The assessment of 'neck' (cervical) and' back' (lumbar) pain is addressed differently in AMA Guides 4 and 5 and this is of critical importance for the changes are complex.
Although records of cases of low back pain are first documented among Egyptians, spinal pain first commonly came to be attributed to injury or trauma in the Victorian era, with the rise of Ehrichsen's 'railway spine' as a diagnosis. The theory was that back pain in people who rode on railroads was due to the excessive speed achieved by steam engine trains. Not co-incidentally, this occurred alongside the rise of the vworkers' compensation system in England, where it was adapted from Bismarck's German model.
Low back pain(LBP) affects more than 70 % of the population in developed countries and poses a major socio-economic cost to countries.The annual incidence in adults is up to 45%, with people aged 35 to 55 years affected most often.Although 90% of episodes of acute LBP resolve within 6 weeks, chronic pain develops in up to 7 % of patients.(SpeedC. Low back pain.BMJ.2004;31:2942-2949).
Approximately 80 % of Americans experience at least one episode of back pain during their lifetime, with 15-20% reporting LBP at some time during a 1-year period.
There are various scientific paradigms for LBP: Idiopathic Paradigm-The Null Hypothesis of Causation; Acute Injury Paradigm; Repetitive Injury(Overuse or Toxological) paradigm; Degenerative (Gompertzian) Paradigm;Chronic Disease Paradigm; Variation of Normal Paradigm;Underuse or Sports Medicine Paradigm; Hormesis/Threshold/Non-Linear J-Curve paradigm and Biophysical & Other Models.
In the repetitive Injury paradigm , NIOSH have identified activities thought to have been harmful to the back(1997).A summary by Waddell lists lifting and heavy vibration as 2 physical factors with "strong evidence" of " moderate effect".According to NIOSH , the recommended weight that should NOT be exceeded assuming ideal lifting conditions and techniques is 51 lb.A small cohort of 10 young military trainees was shown to vastly and repetitively EXCEED NIOSH loading limits during 14 weeks , without MRI evidence of injury.(Ahronys et al.Spine J.Mar 2, 2007).
To further complicate matters, there is a SIGNIFICANT prevalence of ASYMPTOMATIC cervical and lumbar disc protrusion and foraminal stenosis with demonstrable compression of the cord in 7.6 % of asymptomatic subjects, mostly older than 50 years ( Matsumoto M et al.J Bone Joint Surg Br.1998;80-B:19-24); 20% younger than 60 years and 36% older than 60 years were found to have asymptomatic lumbar disc herniations on MRI( Broden SD et al.Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects; A prospective investigation.J Bone Joint Surg Am .1990;72:403-408).
The finding of degenerative discs (i.e. loss of disc height and water concentration0)is common in both sexes after 40 years of age.
AMA 4: LOW BACK PAIN INDUCED BY TRAUMA.
Section 3 , pp 99-102);Determine magnitude of injury, assess clinical history, symptoms and interference with ADLs, examination, performance of flexion and extension X-rays (REQUIRED).
AMA 5 : LOW BACK PAIN INDUCED BTY TRAUMA.
DRE: assess magnitude of injury, clinical history,ADL interference, examination and performance of flexion and extension plain Xrays(REQUIRED).Lumbar Spine pp 384-388, Table 15-3 p 384.
ASSISTANT PROFESSOR MICHAEL CORONEOS CIME
SENIOR NEUROSURGEON & PI ASSESSOR
NATIONAL RACS EXAMINER & RACS SENIOR MORTALITY ASSESSOR (QASM)
FAIM MASE CIME FACS FRACS FRCSI FRCS(EDIN)SN MB BS(1ST CLASS HONOURS) MAPS MNSA MNSQ MANZSOM