Talk:Low back pain/GA1

GA Review
The edit link for this section can be used to add comments to the review.''

Reviewer: Biosthmors (talk · contribs) 07:21, 5 August 2013 (UTC)

Be back later! Biosthmors (talk) 07:21, 5 August 2013 (UTC)


 * Yay! Thanks Biosthmors.   13:04, 5 August 2013 (UTC)


 * You're welcome. Thanks for your paitence. I didn't expect it would be 12 days before I was back. My apologies. Biosthmors (talk) 08:47, 17 August 2013 (UTC)


 * These are great notes, I don't have big chunks of time to focus on this during this week but will address them ASAP.   02:32, 20 August 2013 (UTC)

I'm caught up now on all your bullet points... looking forward to the next round of comments, hope we can finish this up soon. Thanks... 19:59, 30 August 2013 (UTC)

Starting to look today... 18:24, 2 September 2013 (UTC)

caught up to you! 04:10, 3 September 2013 (UTC)

Agreed Furlan 2012 is better than Casazza for acupuncture, made the change. What else is left? 17:42, 13 September 2013 (UTC)

and, I did a little final reviewing and copyediting and added a bit about multifidus from Menezes 2010 per ImperfectlyInformed's suggestion on the Talk page. I think the mattress mention is OK. I think I'm all caught up on all the outstanding items now, and am pretty happy with it. Anything else? 04:23, 15 September 2013 (UTC)

Prose

 * Lead comments from Biosthmors
 * Is the sentence "The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain." necessary for the lead? It it followed by "For most episodes of low back pain, a specific underlying cause is never identified or even sought", which makes it sound kind of insignificant for it to be the third sentence.
 * I think it is needed, the article explains that most LBP episodes are mechanical in nature and although a specific cause isn't identified, the treatment and prognosis for most LBP episodes definitely revolve around the fact that the pain is mechanical in nature. OK with you?  03:20, 27 August 2013 (UTC)
 * "and expert groups recommend the use of acetaminophen as the first thing to try", --> "acetaminophen is recommended as the standard first treatment"? Expert groups are an assumed source of info.
 * ✔️ simplified
 * "With conservative measures". Which measures? Readers might want to know.
 * ✔️ specified
 * "is sensitive to this cause" --> "can identify this cause"? To make it more accessible?
 * ✔️ it had gotten changed to "pick this up" which I didn't think was encyclopedic tone, so I changed it to "identify this cause"
 * "In most cases, imaging tools such as MRI are often not useful", can you pick out the unnecessary word I see towards the end?
 * ✔️ someone already had removed "often"
 * We have the construction of "generally their use is not indicated ... Despite this ... is increasing in popularity." To me, this sounds like it's missing a bit of detail, or perhaps could be better reworded. Is it only increasing in popularity by 3% a year? (If that's the case then so what.) In which countries? To use the word "despite", I'd like to see a bit more context. Maybe I'm being a bit too nit-picky, but it caught my eye.
 * Could we have a more accessible word than "refractory"? Biosthmors (talk) 08:47, 17 August 2013 (UTC)
 * ✔️ I was going to go with "obdurate" as a replacement but ended up replacing with simpler wording...
 * Is it worth an explicit mention, in addition to "Opioids ...are not recommended for general use due to side effects", of addictiveness?
 * Paragraph 3 of medications covers the side effects of opioids, including addictiveness. Because there are so many side effects, and because the sources I used didn't seem to make any bigger deal of addiction as compared to other potential problems, I didn't see a reason to choose any one specific side effect to highlight in the lead over the others.  Is that OK?
 * Can we make "chronic radicular discogenic pain" more accessible?
 * ✔️ Someone did this already
 * "alexander technique" --> "the Alexander technique".
 * ✔️ done
 * Surgical options are probably not available globally. Reword this?
 * ✔️ changed to "exist"


 * Cause
 * In "The majority of LBP is referred to as nonspecific low back pain and does not have a definitive cause" remove the classification details to "The majority of LBP does not have a definitive cause"?
 * This would remove the introduction and definition of the phrase "nonspecific low back pain", which is a very important phrase. If we were to remove it here, where else should we introduce it?
 * ✔️ Wording simplified
 * We tend to avoid one sentence paragraphs. Move the sentence that starts with "Physical causes may include..." up into the preceeding paragraph?
 * ✔️ done


 * Sensation
 * Can "damage or do damage" be shortened to "damage"?
 * Not without changing the content to not represent the source as well as it needs to, in my opinion... Sources that cover pain always include "potential to do damage" in their definition of pain because a stimulus does not have to actually cause damage to cause pain.
 * Currently we have "that have the potential to damage or do damage the body's tissues", which at a minimum is missing a "to". We still can't reword it to only use the word "damage" once?
 * ✔️ Now it's "stimuli that have the potential to or do damage"
 * Now "an event that either damages or can potentially damage the body's tissues", even simpler
 * "The nerve cells that signal pain are individual structures with fibers that reach from the locations in the lower back where pain is sensed to the spinal cord. The body of each cell is located in the dorsal root ganglia. From a cell body, one fiber extends to the sensory location served by the nerve cell, and another fiber terminates in the spinal cord." The first and third sentences here appear largely repetitive. Condense, perhaps into one sentence?
 * ✔️ condensed
 * Afferent should be piped to Afferent nerve fiber.
 * ✔️ fixed
 * In general, it seems like at least some of this content would be happier at pain, and adopted here in more of a summary style.
 * These few paragraphs are a very brief summary of, which is a 12-page document entitled The Physiology of Low Back Pain. It's an excellent secondary source focused specifically on pain and the lower back.  I tried to trim it down to the basic pain transmission systems affected by the OTC drugs, and included detail about how the brain has the capacity to modify its own pain signaling system, which is an important factor in those with chronic pain.  Are you sure it needs to be cut down even more?
 * A general question: is referred LBP consistent with this sentence?: "The process of pain sensation starts when the pain-causing event stimulates the endings of appropriate sensory nerve cells."
 * You're asking me to do a little OR, but... I think so.  "Referred pain" doesn't have a precise definition, and it's a term mostly used to describe displaced feelings of pain in the arm related to a heart attack, and use less frequently related to low back pain.  I actually think you can make a pretty good case for arguing that discogenic radicular pain is a kind of referred pain, but related to LBP, "referred pain" is talking about what feels like LBP but the origin is related to an organ.


 * Pathophysiology
 * In general, it seems like some of this background content is more appropriate at back. Biosthmors (talk) 10:57, 17 August 2013 (UTC)
 * Basically the same plea as I wrote above about the "happier at pain" content... I tried to include the very basic info needed to get the reader to understand why things like spondyloarthritis and herniated discs (covered in the very next section) are associated with low back pain. Are you sure it needs to be cut down even more?


 * Classification
 * I'm uncertain what "which are not specifically related to difficulties with the lower back" is trying to say. Is it trying to say "which are not typically associated with low back pain"? That would make more sense.
 * Hmmm... well, people who have fibromyalgia or somatoform disorders can complain of low back pain, it's not unusual for them to do so, so it would not be correct to say those conditions are not typically associated with low back pain. They are conditions that are not specifically targeting the low back but do result in complaints of low back pain.  Is that OK?


 * Red flags
 * "arriving at a diagnosis of low back pain is not straightforward" appears to create tension with the above statement that "Low back pain itself is not a specific diagnosis". Can we say something like: "concluding that a person has low back pain can be a complicated clinical judgement."? Perhaps better solutions exist, or no solution is better. Not sure.
 * ✔️ Fixed after a closer re-reading of Borczuk, I removed "diagnosis or"... from the earlier section, should work now.
 * "The diagnostic process must" --> "An evaluation should"?
 * ✔️ Actually both "should" and "must" aren't preferred wording, as they're instructive instead of descriptive, fixed: changed to "A complete diagnostic process will uncover..."
 * "The presence of red flags indicates the need for further diagnostic testing for serious underlying problems that might require immediate or specialized treatment." and "Certain signs, termed 'red flags,' may indicate a more serious condition, and prompt a more extensive investigation using diagnostic imaging or laboratory testing" is repetitive. Copy-edit?
 * ✔️ copy-edited, reworded to avoid redundancy
 * "successful finding" --> "identification"?
 * ✔️ simplified by removing unnecessary "successful"


 * Tests
 * The sentence "Most other physical tests, such as evaluating for scoliosis, muscle weakness or wasting, and impaired reflexes, have poor diagnostic value" seems like it would more logically flow at the end of the paragraph.
 * ✔️ agree, moved
 * I find the clause "many patients and doctors use them to try to find the cause of the pain" awkward. Patients can't use then the way doctors do, unless they have medical training, and who's to say the doctors aren't also (or primarily) using them to make money?
 * ✔️ reworded a bit to better reflect point source is making
 * Should we use recommended instead of required in "Such tests are not required"?
 * ✔️ fixed
 * The sentence "In most cases, the tests are not necessary, and most people will feel better after a month regardless of whether they undergo imaging" largely repeats previous material in the paragraph.
 * ✔️ agreed redundant, removed
 * "more imaging is associated with higher expense". More imaging costs more money, so if that's what we're saying then "associated with" is too weak. Or, maybe we're talking over the long term.
 * ✔️ sharper point put on it
 * "higher rates of surgery but no resultant benefit": Is that because the side effects cancel out the benefits? Or because there's no benefit but only side effects, which would be harm? Biosthmors (talk) 21:28, 20 August 2013 (UTC)
 * ✔️ The source (Chou) says "routine imaging is not associated with clinically meaningful benefits but can lead to harms". Added Flynn to support.


 * Management
 * There is "Exercising to restore motion and strength to the lower back can be very helpful in relieving pain and preventing future episodes of low back pain" in management but "Exercise is probably effective in preventing the recurrence of non-acute pain" in prevention. These statements appear contradictory. Biosthmors (talk) 20:02, 29 August 2013 (UTC)
 * ✔️ Someone added that recently, and appears not to have represented the source (Hendrick 2011) quite accurately enough. Hendrick's systematic review covered general increase in physical activity, and not exactly exercise.  Hendrick actually mentions in his systematic review "the role of exercise in the management of LBP generally shows positive results" and distinguishes the subject of his review from exercise.  I've adjusting the wording to clarify.
 * Is there a logic to why "Increasing levels of general physical activity" appears before the Physical therapy subsection but "Active physical therapies include stretching, strengthening and aerobic exercises" appears after? Might we lump physical activity/therapy together?
 * ✔️ Sure, bad logic! I moved stuff around so things are in appropriate subsections now


 * Medications
 * Is "As pain medications are only somewhat effective" for chronic pain? If so, say "As pain medications are only somewhat effective for chronic pain"?
 * The source cited, Miller 2012, doesn't limit that statement to only chronic pain, so it should be OK as is?


 * Surgery
 * This sentence: "Adding the installation of spinal implant devices during spinal fusion increased the risk but provided no added improvement in pain or function." swtiched to past tense. Can we make it present?
 * ✔️ done
 * Can we add links to instrumented posterior lumbar interbody fusion and instrumented posterolateral fusion? Red links (if that's what they would be) help the encyclopedia.
 * ✔️ yeah baby! redlink added but might make it blue pretty soon, love running across opportunities to create a new article
 * Instrumented posterior lumbar interbody fusion is now blue  instrumented posterolateral fusion still red now also blue after Doc created redirect


 * Alternative medicine
 * The first sentence of Chiropractic defines it as "complementary and alternative medicine". Should we name the title of the subsection that way in case Alternative medicine is a more pejorative characterization of the profession than the preponderance of reliable sources attribute to it?
 * Personally I don't think calling something "Alternative" or "CAM" is pejorative. Regardless, I think we should go with how the reliable sources categorize it. Our source Marlowe 2012 clearly characterizes it as CAM, and the NCCAM includes chiropractic in its database, check out its article there and look at how the refs categorize it.  I'd like to leave it where it is unless/until someone brings a source-based reason to move it... if you could point to some sourcing that would clearly indicate it should get moved, perfectly happy with that too.
 * I don't think cognitive behavioral therapy is classified as alternative medicine. Should there be a "Psychological" subsection for the management section?
 * I've got 3 sources that cover these therapies, one is a Cochrane review and it just covers "Behavioral therapy" without trying to classify it, the other two definitely cover it as CAM, so its current classification is supported by sources, I think. So I think it's OK where it is but if you really don't like that classification, let me know and I'll move it.
 * Can we blend "Massage does not appear to provide substantial benefit for acute low back pain" (at the end) with the massage stuff that begins the section? Do "massage" and "massage therapy" have different intended meanings for the reader? They are both go to the same place so only one link is needed. Biosthmors (talk) 18:39, 1 September 2013 (UTC)
 * ✔️ Yes good one, done


 * Prognosis
 * "As well, the studies" reads oddly to me. That's an undefined subset so can we generalize?
 * ✔️ That wording appears to have gotten fixed by someone
 * Is "Determining a general prognosis from the available evidence for low back pain is difficult. Inconsistencies in the evidence are probably due to variations across the source studies in the definitions used for the characteristics of the condition. As well, the studies were not designed to produce the ideal kinds of evidence about the condition." really necessary? Does it help a reader learn anything about the prognosis of low back pain? If so, can we just state the heart of the matter?
 * ✔️ Someone else already edited this out
 * We have "psychological and economic stresses ... can prolong an episode of low back pain". Is it causative or just an association? Biosthmors (talk) 19:02, 1 September 2013 (UTC)
 * Source is Miller 2012 which says "Physicians should assess patients for depression, unemployment, job dissatisfaction, somatization disorder, and psychological distress, as these conditions tend to delay recovery." so the source states it as causative, article wording implies the same, is that OK?


 * Epidemiology
 * "very common". Can we get a number on that? "very" isn't an encouraged word to use, typically. Maybe just remove "very"?
 * ✔️ removed "very"... as for the numbers, this opening sentence just introduces the paragraph, and the hard numbers are indeed provided in the following sentences
 * Is "Within the United States, it is the most common type of pain in adults, and is responsible for a large number of missed work days.[4]" better off in the Society and culture section? I think so.
 * ✔️ agree, merged into there
 * Is it necessary to say "Some analyses report a slightly higher rate among men[67] while others report a higher rate among women."? Why can't we just say "It is not clear whether men or women have higher rates of low back pain." and leave it at that? I don't think readers particularly care about the facts we may encounter when we research a topic, only the main points.
 * ✔️ agree, trimmed wording
 * That's interesting about smoking. Is it an accepted risk factor? If so, then why not include it (with any other risk factors) in the Causes section? Biosthmors (talk) 19:09, 1 September 2013 (UTC)
 * ✔️ yes, it is... I copied the whole risk factors sentence, which mentions smoking, from this NIH website into the article (the content is released as public domain)

Simple English
Also please do all you can to keep the language as simple as possible. Low back pain is one of our most important and most read articles. The translators will appreciated the easier English as we work to bring this content to other languages. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:34, 28 August 2013 (UTC)
 * Looks like you did a lot of work to simplify the language for translators, thanks Doc!  14:47, 12 September 2013 (UTC)

Epidemiology
The possible range often goes up to 80%. I suggest we change it to between 40 and 80% for lifetime prevalence. The current ref mentions the issue of low income countries having a low rate. Data quality is often not as good in these areas. Doc James (talk · contribs · email) (if I write on your page reply on mine) 18:56, 28 August 2013 (UTC)
 * Clarified in the epidemiology section. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 18:59, 29 August 2013 (UTC)
 * ✔️ thanks Doc!  03:04, 30 August 2013 (UTC)

Other Reviewers
Hello, I have had a look at this article and would support its nomination to GA status, this article is structured very well, every sentence has a clear purpose, and overall I find it very easy to read and full of content. If I have one comment it's about the introduction:
 * "Low back pain or lumbago /lʌmˈbeɪɡoʊ/ is a common musculoskeletal disorder affecting 40% of people worldwide at some point in their lives." I think this should say "about 40%", as 40% is rather specific and a minor variation (such as 39% or 41%) was surely within the original sample's margin of error. LT90001 (talk) 05:43, 31 August 2013 (UTC)
 * ✔️ Thanks ! I have added "about" to that sentence in the lead per your suggestion.   17:41, 1 September 2013 (UTC)

Verifiability

 * The first number out the random number generator was 18. Given that this source goes to "Red flags" in the table, but not on any of the specific red flags listed below, I'm not going to dive into the table because it would require me to check all the sources and I don't know what this is supposed to support. I wouldn't call this a violation of the good article criteria, but it doesn't facilitate fact-checking.
 * If you search for red flags in the document you will notice it supports the entire column of the table. These are standard "red flags". Hundreds of articles / books contain the exact same one. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 16:21, 8 September 2013 (UTC)


 * The three sources cited for the "Red flag" column in that table, Casazza 2012, Manusov 2012 and the ACR, all give lists of red flags. Everybody agrees that there are "red flags" and if they are present, imaging might be warranted.  However, there is no perfect agreement across sources as to what the complete list of red flags actually is, but there is about 80% overlap/agreement.  What I did was:  I reviewed three authoritative sources and picked the ones common to all three lists.  Only Casazza gave the suspected underlying causes.  The sources are cited; I'm open to suggestions as to how to make it more clear how the sourcing is supposed to be applied to the table.   01:33, 6 September 2013 (UTC)
 * Perhaps, then, we should bundle the three for the red flags as one citation and explain the methodology. We could explain the methodology – "All red flags listed in the table can be found in the following three sources. Red flags not cited by all three sources were not included." – either as a preface to the cite bundle or it could be a footnote. Biosthmors (talk) 16:28, 6 September 2013 (UTC)
 * ✔️ I've bundled the refs as requested with a note. I tied the content to the sources they came from, which is what WP:V requires and satisfies what the WP:GA process needs to check.  However I don't think it should be explained in the article exactly how it was decided which flags were chosen to include.  It's the job of Wikipedia editors to evaluate the sources and use Wikipedia's content rules and one's own judgment, there's no rule that one must use a certain number of sources and exactly choose the items that are common across, I don't think it would be correct to codify that process in the article content.   01:09, 8 September 2013 (UTC)
 * Thanks. And now the section has been edited. Generally speaking, it sounds like you're saying it's not good to clarify to readers how we're presenting content, as I've done with this note. I'm not suggesting we codify anything, I'm just suggesting an explanatory note could be helpful if we've used a specific methodology. Biosthmors (talk) 16:27, 8 September 2013 (UTC)
 * No, that's really not what I'm saying. Yes, include footnotes that explain the content when it's a bit of a tangent off the main line of the prose, but is still worth mentioning.  What I don't agree is that we should include in article content (including footnotes) is "meta-comments" that explain how the content got there.  The editorial process should be invisible to the article reader.  But as noted, it's been edited out now, I agree with Doc providing just the one ref meets our needs and more or less makes this discussion moot.   17:07, 8 September 2013 (UTC)
 * Cool. Done with this. ✔️


 * I can check this for "Between 1990 and 2001 there was a 220% increase in spinal fusions in the United States, despite the fact that during that period there were no changes, clarifications, or improvements in the indications for surgery or new evidence of improved effectiveness". Biosthmors (talk) 19:02, 5 September 2013 (UTC)
 * This is supported, though I'd link and state efficacy. Efficiacy is used in terms of clincal data. Effectiveness is evidence about people in general medical practice. Biosthmors (talk) 19:52, 5 September 2013 (UTC)
 * ✔️ some helpful gnome just went ahead and did this I guess   02:13, 8 September 2013 (UTC)


 * "Afferent nerve fibers carry nerve impulses from sensory nerve cells in the lower back towards the central nervous system." doesn't seem to need an inline citation, plus the one it had was to a book without a page number so I removed it.
 * ✔️ Works for me!


 * I would like to verify "Epidural corticosteroid injections provide only slight improvement of sciatica with no long term benefit" from . Same story about access.
 * ✔️ Verified. Biosthmors (talk) 17:31, 6 September 2013 (UTC)


 * I need to verify "Additionally, in degeneration, a disc can cause low back pain by losing height, which results in stress on the surrounding joints and tissues. Extruded disc material can also cause pain by impinging directly on a nerve root." from here.
 * The source says "that can potentially lead to LBP". Are we overstating it? Should we say "potentially cause"? Also, I found "Loss of disc height can contribute further to compression of the exiting nerve root, resulting in pain in the buttock and lower limb", but I'm not sure that matches what is stated. Biosthmors (talk) 19:44, 5 September 2013 (UTC)
 * Added "potentially", not sure why you don't think the content matches source... are you saying the content implies the pain caused by nerve root impingement is low back pain but the source is talking about radicular pain??  01:19, 8 September 2013 (UTC)
 * Well, to be honest, I don't have a definition of radicular pain in my head. ;-) I'm trying to verify "Extruded disc material can also cause pain by impinging directly on a nerve root", and I don't see it stated in the source. Maybe it's common sense somehow, but it's not common sense to me. Biosthmors (talk) 18:40, 8 September 2013 (UTC)
 * Simplified / clarified it. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 04:54, 11 September 2013 (UTC)
 * Thanks. ✔️


 * I can get access to to check "but may benefit those with chronic pain, particularly when used as part of an integrated therapeutic program that also includes physical exercises and education".
 * I find "Our findings suggest that massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially if combined with exercise and delivered by a licensed therapist" in the source in the discussion portion. Should we add sub-acute and the licensed bit? In the Implications for practice section: there is :"Massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function. Massage therapy is costly, but it may save money [otherwise] ... [and combine with mentioned therapies for best use]. The beneficial effects of massage in patients with chronic LBP are long lasting (at least one year after end of sessions). It seems that acupuncture massage is better than classic massage, but this needs confirmation..." In general, I feel like the Cochrane source creates tension with the bits we have written later about massage and acupuncture. Cochrane seems to say massage and accupuncture massage can be part of a recommended therapy. Are the other sources just commenting on the clinical value of one thing, like massage alone? Then we can specify massage alone. I also don't know the difference between accupuncture and accupuncture massage. Biosthmors (talk) 16:20, 6 September 2013 (UTC)
 * ✔️ Added mentions of licensed, added sentence about "acupuncture massage" (I don't know what it is either). There was a mention in the lead that massage cannot be recommended confidently, I removed this mention per Cochrane.
 * I'm not seeing the tension... sources are stating regular massage is not helpful for acute but it is helpful for non-acute. We have one source specifying that Thai and Swedish massage specifically are not helpful for chronic (although I don't know exactly how the massage that Cochrane researched is different from Thai and Swedish massage).  Those are all the things the article says about massage.  So, regular massage is helpful for non-acute but can't recommend Thai or Swedish massage chronic.  That's it.  I'm not sure why you're saying this source conflict with acupuncture... the only thing this source said was about "acupuncture massage", not (plain) acupuncture, and the article didn't have the sentence about acupuncture massage in it until I added it just now.    02:07, 8 September 2013 (UTC)
 * My concern is that "There is insufficient evidence to support a positive recommendation for either Thai or Swedish massage to treat chronic low back pain" might not be factual. If Thai or Swedish massage is done in the way Cochrane suggests for massage to be done (with licensing, education, and exercizes) is it still accurate? Biosthmors (talk) 18:45, 8 September 2013 (UTC)
 * ✔️ Yes I agree, I see it now. Netchanok 2012 wasn't saying there wasn't enough evidence to say they were effective, but rather that there wasn't enough evidence to say one was more effective.  Both this source and Cochrane agree massage is effective for non-acute pain, and as Netchanok 2012 wasn't conclusive the most straightfoward thing to do is remove it, updated.   20:36, 8 September 2013 (UTC)


 * I would like to verify "Therapeutic procedures such as nerve blocks can themselves be used as tests for diagnostic purposes to identify a specific source of pain." I can check for access in about 12 hours and report back if I don't have access.
 * I don't have access to Manusov, email? Thanks.
 * emailed!
 * This is sourced to Manusov Evaluation and diagnosis of low back pain, see pp. 478-479 where it says, "There is evidence for diagnostic procedures such as facet joint blocks and transforaminal epidural injections. There is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, and moderate evidence for transforaminal epidural injections. Sacroiliac injections can also be helpful for diagnosis. Pain reduction with anesthetic injection can support a specific anatomic source."  15:11, 12 September 2013 (UTC)
 * Thanks, ✔️ =)


 * I would like to verify "Annually, low back pain disables a greater fraction of the work force populations in Canada, Great Britain, the Netherlands and Sweden as compared to the United States and Germany." from . Will check on access. (Added free url link).
 * I thought I'd check Manchikanti for "Lumbar provocative discography may be a useful diagnostic tool to identify intervertebral disc disorders in those with chronically high levels of lumbar pain". I'm trying to verify the "useful ... to identify" portion but not finding it right away. How might it be useful, exactly? I see "The treatment of discogenic pain continues to be a challenging endeavor, with no treatment having been found that provides significant relief to a majority of presumed patients on a consistent basis." I think I'm missing something here. Biosthmors (talk) 18:10, 6 September 2013 (UTC)
 * Conclusions says "Based on the current systematic review, lumbar provocation discography performed according to the IASP criteria with control disc (s) with minimum pain intensity of 7 of 10, or at least 70% reproduction of worst pain (i.e. worst spontaneous pain of 7 = 7 x 70% = 5) may be a useful tool for evaluating chronic lumbar discogenic pain. Discography is an important imaging and pain evaluation tool in identifying a subset of patients with chronic low back pain secondary to intervertebral disc disorders." Did I not paraphrase it accurately?
 * I think I'm getting caught up on the word "useful". I'm wondering what is it useful for, exactly? Maybe I just need to look with some fresh eyes later. Biosthmors (talk) 18:23, 6 September 2013 (UTC)
 * Diagnosis isn't done for diagnosis' sake. I'm wondering how the treatment differs, I guess. Biosthmors (talk) 18:25, 6 September 2013 (UTC)
 * "Effective"?? "Productive"??  Basically they're saying that LPD actually does its intended job of identifying the root cause of the pain as discogenic in cases of chronic lumbar discogenic pain. Because one disk is tested at a time, LPD can identify the specific disc.
 * Hello. Biosthmors has invited me to comment on the references, particularly Manchikanti. The source states "lumbar provocation discography... may be a useful tool for evaluating chronic lumbar discogenic pain." Thus the statement here in Wikipedia's article is verified in the source. To answer Biosthmors' question, the reasoning is: "When performed appropriately, [provocation] discography can enhance sensitivity and specificity compared to non-provocative imaging. This in turn can improve clinical outcomes and prognostication through better selection of candidates and therapies. Equally important, it can reduce the likelihood that discs which are not contributing to pain are inappropriately treated." The implication is that MRI may find minor anomalies in a disc. However that is not sufficient evidence that those anomalies are the cause of the back pain, and that surgery will resolve the pain. Such anomalies are commonplace and often do not cause pain. Provocation discography will "prove" that the anomalous disc is the cause of the pain, implying that surgery is likely to be helpful. Axl  ¤  [Talk]  09:03, 7 September 2013 (UTC)
 * ✔️ Thanks Axl.  01:45, 8 September 2013 (UTC)
 * Yes, thanks Axl. Can we, instead of saying "useful diagnostic tool to identify intervertebral disc disorders" say something like "useful diagnostic tool to identify pain from specific discs"? Biosthmors (talk) 17:28, 8 September 2013 (UTC)
 * You're welcome. Biosthmors, your suggestion would be fine. Axl  ¤  [Talk]  19:44, 8 September 2013 (UTC)
 * Done ✔️


 * I would like to verify "There is very little evidence that lumbar support lifting belts (corsets) are any more helpful in preventing low back pain than education about proper techniques for lifting." (cochrane) and  support it.
 * Cochrane states "There was moderate evidence that lumbar supports are not more effective than no intervention or training in preventing low-back pain" which to me supports a different thing. The current wording implies there's a bit of evidence corsets are helpful. Cochrane seems to state there's evidence to support that they're not helpful. Biosthmors (talk) 18:39, 6 September 2013 (UTC)
 * ✔️ That Cochrane review is from 2008. Not sure why you're not also looking at Guild 2012, the other source cited there? Guild 2012 says"In a review of randomized controlled trials a total of 13,995 patients with lumbar supports, also known as corsets, were assessed for the effect on prevention of low back pain and treatment. Little to no evidence was found that lumbar support prevented back injury more than education on proper lifting technique. The review included 954 patients in a comparison of lumbar supports with no treatment for prevention of low back pain, with similar results. There was little to no evidence to support their use for prevention of low back injury."and this is cited to a 2011 Cochrane review, which I don't have, I'm using Guild's report on it. As we have a newer review which is pointing to a newer Cochrane review, I will age out the 2008 Cochrane review, which should resolve this.   01:40, 8 September 2013 (UTC)
 * Thanks ✔️


 * I can check on "For those with acute pain, acupuncture may provide short-term relief similar to over-the-counter pain medications, but the evidence for it is too weak to recommend it". also  is cited to this.
 * To help this along: We're using Casazza 2012 writing in Am Fam Phys, and Marlowe 2012 in The Clinics (in Prim. Care).  Casazza comes across as a skeptic regarding CAM.  Cassaza says in his abstract "No substantial benefit has been shown with ... acupuncture" but in the discussion does say "Several low-quality trials show that acupuncture has minimal or no benefit over sham treatment, naproxen (Naprosyn), or the Chinese herbal therapy moxibustion. Although evidence to support its effectiveness is limited, acupuncture may be cost-effective in patients with pain lasting longer than four weeks." I am not sure how something that doesn't work at all can be cost-effective so I think he's saying it's a touch better than nothing, also he sources this to Lin 2011 (the review of guideline-endorsed treatments worldwide we use here), which also states acupuncture is a cost-effective thing to try. Meanwhile, Marlowe is accepting of CAM and acupuncture in particular, see his enthusiastic discussion of energy meridians and Qi, which aren't concepts exactly well-accepted by empiricists. In Marlowe states it does more than nothing but it's no more effective than basic meds.  Casazza and Marlowe aren't in complete conflict but they don't dovetail nicely.  So in the article I state that acupuncture may be helpful but the evidence is weak.   02:37, 8 September 2013 (UTC)
 * I don't think it's neutral to say "the evidence for it is too weak to recommend it use" and cite Casazza, who says, as you note, "Although the evidence to support its effectiveness is limited, acupuncture may be cost-effective in patients with pain lasting more than 4 weeks". I'd like to see Marlowe, thanks. Is that where the "short term relief" bit is verified? Biosthmors (talk) 21:27, 12 September 2013 (UTC)
 * How do you like my changes? Thanks for emailing Marlowe. Biosthmors (talk) 22:06, 12 September 2013 (UTC)
 * Well I didn't really like how the statement about acupuncture for acute pain was weakened in this change from "For those with acute pain, acupuncture may provide short-term relief similar to over-the-counter pain medications, but the evidence for it is too weak to recommend it use." to "...the evidence for it is limited." sourced to Casazza. Casazza says in his abstract "No substantial benefit has been shown with ... acupuncture" and in the body of the article clearly categorizes acupuncture as an "UNSUPPORTED" treatment for LBP.  This is echoed by other sources, for example Borczuk says (referring to a Cochrane review) "The acute pain trials had small numbers of patients and were inconclusive.", Cohen 2008 says "The benefits of acupuncture for acute low back pain are unclear.".  I think the current wording overstates the consensus view regarding its value.  Would you agree to put back "too weak to recommend it use"?   01:57, 13 September 2013 (UTC)
 * Edit made and recommendation at Talk:Low_back_pain. Biosthmors (talk) 13:53, 13 September 2013 (UTC)
 * I tweaked the edit just a bit for flow, I don't believe I changed the meaning. Ok now?  If you're good I'm good. Will look at Talk page.   14:06, 13 September 2013 (UTC)
 * After looking at Furlan 2012, agree it's better than Casazza on acupuncture, article updated to remove Casazza's negative punch, take a look.  17:44, 13 September 2013 (UTC)
 * ✔️ thanks

Neutral/broad in coverage/images

 * Is not not worth mentioning proper lifting technique in the prevention section, possibly with a picture if available? Biosthmors (talk) 19:06, 5 September 2013 (UTC)
 * ✔️ Maybe someone else moved it but the mention of proper lifting techniques is in the Prevention section now. Will add image if I can find one.... image now added


 * If I had to say, I'd say this topic could be better illustrated. The four pictures are tagged with their copyright status, but there are only four. Biosthmors (talk) 19:09, 5 September 2013 (UTC)
 * ✔️ More images now
 * The main picture caption: "The five vertebrae in the lumbar region of the back are the largest and strongest in the spinal column", sounds more like trivia than something relevant to LBP. Biosthmors (talk) 19:11, 5 September 2013 (UTC)
 * ✔️ Improved now, more relevant to article content
 * "The lumbar region in regards to the rest of the spine" is a caption but couldn't we say something like "the lumbar region of the spine is towards the lower portion of the back"? Biosthmors (talk) 19:12, 5 September 2013 (UTC)
 * ✔️ improved
 * You might like trying double image for the two that are side-by-side. Biosthmors (talk) 19:14, 5 September 2013 (UTC)
 * I didn't know about the double image template, thanks for the tip! I used it because it handles the longer captions better.
 * "The nerve and bone components of the vertebrae" isn't engaging prose. Maybe we could help the reader interpret the image a bit? Biosthmors (talk) 19:16, 5 September 2013 (UTC)
 * ✔️ improved
 * The partial title is Overtreating chronic back pain for one paper cited. Shoudl we link overtreatment somewhere in the article? Biosthmors (talk) 19:56, 5 September 2013 (UTC)
 * Yes! I love talking about overtreatment and treatment for low back pain is one of the most common types of unnecessary health care. This article already has an excellent section about not immediately seeking imaging on low back pain, but rather treating the pain for 6 weeks while waiting for pain to subside. Something interesting about this section is that there are several sources already talking about the overtreatment problem, and I myself just added four more. I think I would like to review all the sources, see what they have in common, and WP:BUNDLE them and rearrange the sentences for clarity and better association between assertions and sources. Cool stuff!  Blue Rasberry    (talk)   21:11, 5 September 2013 (UTC)
 * ✔️ Wikilink to Unnecessary health care now in Tests
 * I am of the opinion that images must be directly related to the topic at hand. Have removed the one of morphine as it is just a random vial and this is not the treatment of choice. Also chiro does not have great evidence for it thus IMO an image of someone pushing on a back is not needed either. Okay with the other three images Doc James (talk · contribs · email) (if I write on your page reply on mine) 14:34, 6 September 2013 (UTC)


 * The caption from the infobox picture is "Low back pain is a common, widespread and costly complaint." What is the difference between "common" and "widespread"? Axl  ¤  [Talk]  19:48, 8 September 2013 (UTC)
 * "Widespread" removed  20:10, 8 September 2013 (UTC)
 * Thanks. Axl  ¤  [Talk]  20:48, 8 September 2013 (UTC)


 * In "Pathophysiology", subsection "Back structures", a caption reads "The lowest five bones of the spinal column are the lumbar vertebrae, and define the lower back region." That's just not true. Axl  ¤  [Talk]  19:52, 8 September 2013 (UTC)
 * Does the change from "lowest five bones" to "lowest five articulating vertebrae" fix it?  20:05, 8 September 2013 (UTC)
 * Hmm, I'm not sure. It is possible to quibble over the definition of "articulation". Axl  ¤  [Talk]  20:50, 8 September 2013 (UTC)
 * Removed the phrase altogether, now it is "The five lumbar vertebrae define the lower back region"  13:10, 9 September 2013 (UTC)
 * Thanks, that's fine. Axl  ¤  [Talk]  15:50, 9 September 2013 (UTC)
 * ✔️ thanks

Passing
After all the recent edits/copyedits, I think we now have ourselves a good article. My thanks to all involved! Biosthmors (talk) 09:05, 15 September 2013 (UTC)