between nerve roots of adjacent levels [20]. Variation exists in the position of the dorsal root ganglia (DRG) relative to the intervertebral foramen. An intraforaminal position seems to be more common at L4 and L5 levels; an intraspinal position has to be expected for the S1 DRG. Intraspinal position of L4 and L5 DRG renders them more susceptible to compression from a superior articular facet or a bulging disc. Cases of extraforaminal positions of dorsal root ganglia have been reported at L4 and L5 levels [22]. On its recurrent course through the lateral canal, the sinuvertebral nerve(s) supplies the laterodorsal outer annulus of the intervertebral disc, the PLL, the anterior 2/3 of the dural sac and the anterior vascular plexus [4, 14]. Many blood vessels pass through the lateral neural canal: the anterior and posterior spinal canal branches, anterior and posterior radicular branches, and veins of the anterior and posterior internal vertebral venous plexus [9]. Per segment, one ore two thick and one to four thin sinuvertebral nerves (SVN) originate from rami communicantes close to the connection of the latter to the spinal nerve [14]. The extensive ramifications of the thin SVNs complete a thorough network at the floor of the central lumbar canal. A large part of it supplies the PLL. The PLL is assumed to play an important role in proprio- and nociception [34, 39]. It is probably one of the first structures to mediate nociceptive information from disc tissue [14]. After injection of neuronal tracers into the sympathetic trunk at L3-L4 in rats, labeled cells were found in higher DRGs as well as labeled nerve fibers in the dura mater at lower levels. These findings indicate both a segmental and a non segmental pathway of sensory innervation of the dura mater and a role of higher DRGs in mediating LBP [25]. In the neighborhood of the SVN, other small branches emanate from the rami communicantes and join the dorsal ramus and the segmental artery that enters the neural canal. The sympathetic nerve plexus inside the anterior longitudinal ligament and the SNVs provide a network of nerve fibers around the vertebral bodies and intervertebral discs. These pathways explain the sympathetic component of the innervation of a number of spinal structures. The dorsal ramus innervates the facet joints at the corresponding level and one below, before it gives off muscular and cutaneous branches.     

Zentrale Schmerzverarbeitung bei chronischem Rückenschmerz

Introduction

A study of patients with low back pain (LBP) had revealed altered central pain processing. At an equal pain level LBP patients had considerably more neuronal activation in the somatosensory cortices than controls. In a new analysis of this dataset, we further investigated the differences in central pain processing between LBP patients and controls, looking for possible pathogenic mechanisms.

Methods

Central pain processing was studied by functional magnetic resonance imaging (fMRI), using equally painful pressure stimuli in a block paradigm. In this study, we reanalyzed the fMRI data to statistically compare pain-elicited neuronal activation of both groups.

Results

Equally painful pressure stimulation resulted in a significantly lower increase of regional cerebral blood flow (rCBF) in the periaqueductal gray (PAG) of the LBP patients. The analysis further revealed a significantly higher increase of rCBF in LBP than in HC in the primary and secondary somatosensory cortex and the lateral orbitofrontal cortex (LOFK), elicited by these same stimuli.

Conclusions

These findings support a dysfunction of the inhibitory systems controlled by the PAG as a possible pathogenic mechanism in chronic low back pain.     

Hirnmetabolische Veränderungen bei chronischem Rückenschmerz

Background

The manifestation of chronic pain and psychological impairments are related to alterations of neurotransmitter metabolism in cerebral pain processing regions, e.g., anterior cingular cortex (ACC), insula. Magnetic resonance spectroscopy (¹H-MRS) enables in vivo quantification of neurotransmitters in the brain and was applied in this study to examine the hypothesized chronic pain-related imbalance between excitatory (glutamatergic) and inhibitory (GABA-ergic) neurotransmitter turnovers in the brain of patients with nonspecific chronic pain.

Materials and methods

A total of 19 patients with nonspecific chronic (>?3 months) back pain and 19 age- and gender-matched healthy subjects participated in this study. Glutamate and GABA as well as glutamate/GABA ratios were determined in the ACC and insula using ¹H-MRS. Sociodemographic, psychological, and pain-related features were measured with standardized questionnaires.

Results

There was a strong variance of glutamate/GABA ratios for both patients and healthy subjects with no significant difference between the two groups. Regression analysis revealed certain significant predictors, such as anxiety as causal variable for reduced glutamate and depression and age as predictors for reduced GABA in ACC. In the patient group, intensity of pain was a significant predictor for glutamate and GABA levels in the insula.

Conclusions

Despite the uniform diagnosis of nonspecific chronic back pain, we observed a strong variance of neurotransmitters in cerebral pain processing regions. It is necessary to include psychological as well as clinical parameters (e.g., intensity of pain or depression) for a proper interpretation of neurotransmitter turnovers.

     

Psychosoziale Risikofaktoren für chronischen Rückenschmerz in der Allgemeingesellschaft und im Leistungssport

Background

Lumbar back pain and the high risk of chronic complaints is not only an important health concern in the general population but also in high performance athletes. In contrast to non-athletes, there is a lack of research into psychosocial risk factors in athletes. Moreover, the development of psychosocial screening questionnaires that would be qualified to detect athletes with a high risk of chronicity is in the early stages. The purpose of this review is to give an overview of research into psychosocial risk factors in both populations and to evaluate the performance of screening instruments in non-athletes.

Methods

The databases MEDLINE, PubMed, and PsycINFO were searched from March to June 2016 using the keywords “psychosocial screening”, “low back pain”, “sciatica” and “prognosis”, “athletes”. We included prospective studies conducted in patients with low back pain with and without radiation to the legs, aged ≥18 years and a follow-up of at least 3 months.

Results

We identified 16 eligible studies, all of them conducted in samples of non-athletes. Among the most frequently published screening questionnaires, the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) demonstrated a sufficient early prediction of return to work and the STarT Back Screening Tool (SBT) revealed acceptable performance predicting pain-related impairment. The prediction of future pain was sufficient with the Risk Analysis of Back Pain Chronification (RISC-BP) and the Heidelberg Short Questionnaire (HKF).

Conclusion

Psychosocial risk factors of chronic back pain, such as chronic stress, depressive mood, and maladaptive pain processing are becoming increasingly more recognized in competitive sports. Screening instruments that have been shown to be predictive in the general population are currently being tested for suitability in the German MiSpEx research consortium.

     

Effekte eines interdisziplinären Functional-restoration-Behandlungsprogramms mit kognitiv-behavioraler Therapie beim chronischen Rückenschmerz

Introduction

The efficacy of functional restoration programs for the treatment of chronic back pain is well documented. Nevertheless, there are only a few such centres in Germany and few trials have been conducted in German-speaking regions to demonstrate that implementing such programs in everyday clinical settings with large numbers of patients is just as effective as in a research setting. The present study examined whether the positive effects of such programs can also be observed in the clinically relevant context of a standardized day clinic treatment regimen.

Material and methods

A total of 681 back pain patients in 2 German cities were examined at 4 measurement points (before and immediately after the program, as well as 6 and 12 months after treatment) using a comprehensive questionnaire on perceived pain and symptoms of anxiety and depression, as well as the work situation.

Results

In both cities significant and long-term improvements in back pain, pain-related impairment and degree of chronification were observed, as well as a high return-to-work rate after treatment. Hence, the quality of such programs was also confirmed for a large patient population.     

R��ckenschmerz und Sozialschicht bei Berufst?tigen

Background

Little empirical evidence is available on differential associations between social status indicators and back pain in Germany. This study therefore systematically evaluated associations between different indicators of social status and back pain.

Methods

In total 4,412?employed adults, aged 18 to 65?years participated in a postal survey in 5?regions of Germany. The point prevalence and 1-year prevalence of back pain were assessed as well as the level of disabling back pain. Educational level, professional category and household income served as measures of social status. Associations between social status and back pain have been assessed cross-sectionally using Poisson regression.

Results

Educational level was the best predictor for back pain among the assessed social status indicators. Adults with a low educational level had almost a 4-fold risk of reporting disabling back pain compared to subjects with a high educational level. Associations were highest for disabling back pain and attenuated strongly over the point prevalence towards the 1-year prevalence.

Discussion

Back pain cannot generally be regarded as a symptom of a low social status. However, social inequality is of major importance regarding the prediction of severe back problems. A better understanding of mediating factors is essential for the prevention and therapy.     

Psychosoziale Faktoren der Schmerzchronifizierung bei Patienten in der stationären orthopädischen Rehabilitation von chronisch unspezifischem Rückenschmerz

Background

The aim of this study was to investigate the criterion validity of the Mainz Pain Staging System (MPSS), considering the four axes of the MPSS separately.

Methods and design

Psychological and pain-related impairments were analysed depending on the stage of axis (I, II, III) for each single axis of the MPSS in a consecutive sample of 280 patients with chronic low back pain in orthopaedic inpatient rehabilitation. In addition, the distribution of frequency of clinically significant symptoms in depression, anxiety and somatisation were examined depending on the stage of axis.

Results

For all axes, an increasing stage was associated with greater psychological and pain-related impairments. Particularly patients assigned to stage III on axis 1 (temporal aspects) and 2 (spatial aspects) and patients assigned to stage II on axis 3 (drug intake) and 4 (utilisation of the health care system) showed enhanced psychosocial impairments and more frequently had clinically relevant symptoms in psychological variables.

Conclusion

Findings confirm the criterion validity of the MPSS for chronic low back pain. In addition, results support the significance of psychosocial factors for the further development of chronicity.     

Ver?nderte Beckenmuskelaktivierung bei Patienten mit chronischem nichtspezifischem R��ckenschmerz

Background

The aim of this study was to examine postural control in patients with chronic non-specific low back pain (CNRS). Furthermore the influence of visual information (eyes open versus eyes closed) was analyzed.

Material and methods

A total of 8?patients with CNRS and 12?healthy control subjects were examined. Surface electromyography (SEMG) recordings were made from 5?trunk and 5?lower limb muscles as well as one hip muscle during application of distal lateral perturbation.

Results

Healthy controls (mean?±?standard deviation: 96.42±64.77???V) showed a significantly higher maximum amplitude of the gluteus medius muscle in comparison to patients with CNRS (56.29±39.63???V). Furthermore activation of several lower limb muscles was found to be dependent on visual information.

Conclusion

Patients showed an altered reflex response of the gluteus medius muscle which could be associated with reduced hip stability.     

Rückenmarknahe Schmerztherapie

Ohne Zusammenfassung     

Besteht ein Zusammenhang zwischen Rückenschmerz und der Stabilit?t der lumbalen Wirbels?ule in der Schwangerschaft?

During pregnancy approximately 50% of women suffer from low back pain (LBP), which significantly affects their everyday life. The pain could result in chronic insomnia, limit the pregnant women in their ability to work and produce a reduction of their physical activity. The etiology of the pain is still critically discussed and not entirely understood. In the literature different explanations for LBP are given and one of the most common reasons is the anatomical changes of the female body during pregnancy; for instance, there is an increase in the sagittal moments because of the enlarged uterus and fetus and the occurrence of hyperlordosis.The aim of this study was to describe how the anatomical changes in pregnant women affect the stability and the moments acting on the lumbar spine with the help of a simplified musculoskeletal model.A two-dimensional musculoskeletal model of the lumbar spine in the sagittal plane consisting of five lumbar vertebrae was developed. The model included five centres of rotation and three antagonistic pairs of paraspinal muscles. The concept of altered acting torques during pregnancy was explored by varying the geometrical arrangements. The situations non-pregnant, pregnant and pregnant with hyperlordosis were considered for the model-based approach. These simulations were done dependent on the stability of the erect posture and local countertorques of every lumbar segment.In spite of the simplicity of the model and the musculoskeletal arrangement it was possible to maintain equilibrium of the erect posture at every lumbar spinal segment with one minimum physiological cross-sectional area of all paraspinal muscles. The stability of the musculoskeletal system depends on the muscular activity of the paraspinal muscles and diminishing the muscular activity causes unstable lumbar segments.The relationship between the non-pregnant and the pregnant simulations demonstrated a considerable increase of acting segmental countertorques. Simulating an increased lordosis for the pregnant situation in the sagittal plane substantially reduced these acting countertorques and therefore the demand on the segmental muscles.It is assumed that hyperlordosis is a physiological adaptation to the anatomical changes during pregnancy to minimize the segmental countertorques and therefore the demand on the segmental muscles.Further, it can be expected that an enhanced muscle activity caused by selective activity of lumbar muscles increases the stability of the lumbar spine and may improve the situation with LBP during pregnancy.     

?Rücken-Coach“

Question

Back pain is a challenge for case management but is a health insurance fund (HIF) that identifies high risk patients and includes them in a back pain assessment and a multimodal program cost-effective?

Methods

Case managers of a HIF contacted selected patients and requested information on pain and current perspectives. Patients in the intervention group were offered a multimodal assessment and, if applicable, a multimodal treatment program. Control group patients received verbal or written (back book) information. Cost data were evaluated with respect to the interview data 1 year prior and 1 year afterwards.

Findings

Of the 800 insured persons contacted 621 were nationwide, 88 were regional controls and 91 were intervention patients. Inability to work was still rising in all groups but less in the intervention group versus both control groups. Drugs, hospital as well as cure/adjuvant costs were less for intervention patients than in both control groups. The investment for the program was thus more than refinanced.

Interpretation

Case management was well accepted but the intervention was in need of training for case managers and the specific diagnostic and treatment option regionally.

Funding

The HIF was responsible for the study investment and project partners shared the training of the HIF regional case managers.     

Rückfußarthroskopie

Hindfoot arthroscopy is a minimally invasive surgical method for treatment of Haglund’s deformity and pathologies of the posterior ankle and subtalar joints. From June 2006 to December 2008 a total of 53 patients were treated with hindfoot arthroscopy of which 46 patients were available for follow-up. The AOFAS hindfoot score improved from an average of 60 points preoperatively (range 42–80 points) to 90 points (50–105) postoperatively (p <0.001). The postoperative Hannover score averaged 91 points (76–100 points). Pain on the visual analog scale (VAS) improved significantly from 7.3 (3–10) to 1.8 (0–5). In the following paper the indications and technique of hindfoot arthroscopy are described.     

Differenzialtherapie lumbaler Rückenschmerzen

Background

Back pain patients present with complex symptomatology. To demonstrate the possibilities of primary treatment viewed from the perspective of manual medicine, treatment data covering a period of 2.5 years of patients consulting a general practitioner for complaints of “lumbar back pain” were analyzed.

Results

In more than 90% of these patients, manual medical examination was able to detect conditions such as segment obstruction, myofascial trigger points, static imbalance, and psychosomatic disorders. Further paraclinical tests and imaging diagnostics were only needed in exceptional cases to distinguish potentially dangerous processes. It was not possible to prevent a decline in social status in only 1% of the cases due to lumbar back pain that was considerably influenced by psychosomatic factors.

Conclusion

Differential therapy of the findings based on aspects of manual medicine including psychosomatic interventions proved to be extraordinarily effective, long-lasting, and without side effects when applied for primary treatment in the family practice setting.     

Akupunktur bei Rückenschmerzen

BACKGROUND: Acupuncture is commonly used to treat back pain. A meta-analysis of clinical trials of acupuncture for this condition came to a positive conclusion whilst a qualitative review was negative. AIM: To compare our meta-analysis of trials of acupuncture for the treatment of back pain with a qualitative review and the most recent studies on the subject. METHODS: A systematic literature search was conducted to retrieve all randomised controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture was assessed by consulting six experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of subjects who where improved at the end of treatment. These data are discussed in relation to the qualitative review and the most recent studies. RESULTS: Twelve studies were included of which nine presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval 1.28 to 4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25). The results from the majority of the most recent studies also support the effectiveness of acupuncture in the treatment of back pain. CONCLUSIONS: Collectively, these data imply that acupuncture is superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.     

Diagnostik des Rückenschmerzes

Many different diagnostic procedures are used in patients with low back pain. Medical history and clinical examination, X-rays, computed tomography (CT)-scan, magnetic resonance imaging (MRI), diagnostic nerve root blocks and facet injections, functional tests in physiotherapy, strength tests of trunk muscles and work-related performance, and psychological and social evaluation including psychometric tests are only some of them. Despite this large number of procedures available, the scientific literature has not changed its conclusion that in about 80% of all back pain episodes the cause remains unknown. During the course of back pain episodes the relevant factors may change. The cause of the problem or the triggering factor of the pain episode may no longer be important during subacute stages, while others may be decisive for the transition to chronic stages. Thus, assessment of the cause is different from that of prognostic factors. There seems to be no consistent distribution of causes or ongoing factors in the population(s) of patients. While individual social factors may be the one important factor in one patient, functional and structural factors may be significant in another patient. Clinical examination is important, but several problems occur in the evaluation of patients with low back pain. Due to their anatomical location, important bony structures of the lumbar spine, e.g., disks or facet joints, are difficult to access by clinical examination. Additionally, there are only few diagnostic tests during clinical examination that do not rely on the patient's cooperation or communication. The term "unspecific back pain" for the majority of patients is scientifically sound, because it reflects the fact that the cause is unknown. It must be taken into consideration that this term enjoys only limited acceptance by both patients and physicians. Physicians are in charge of certifying work disability by assessing the interference of the patient's illness/disease with the specific requirements of his daily life or job. However, in clinical practice both the job tasks and the patient's abilities to perform these tasks with the given symptoms and signs is still difficult to evaluate and requires further definition.