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Rapid Responses: Rapid Responses published:
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Serious disease and secondary gain.
- George J Addis (3 May 1998)
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Non attendance and morbidity from low back pain.
- Alastair Hay (12 May 1998)
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Evidence based, beneficial and cost effective care for back pain is available.
- Jeffrey M Shurr (10 June 1998)
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Kudos for your research
- Bruce J Haggart (6 April 1999)
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Re: Evidence based, beneficial and cost effective care for back pain is available.
- Steve Lockhart (1 May 1999)
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Workers' Compensation Costs Lowered by Making Back Exercises Mandatory
- Gregory T Wright (18 June 1999)
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Re: Re: Evidence based, beneficial and cost effective care for back pain is available.
- Frank Conijn (6 October 1999)
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Re: Non attendance and morbidity from low back pain.
- Susan Smithson (24 February 2001)
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George J Addis, Consultant Physician 49 Whittingehame Court Glasgow, G12 0BQ
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I find it hard to work out what the conditions were that underlay the complaint that this paper studies. Metastatic disease, tuberculosis, and osteoporosis for example are all causes of back pain with more or less forseeable but different outcomes in time. On the other hand people who have undoubted secondary gain in the form of money, love, or avoidance of unpleasant duties through a pain that the doctors cannot cure are not likely to give up their pain. Those on Disability Benefit or other recompense for example would be much worse off if they were to recover and become unemployed instead. Without knowing something about the case mix this study does little mor than tell us that back pain is a big and chronic problem to a lot of people. I suppose that we should be glad to have our intuition supported by factual information but harder facts are needed. |
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Alastair Hay, Clinical Lecturer in General Practice University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW
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Dear Sir The prospective study of low back pain (LBP) in general practice by Croft et al. reminds us of the important fact that non attendance for further care does not equal recovery. They measure morbidity which often remains unrecognised, and their data counter the claim that 90% of patients with LBP have fully recovered by one month. However, 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 analysing patients' experience outside the surgery was only available in a minority of the original group, 170/463 (37%), leaving considerable room for selection bias. Although an attempt was made to quantify this bias, the 'validation group' was too small (44) to be conclusive. Two further factors may have exagerated this bias. Both the original cross sectional survey and the interview process may have altered patients perceptions of their LBP (the Hawthorne effect). |
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Jeffrey M Shurr, Doctor of Chiropractic, Clinic Director Chiropractic Associates 133 Chorley Road Walton le Dale Preston Lancashire PR5 4JR
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This study would suggest that the "wait and see" approach is ineffective and contributes to the large cost of back pain. In 1993 back pain cost the UK 5.3 billion pounds, most of which was made up of Social Services and lost production costs. Only 481 million pounds was estimated as NHS costs. The Clinical Standards Advisory Group (DEC 94) and the Royal College of General Practitioners (SEPT 96) in guidelines for the treatment of back pain in the UK recommend a shift of resources towards primary care. Skilled spinal manipulation is recommended as a beneficial and cost effective means of treatment. Chiropractors, osteopaths and specially trained physiotherapists offer evidence based primary care which is both beneficial and cost effective. This care consist of history, appropriate physical, orthopaedic and neurological examination, diagnosis and suggested action or treatment plan outlined in a written report of findings to the GP and a verbal review of findings with the patient using models and illustrations. Treatment consists of spinal manipulation/mobilisation, soft tissue therapy, physiotherapy modalities as indicated and advice on posture and ergonomics to facilitate recovery and early return to normal tasks of daily living. Encouragement and a positive approach to recovery accompanies an emphasis away from passive therapy to active spinal rehabilitation to promote self sufficiency and decreased dependence on treatment. A follow up report of progress is sent to the GP. This protocol is low cost, low tech and effective for the majority of simple back pain and nerve root entrapment sufferers. In view of this study the locality purchasing commissioners within the NHS as well as the general practitioners themselves would do well to take heed of the guidelines and seek out local reputable qualified chiropractors, osteopaths and physiotherapists skilled in spinal manipulation. The reduction of back pain costs to the nation may be substantial as would I venture patient satisfaction. |
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Bruce J Haggart, Private practice chiropractic physician Bilingual Health Care Center of Utah
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I was pleased to read that someone has actually taken the time and effort needed to begin researching the natural history of low back pain with a scientific vein. It is a welcome first step and you are all to be commended. I sense that North American and British patients will have a similar pattern of findings and that the results of this study may ultimately have influences beyond those anticipated by the authors. Sincerely yours, Dr. Haggart |
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Steve Lockhart, SLM Practitioner Sydney Australia
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I really have to question the statements of Jeffery M Sherr on the bases that it has already been found that the majority of back pain sufferers still have their pain 12 months after it started even though they haven't gone back to their GP. I'm sure a study would find that those sufferers have in that time consulted chiropractors, oesteopaths and physical therapists still with no solution to their pain. The notion that these modalities can provide any sort of long term solution to back pain, by my logic, is totally floored by the fact that pain is still present 12 months on and back pain is a topic that warrants all this discussion as a largely untreatable condition. Lets face it if chiropractors, oesteopaths or physical therapists had the answers to solve back pain episodes we wouldn't need to be talking about it. |
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Gregory T Wright, Team Physician and Trainer, Cape Cod League Baseball Private Practice, Harwich Port, Massachusetts, USA
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As a practicing chiropractic physician and team physician for professional and university level athletes, I am surprised to see that the results of Croft et al.'s research are so unpalatable to so many. I agree with Dr. Addis' comments regarding the multitude of causes for LBP and the confounds and shortcomings of this study. I do not believe that he has any important data supporting his implication that malingerers and secondary gainers comprise a significant proportion of LBP sufferers. There is also no evidence in the literature to suggest that a "litigation neurosis" exists in LBP patients. In 1976, I personally sustained a bilateral pars fracture to my fifth lumbar vertebra, visited three very respected Boston orthopedists who found nothing, the third of whom referred me for psychiatric evaluation because "there was nothing wrong". I was urged to seek alternative opinions and a friend dragged my parents and myself to a chiropractor. My parents were quite skeptical given the medicopolitical situation for U.S. chiropractors at the time. When an A-P tilt-up view (see Yochum & Rowe) of the lumbar spine on a plain film radiograph taken by the chiropractor revealed the problem, I was braced, and advised to rest. I was prescribed exercises later that still help me today. That was 1976. Hopefully, spondylolysis is more readily recognizable to physicians today. But my example begs the question: If physicians do not adequately look for a problem, does that mean it doesn't exist? Does a lack of objective findings mean that the LBP patient does not have a reason for his subjective complaints? Estimates of costs of LBP in the U.S. rise as high as the 50 billion dollars per annum. Studies have supposedly "proved" that "Back Schools" and other varied injury prevention programs for industrial LBP are ineffective. Malingering and secondary gain are often suspected by persons who have never themselves experienced LBP, and who have no proof that objective findings do not exist, just because they cannot (or will not) find them. I would like to propose an easy solution: make exercise a mandatory part of the job description where lost time at work due to LBP is the problem. Make it a daily event, with exercises for trunk extensors, flexors and lateral flexors. Try videotaping different job tasks, and then designing an obstacle course for employees who must demonstrate proficiency at proper lifting, bending postures, etc. for the jobs you want them to perform. Clearly, most LBP is the result of strain injuries to muscle belly or tendon. Mandatory, paid exercise has worked well for U.S. companies that have integrated exercise into the workplace. Most patients to whom I have prescribed home exercise do not perform the exercises properly. With office supervision, performance improves. Studies like the recent New England Journal of Medicine study comparing the McKenzie method, a one- dollar pamphlet on exercises and one or two cracks to the back are deeply flawed because most practitioners in my profession use all three of these treatment methods simultaneously, which most likely have a cumulative beneficial effect. It takes time, perhaps 3-6 months of dedicated effort by patients, to see real strength, flexibility and balance improvements in trunk muscles. These muscles are often ignored by orthopedists, physical therapists and chiropractic physicians who are not knowledgable enough regarding rehabilitaion of LBP. Studies which do not measure exercise compliance statistics will be left behind. Sincerely, Gregory T. Wright, D.C. |
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Frank Conijn, physiotherapist Amsterdam
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Mr. Steve's Lockhart's reaction calls for an invitation to visit the next website: www.mckenziemethod.com (click on "Low Back Pain"). After reading the stories of patients of just one (!) practice (in Texas), you will probably want to surf to: www.mckenzie.nl/literatu.html (it's a Dutch site, but this page is in English), to see that new insights and a new (working!) approach to LBP have come up in the last few years, backed by literally dozens of scientific studies and papers (it's not just a "here today, gone tomorrow" method!). Spinal problems largely untreatable? No sir, not anymore. Are physiotherapy/chiropractic/osteopathy still in their growing years: yes, very much so. Try reading McKenzies book "The Lumbar Spine, mechanical diagnosis and therapy" (ISBN: 0 473 00064 4), and see if it will arouse the same reaction as it did in me: "We didn't even learn the most basic principles of the functional anatomy of the spine in college!" After years of (trying to) treat(ing) patients with so-called "Non-specific low back pain", with -amongst others- manipulation of the spine, I'm willing to say that we as orthopedic (para)medics never really knew what we were doing, or at least thought we knew but didn't. That has changed lately, as pertains to the availability of an effective, evidence-based and very cost -effective therapy. (Not that the respective colleges have incorporated it yet: they remain way behind). Just look at the sites (and read his book if you like), and judge for yourself: it's all a matter of insight on how the spine really works! |
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Susan Smithson
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As a patient with sciatica of unknown origin of 6 months standing I can vouch for the assumption that non attendance does not correlate with either an improvement or cessation of low back pain or sciatica. The GP's attitude and the lack of interest in finding the causes must be a prime factor in the non attendance, so one suffers in silence. |
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