This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
Principal Investigator: Richard A. Deyo, M.D., M.P.H., University of Washington
School of Medicine, Seattle.
Grant Number: HS 06344.
Project Period: September 1989 to September 1994.
The back pain PORT, supported by AHCPR, analyzes back surgery practice variations
and examines the relative effectiveness of alternate ways of diagnosing and treating low back
Back Pain PORT Contents (Summer 1994)
The problem of back pain is widespread (affecting up to 8 of
every 10 adults some time in life), causes suffering and stress, and is the second leading reason
why Americans see physicians. Back pain also affects the Nation's economy. According to some
estimates, back pain costs as much as $50 billion a year for medical care, workers compensation
payments, and time lost from work. However, the true economic impact of back pain is more
extensive, because these estimates include neither unrealized earnings due to physical limitations
caused by back pain nor employer productivity losses.
To determine what treatment strategies work best and for whom, the back pain PORT is
examining the relative value of diagnostic tests such as myelography, computed tomography,
magnetic resonance imaging, and thermography. The PORT is also examining surgical
procedures (such as fusion, laminectomy, and discectomy) and nonsurgical interventions (such as
traction and therapeutic injections).
The multidisciplinary team studying back pain includes orthopedic surgeons, primary care
physicians, physical therapists, epidemiologists, and economists. Other professions, including
chiropractors, are represented on the team's advisory committee. The research is being carried
out at sites in the State of Washington and one site in Maine.
Return to Back Pain PORT Contents
The final results of the back pain PORT will be known after the researchers complete their work
in the third quarter of 1994. However, they have already published a large number of articles
describing findings from their comprehensive review of the back pain literature and on
variations in the rates that different procedures are used to diagnose and treat back pain.
Among their findings are the following:
- There is no evidence that spinal fusion—one of the most common operations for low
problems—is superior to other surgical procedures for common degenerative conditions of
- Patients who undergo spinal fusions have more complications, longer hospital stays, and
higher hospital charges than do patients undergoing other types of back surgery.
- Morbidity and mortality rates as well as hospital charges increase with age among persons
having lumbar spine surgery.
- Evidence is growing against conventional spinal traction for the treatment of sciatica or
herniated disks, against the use of transcutaneous electrical nerve stimulation for chronic low
pain, and against the use of special corsets.
- Spinal thermography, a test advocated by some physicians and chiropractors for diagnosing
disk abnormalities, is inaccurate and poorly validated. The PORT researchers recommend that
use be limited to research settings.
- Evidence is growing against bed rest as therapy, even for a period of 1 to 2 weeks.
- A county-by-county analysis of rates for all types of back surgery procedures performed on
Washington State residents in 1985 revealed a fifteenfold difference between the highest and
Return to Back Pain PORT Contents
Dissemination of research findings is key to helping health care practitioners and consumers
informed decisions regarding therapy. The back pain PORT has contributed to this goal through
broad dissemination of its findings to the medical community and the public.
To date, Dr. Deyo and his colleagues have had 70 journal articles, editorials, and book chapters
published. Their articles have appeared in such journals as the Journal of the America
Association, Annals of Internal Medicine, Journal of Family Practice,
Journal of Bone and Joint Surgery, Spine, and Chiropractic Technique.
The Back Letter, a newsletter for back care specialists, also has published information
from the PORT. Members of the back pain research team have appeared on 2 nationally
medical programs for physicians and have presented their findings at 235 meetings of
groups in the United States and abroad.
Dissemination Summary: Back Pain PORT
|Health Industry Articles: ||43|
|Consumer Print: ||25|
|Consumer Broadcast: ||6|
The general public is learning about the back pain PORT's findings through an increasing
of newspaper and magazine articles. They include reports in U.S. News and World
Report, Better Homes and Gardens, American Health, Allure,
Fortune, and the Chicago Tribune, New York Times, and Wall Street
Journal. Seattle radio has also interviewed the researchers.
The PORT's findings have been incorporated in an interactive video disk for patients that is now
being commercially marketed to physicians.
The back pain PORT has published a brochure for consumers called Back in Action that
teaches consumers about low back pain and what they can do about it.
Return to Back Pain PORT Contents
It is too early to know if these preliminary findings are affecting physician behavior. However,
anecdotal evidence in the State of Washington suggests that the findings of the
AHCPR-supported PORT may be contributing to a decline in spinal fusion and perhaps other
back surgery procedure rates. Similar to back surgeons in other States, those practicing in
Washington have learned about the PORT's findings from articles in professional journals and
from the presentations made by the team's researchers at national, State, and local professional
meetings. Unlike those in other States, back surgeons in Washington also benefit from a unique
community physician feedback program that is part of the back pain PORT's dissemination
The PORT's principal investigator, Dr. Richard A. Deyo, cautions that there is no scientific
evidence at this point to prove that the research project's activities are changing physician
behavior. A rigorous evaluation of the physician feedback program is under way.
Return to Back Pain PORT Contents
Batti, M. C., Cherkin, D. C., Dunn, R., and Wheeler, K. J. (in press). Managing low back pain:
Attitudes and treatment preferences of physical therapists. Physical Therapy.
Batti, M. C., Videman, T., Gill, K., Moneta, G. B., Nyman, R., Kaprio, J., and Koskenvuo, M.
(1991). Smoking and lumbar intervertebral disc degeneration: An MRI study of identical twins.
Spine 16(9), 1015-1021.
Bigos, S. J., Batti, M. C., Fisher, L. D., Hansson, T. H., Spengler, D. M., and Nachemson, A. L.
(1992). A prospective evaluation of preemployment screening methods for acute industrial back
pain. Spine 17(8), 922-926.
Bush, T., Cherkin, D. C., and Barlow, W. (in press). The impact of physician attitudes on
satisfaction with care for low back pain. Archives of Family Medicine.
Cain, K. C., and Diehr, P. (1992). Testing the null hypothesis in small area analysis. Health
Services Research 27(3), 267-294.
Cherkin, D. C. (1990). Patient satisfaction as an outcome measure. Chiropractic
Technique 2(3), 138-142.
Cherkin, D. C. (1992). Family physicians and chiropractors: What's best for the patient
(Editorial). Journal of Family Practice 35(5), 505-506.
Cherkin, D. C., and Deyo, R. A. (1993). Non-surgical hospitalization for low back pain: Is it
necessary? Spine 18(13), 1728-1735.
Cherkin, D. C., Deyo, R. A., and Berg, A. O. (1991). Evaluation of a physician education
intervention to improve primary care for low-back pain II: Impact on patients. Spine 16(10), 1173-1178.
Cherkin, D. C., Deyo, R. A., Berg, A. O., Bergman, J. J., and Lishner, D. M. (1991). Evaluation
physician education intervention to improve primary care for low-back pain I: Impact on
Spine 16(10), 1168-1172.
Cherkin, D. C., Deyo, R. A., Loeser, J. D., Bush, T., and Waddell, G. (in press). An
international comparison of back surgery rates. Spine.
Cherkin, D. C., Deyo, R. A., Volinn, E., and Loeser, J. D. (1992). Use of the international
classification of diseases (ICD-9-CM) to identify hospitalizations for mechanical low
back problems in administrative
databases. Spine 17(7), 817-825.
Cherkin, D. C., Deyo, R. A., Wheeler, K., and Ciol, M. A. (in press). Physician variation in
diagnostic testing for
low back pain: Who you see is what you get. Arthritis and Rheumatism.
Ciol, M. A., Deyo, R. A., Kreuter, W., and Bigos, S. J. (in press). Patient's characteristics
reoperation following lumbar spine surgery in Medicare beneficiaries. Spine.
Deyo, R. A. (Guest Commentator) (1990). Determining the cause of low back pain.
Hospital Physician 26(10), 34-39.
Deyo, R. A. (1990). Measuring the functional status of patients with low back pain.
Chiropractic Technique 2(3), 127-137.
Deyo, R. A. (1991). Early detection of cancer, infection, and inflammatory diseases of the spine.
Back and Musculoskeletal Rehabilitation 1(1), 69-81.
Deyo, R. A. (1991). Low back pain. In M. Max, R. Portenoy, and E. Laska (Eds.),
Advances in Pain Research
and Therapy 18. New York: Raven Press, Ltd. (pp. 291-303).
Deyo, R. A. (1991). Non-operative treatment of low back disorders: differentiating useful from
useless therapy. In
J. W. Frymoyer (Ed.), The Adult Spine: Principles and Practice pp. 1567-1580.
York: Raven Press, Ltd.
Deyo, R. A. (1991). Clinical research methods in low back pain. Physical Medicine and
Rehabilitation: State of the Art Reviews 5(1), 209-222.
Deyo, R. A. (1991). The quality of life, research, and care (Editorial). Annals of Internal
Medicine 114(8), 695-697.
Deyo, R. A. (1991). Fads in the treatment of low back pain. New England Journal of
Medicine 325, 1039-1040.
Deyo, R. A. (1991). Non-surgical care of low back pain. Neurosurgery Clinics of North
America 2(4), 851-862.
Deyo, R. A. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM
administrative data: A response.
Journal of Clinical Epidemiology 46(10), 1081-1082.
Deyo, R. A. (1993). Clinical strategies for controlling costs and improving quality in the
primary care of low back
pain. Journal of Back and Musculoskeletal Rehabilitation 3(4), 1-13.
Deyo, R. A. (1993). Newer thinking on diagnosis and therapy. Consultant 33(2), 88-100.
Deyo, R. A. (1993). Results of discectomy compared with discectomy and fusion. Acta
Scandinavica 64(Suppl), 45-46.
Deyo, R. A. (in press). Exercise in the prevention and treatment of low back pain. In L.
Goldberg and D. Elliot,
(Eds.) Exercise for the Prevention and Treatment of Medical Illness. Philadelphia: F. A.
Deyo, R. A., Bigos, S. J., and Maravilla, K. R. (1989). Diagnostic imaging procedures for the
Annals of Internal Medicine 111(11), 865-867.
Deyo, R. A., and Carter, W. B. (1992). Strategies for improving and expanding the application
of health status
measures in clinical settings. Medical Care 30(5S), MS176-MS186.
Deyo, R. A., Cherkin, D. C., and Ciol, M. A. (1992). Adapting a clinical comorbidity index for
use with ICD-9-CM
administrative databases. Journal of Clinical Epidemiology 45(6),
Deyo, R. A., Cherkin, D. C., and Conrad, D. (1990). The Back pain Outcome Assessment
Services Research 25(5), 733-737.
Deyo, R. A., Cherkin, D. C., Conrad, D., and Volinn, E. (1991). Cost, controversy, crisis: Low
back pain and the
health of the public. Annual Review of Public Health 12, 141-156.
Deyo, R. A., Cherkin, D. C., Loeser, J. D., Bigos, S. J., and Ciol, M. A. (1992). Morbidity and
association with operations on the lumbar spine: The influence of age, diagnosis, and procedure.
Bone and Joint Surgery 74-A(4), 536-543.
Deyo, R. A., Ciol, M. A., Cherkin, D. C., Loeser, J. D., and Bigos, S. J. (1993). Lumbar spine
fusion: A cohort
study of complications, reoperations, and resource use in the Medicare population. Spine
Deyo, R. A., Loeser, J. D., and Bigos, S. J. (1990). Herniated lumbar intervertebral disk.
Annals of Internal
Medicine 112(8), 598-603.
Deyo, R. A., Rainville, J., and Kent, D. L. (1992). What can the history and physical
examination tell us about low
back pain? Journal of the American Medical Association 268(6),
Diehr, P., Cain, K. C., Kreuter, W., and Rosenkranz, S. (1992). Can small area analysis detect
variation in surgery
rates? The power of small area variation analysis. Medical Care 30(6),
Diehr, P., Cain, K. C., Ye, Z., and Abdul-Salam, F. (1993). Small area variation analysis:
Methods for comparing
several diagnosis-related groups. Medical Care 31(5),YS45-YS53.
Einstadter, D., Kent, D. L., Finn, S. D., and Deyo, R. A. (1993). Variation in the rate of cervical
spine surgery in
Washington State. Medical Care 31(8), 711-718.
Fordyce, W. E., Bigos, S. J., Batti, M. C., and Fisher, L. D. (1992). MMPI scale 3 as a
predictor of back injury
report: What does it tell us? Clinical Journal of Pain 8(3), 222-226.
Goldberg, H. I., and McGough, H. (1991). Testing the implementation of clinical guidelines.
IRB: A Review of
Human Subjects Research 13(6), 1-7.
Haselkorn, J. K., and Haselkorn, M. P. (1991). Hypermedia in medical care and education.
Bulletin 9, 125-144.
Herron, L., Turner, J. A., Ersek, M., and Weiner, P. (1992). Does the Millon Behavioral Health
predict laminectomy outcome? A comparison with the Minnesota Multiphasic Personality
Journal of Spinal Disorders 5(2), 188-192.
Hoffman, R. M., Kent, D. L., and Deyo, R. A. (1991). Diagnostic accuracy and clinical utility of
lumbar radiculopathy: A meta-analysis. Spine 16(6), 623-628.
Hoffman, R. M., Wheeler, K. J., and Deyo, R. A. (1993). Surgery for herniated lumbar discs: A
Journal of General Internal Medicine 8, 487-496.
Jensen, M. P., Strom, S. E., Turner, J. A., and Romano, J. M. (1992). Validity of the Sickness
Roland scale as a measure of dysfunction in chronic pain patients. Pain 50,
Kent, D. L. (1991). Decision analysis and assessment of the clinical impact of diagnostic tests.
Medicine 22(10), 718-724.
Kent, D. L., Haynor, D. R., Larson, E. B., and Deyo, R. A. (1992). Diagnosis of lumbar spinal
stenosis in adults: A
meta-analysis of the accuracy of CT, MR, and myelography. American Journal of
Roentgenology 158, 1135-1144.
Kent, D. L., and Weinstein, M. C. (1992). Clinical decision analysis. In American Academy of
Surgery (Eds.), Clinical Efficacy and Outcome in Diagnosis and Treatment of Low Back
Loeser, J. D. (1991). What is chronic pain? Theoretical Medicine 12,
Loeser, J. D., Deyo, R. A., Cherkin, D. C., Conrad, D., and Wiesman, J. (1993). Back Pain
Team: Background and progress. Journal of Musculoskeletal Pain 1(2),
Loeser, J. D., Van Konkelenberg, R., Volinn, E., and Cousins, M. J. (1993). Small area analysis
of lumbar spine
surgery in South Australia. Australian and New Zealand Journal of Surgery 63,
Loeser, J. D., and Volinn, E. (1991). Epidemiology of low back pain. Neurosurgery Clinics
of North America 2(4), 713-718.
Nelson, D. V., Turner, J. A., and McCreary, C. (1991). MMPI short forms as predictors of
response to conservative
treatment for low back pain. Journal of Clinical Psychology 47(4), 533-537.
Parkerson, G. R., Jr., Deyo, R. A., Golden, W. E., Blim, R. D., Patrick, D. L., Tuteur, P. G.,
Ware, J. E., Jr., Bergner,
M., Spilker, B., Feinstein, A. R., and Neugebauer, E. (1992). Strategies for improving and
application of health status measures in clinical settings. Medical Care 30(5,
Romano, J. M., Turner, J. A., and Jensen, M. P. (1992). The Chronic Illness Problem Inventory
as a measure of dysfunction in chronic pain patients. Pain 49(1), 71-75.
Snowden, M. L., Haselkorn, J. K., Kraft, G. H., Bronstein, A. D., Bigos, S. J., Jefferson, C. S.,
and Stolov, W. C.
(1992). Dermatomal somatosensory evoked potentials in the diagnosis of lumbosacral spinal
with imaging studies. Muscle and Nerve 15, 1036-1044.
Street, J., Hunt, M., Cherkin, D. C., and Deyo, R. A. (1991). Back in action: A guide to
understanding your low
back pain and learning what you can do about it (pamphlet).
Taylor, V. M., Deyo, R. A., Cherkin, D. C., and Kreuter, W. (in press). Low back pain
U.S. trends and regional variations. Spine.
Turner, J. A., and Denny, M. C. (1993). Do antidepressant medications relieve chronic low back
of Family Practice 37(6), 545-553.
Turner, J. A., Ersek, M., Herron, L., and Deyo, R. A. (1992). Surgery for lumbar spinal
meta-analysis of the literature. Spine 17(1), 1-8.
Turner, J. A., Ersek, M., Herron, L., Haselkorn, J. K., Kent, D. L., Ciol, M. A., and Deyo, R. A.
outcomes after lumbar spinal fusions. Journal of the American Medical Association 268(7), 907-911.
Turner, J. A., Herron, L., and Deyo, R. A. (1993). Meta-analysis of the results of lumbar spine
fusion. Acta Orthopaedic Scandinavica 64(Suppl 251), 120-122.
Volinn, E., Mayer, J., Diehr, P., Van Koevering, D., Connell, F. A., and Loeser, J. D. (1992).
Small area analysis of
surgery for low-back pain. Spine 17(5), 575-581.
Volinn, E., Turczyn, K. M., and Loeser, J. D. (1991). Theories of back pain and health care
Neurosurgery Clinics of North America 2(4), 739-748.
Volinn, E., Van Koevering, D., and Loeser, J. D. (1991). Back sprain in industry: The role of
factors in chronicity. Spine 16(5), 542-548.
Volinn, E., Turczyn, K. M., and Loeser, J. D. (in press). Patterns in low back pain
hospitalizations: Implications for
the treatment of low back pain in an era of health care reform. Clinical Journal of
Von Korff, M. R., Deyo, R. A., Cherkin, D. C., and Barlow, W. (1993). Back pain in primary
care: Outcomes at 1
year. Spine 18(7), 855-862.
Von Korff, M. R., Ormel, J., Keefe, F. J., and Dworkin, S. F. (1992). Grading the severity of
chronic pain. Pain 50, 133-149.
Return to Back Pain PORT Contents
Return to MEDTEP Update Contents