Letters
Outcome of low back pain in general practice
Evidence based practice can improve outcomeStudy's methods may have altered patients' perceptions of their
painUse of disease specific questionnaire may have influenced resultsAuthors' replyEvidence based practice can improve outcome
EDITOR We believe that evidence based management of acute back pain will
improve outcome. While undertaking a prospective randomised controlled
trial of manipulative treatment that aimed to compare the outcome of
osteopathy and of physiotherapy we inadvertently showed the
effectiveness of the college's guidelines. Two general practices in
Kingston-upon-Hull participated in this study, with a total practice
population of 15 000. Both practices are in deprived areas.
All patients presenting with acute non-specific back pain (defined as
their first episode of back pain or an episode more than three months
after a previous episode) were managed according to the college's
guidelines; this ensured that patients in each arm of the trial were
similar. Patients were advised on active management, minimal rest,
early commencement of exercise, and rapid return to normal activity and
work. All patients were given copies of The Back Book.
They were advised to return if their symptoms deteriorated or if there
was no improvement after three weeks. Patients returning to their
general practitioner were entered into the trial. In the 12 month study
period over 250 new patients were seen. Only five returned to their
general practitioner with continued back pain. The Roland and Morris
score5 improved with manipulative treatment in all five
patients.
This study showed that patients recovered rapidly when general
practitioners initiated active management of back pain. The Back
Book was introduced to these practices at the time, and we believe that it made a major contribution to the success of
implementation of the college's guidelines.
The East Riding Research Ethics Committee gave ethical
approval for the study. Practices participating received a small amount of funding from the Department of Health.
Study's methods may have altered patients' perceptions of their
pain
EDITOR This study is not methodologically robust enough to support the
statement that, of the non-attenders, "most will still be experiencing low back pain and related disability one year after the
[index] consultation." Detailed follow up data on patients' experience outside the surgery were available in only a minority of the
original group, 170 of 463, which leaves considerable room for
selection bias. Although an attempt was made to quantify this bias, the
"validation group" was too small (n=44) for findings to be
conclusive. Two further factors may have exaggerated this bias. Both
the original cross sectional survey and the interview process may have
altered patients' perceptions of their low back pain (the Hawthorne
effect).
Use of disease specific questionnaire may have influenced results
EDITOR One important question not addressed in this study is why most (three
quarters) of the interviewed cohort did not consult their general
practitioner after three months despite still being in pain or
disabled. The answer would have important implications when the
patients with chronic back pain who consume most healthcare expenditure
on this disorder are being targeted.
Caution should also be exercised when interpreting results based on a
disease specific self report questionnaire. The choice of outcome
measure may itself influence the reported severity of residual symptoms
or functional capacity.4 Addition of a generic health
questionnaire (such as the short form 365) would allow
comparison with normative population data. It might also provide
insights into the subtle psychosocial changes that occur with time
after a period of back pain; these insights might not be reflected in a
single disability score.
Although we applaud the authors' efforts in confirming the prolonged
disability after an episode of back pain, many unanswered questions
remain regarding the aetiology in these patients.
Authors' reply
EDITOR Hay suggests that selection bias explained the poor progress in the
patients followed up in our study. We discussed this possibility in
detail and pointed to the similar consultation rates for low back pain
among non-responders and responders. We should also point here to a
study, not cited in our paper, carried out in primary care in the
United States.2 Cherkin et al carried out a one year
follow up of 90% of patients with low back pain recruited to a trial
of early treatment and found that 61% still had symptoms and
disability related to back pain We agree with Kothari et al that history is an important predictor of
outcome, as studies in the literature have reported.3 The
other indicators that they mention, however, have repeatedly been shown
to be weaker predictors of outcome in primary care than psychosocial
factors.4 Kothari et al also raise the issue of outcome
measures. There is a growing literature on generic versus specific
instruments in regional musculoskeletal pain, including a specific back
pain instrument derived from the short form 36.5 The
general conclusion is that disease specific measures are more
discriminating and more sensitive to change than generic measures
alone. The issue, however, is to choose a sensible instrument for the
particular question that you wish to address. Our study's objective
was to chart the course of low back disability over time, not to
compare this disability with other conditions.
Croft et al describe 12 month outcome in low back
pain.1 Their paper documents the disease course, but it is
surprising that they do not describe patient management. The Royal
College of General Practitioners has published evidence based
guidelines for the management of acute back pain.
2 3
These guidelines recommend active management followed by manipulative
treatment at 4-6 weeks if active management fails. An evidence based
book for patients with back pain (The Back Book) was
launched with the guidelines.4
Tees Health Authority, Middlesbrough TS7 0NJ
David Crick
723 Beverley High Road, Kingston-upon-Hull HU6 7ER
Croft et al's prospective study of low back pain in general
practice reminds us that non-attendance for further care does not equal
recovery.1 They measured morbidity which often remains
unrecognised, and their data counter the claim that 90% of patients
with low back pain have fully recovered by one month.
University of Leicester, Leicester General Hospital, Leicester
LE5 4PW
Croft et al raise the question of whether early treatment of low
back pain reduces the incidence of long term pain and disability after
an episode of back pain.1 Unfortunately, they did not
collect the data that might have identified a subgroup of patients who
were likely to fare badly. Factors such as employment status,
occupation, cigarette smoking, and physical fitness are important
prognostic determinants of recovery from an episode of back
pain.
2 3
The interviewees' history of back pain seems to
have been ignored. Altogether 60% of those with pain and disability at
initial interview had the same status at 12 months; does this group
represent a homogeneous population or rather those patients with
previous chronic back disability?
Thomas Niemeyer
Michael Grevitt
Centre for Spinal Studies and Surgery, Queen's Medical
Centre, University Hospital, Nottingham NG7 2UH
Deane and Crick are correct in stating that our paper was not
about the management of back pain in primary care. As they point out,
since our study was carried out guidelines have been published on the
primary care management of low back pain. They are wrong to suppose
that their findings provide evidence that treatment according to these
guidelines helped their patients. Acute new episodes of back pain can
get better quickly,1 but non-return to the general
practitioner is no measure of that improvement. This was the starting
point of our study, the purpose of which was to identify pain and
disability independently of consulting behaviour. Future cohort studies
with a similar design to ours will be able to assess whether changes in
treatment in general practice result in lower rates of recurrence and
chronicity.
figures similar to our own. We accept
that participation in data collection may have influenced outcome, but
this is unlikely to have explained our results. It is difficult to
envisage a design for a "methodologically robust" prospective study
that does not require data collection from patients.
University of Keele, School of Postgraduate Medicine,
Industrial and Community Health Research Centre, Hartshill, Stoke on
Trent ST4 7QB
Gary J Macfarlane
Ann C Papageorgiou
Elaine Thomas
Alan J Silman
ARC Epidemiology Research Unit, School of Epidemiology and
Health Sciences, University of Manchester, Manchester M13 9PT
© BMJ 1998
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Related Article
- Outcome of low back pain in general practice: a prospective study
- Peter R Croft, Gary J Macfarlane, Ann C Papageorgiou, Elaine Thomas, and Alan J Silman
BMJ 1998 316: 1356-1359.[Abstract] [Full Text] [PDF]
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[Abstract] [Full text]
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