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Rapid Responses: Rapid Responses published:
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Is physiotherapy any use for back pain?
- Pamela A Hunter (25 September 2004)
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Back pain and magnesium deficiency
- Ellen CG Grant (27 September 2004)
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Funding for Patient Education Needed
- B. Kim Humphreys (27 September 2004)
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Back Pain and Physiotherapy
- Roderic S MacDonald (27 September 2004)
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Better training for GP's
- Bronwyn F Thompson (28 September 2004)
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Try the orthopaedic medical approach
- Gabriel Symonds (30 September 2004)
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views from the frontline...
- Ian P Stevens (30 September 2004)
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Back pain - effective interventions are available
- Brian J Marien (7 October 2004)
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..so what can be done for back pain?
- Vera Neumann, Andrew Frank (15 October 2004)
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Nice try but, you are all missing the mark
- Stanley W. Wisnioski, III (23 October 2004)
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..if we claim to treat the cause, not the symptoms....
- Dr. Herbert H. Nehrlich (24 October 2004)
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Re: ..if we claim to treat the cause, not the symptoms....
- Stanley W. Wisnioski, III, DO (25 October 2004)
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Re: Re: ..if we claim to treat the cause, not the symptoms....
- Dr. Herbert H. Nehrlich (26 October 2004)
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Pamela A Hunter, Freelance microbiological consultant Burnthouse, Cowfold, West Sussex. RH13 8DH
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The article refers to NHS physiotherapists; as a long-time sufferer of lower back pain, I have been through the gamut of physiotherapists, mainpulative therapists, osteopaths, chiropracters, masseurs and even had aqupuncture. In my now quite considerable experience, the answer to how valuable is physiotherapy for lower back pain is 'it depends on the physiotherapist'! I found that in the NHS physiotherapists did very little except tell you what to do, presumably a reflection of their heavy workload. In marked contrast private physiotherapists were far more 'hands on', using massage, manipulation and ultrasound as well as designing an exercise plan and making you do a number of them to check that you understood how to do them properly. The effects I found were thus very different. It was only when I went for private treatment that I had any beneficial effects. If NHS physiotherapists only have time to talk about exercises, surely anyone can do that. Why waste NHS money, just hand out a sheet of standard exercises. Competing interests: None declared |
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Ellen CG Grant, physician and medical gynaecologist 20 Coombe Ridings, kingston-upon-Thames, KT2 7JU. UK
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The most valuable treatment for "idiopathic" back pain in my experience, and that of other doctors practising Nutritional Medicine, is repletion of magnesium status. Unfortunately serum magnesium levels do not indicate intracellular magnesium deficiencies because serum levels are maintained by homeostatic mechanisms in most patients. Diagnosis can be made using red blood cells or passive sweat magnesium concentrations. Biolab Medical Unit in London offers these tests and also a myothermogram, which shows irregular heat output patterns from magnesium deficient muscles. I find these tests are invaluable for preventing back pain by verifying magnesium repletion. Monitoring essential nutrient levels are also very important for preconception care, preventing recurrent miscarriages and "unexplained " infertility and improving semen quality.1 Excessive excercise can intensify magnesium deficiencies and cause muscle, ligament and joint problems. 1 Grant ECG. Monitored nutritional supplements to prevent pregnancy complications. http://bmj.com/cgi/eletters/329/7458/152#70176, 6 Aug 2004 Competing interests: None declared |
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B. Kim Humphreys, Dean, Graduate Education and Research Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Canada M2H 3J1
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I would like to thank Dr. MacAuley for his thoughful editorial in response to the Frost et al. RCT on physiotherapy versus advice for mild to moderate low back pain. Back pain is indeed a difficult problem. Dr. MacAuley's article certainly gave me greater appreciation for the plight of GPs trying to find the best solutions for their back pain sufferers within the limited NHS resources. Being involved with treating and researching mechanical back and neck pain problems for two decades, it is my belief that the biopsychosocial model is still our best approach for managing these conditions. One specific treatment is commonly not the answer for most of these problems and especially not for chronic conditions. Specific advice on keeping active, fear vs. harm, active rehabilitation exercises, a positive attitude and an effective treatment modality (pain/anti-inflammatory medication, manipulation, physiotherapy) should work in most cases if employed early enough. However with NHS time and resource constraints, many patients are likely not getting the treatment they need, or seen early enough to reduce the liklihood of anxiety, depression and chronic illness behaviour. We all know the downward spiral that occurs as a result. Yes, back pain is a difficult problem but it is a problem where significant resources would be better placed in public education. Patients need to know the nature of the conditon, what they can do to help themselves, how quickly they need to respond and how to cope if the condition is slow in resolving. They also need to know when to seek treatment, what options are available and the likely outcomes if combined with compliance to advice, activity and exercise programmes. Until there is the will to allocate significant funds for education programmes as well as greater resources to help patients manage their problems earlier, I think back pain will continue to be the massive problem it is. Sincerely B. Kim Humphreys DC, PhD Dean, Graduate Education and Research Canadian Memorial Chiropractic College 6100 Leslie Street Toronto, Ontario M2H 3J1 Competing interests: None declared |
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Roderic S MacDonald, Specialist and educator in Musculoskeletal Medicine London College of Osteopathic Medicine, 8, Boston Place, London NW1 6QH.
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Domhnall MacAuley's editorial [1] is worryingly inadequate in these days when healthcare planning decisions are made on the basis of evidence by people who often have not the knowledge to assess it and may be swayed by supposedly authoritative opinion in the BMJ. The study by Frost et al [2] that seems to have prompted the editorial has many of the flaws of the pragmatic trials currently favoured in this area : poorly categorised entrants, far too many uncontrolled variables, inadequate description of management components especially the nature of the advice given to patients. If a significant benefit were identified from such a trial it would be difficult, in other centres, to select a similarly responsive patient group and reliably reproduce the beneficial regime. In the treatment of back pain, physiotherapy, osteopathy, chiropractic all have many components of their managements which vary between and within their practitioner groups. The only way for these disciplines to be assessed is not by the "fast and dirty" pragmatic study but by fastidious trials that tease out the sources of benefit and not only justify a profession's work but allow their practice to develop according to evidence. A less uncritical approach to the paper should have been incorporated into the editorial. However I take issue most with the author when he dismisses manipulation as not seeming "to produce clinically worthwhile changes in pain or function" and gives references for this assertion that are out of date [3] or are a review of evidence [4]. A basic computer search for evidence of effectiveness of manipulation for back pain would have revealed the trial of Aure et al from Norway, published in early 2003 [5], in which patients already off work for more than two months were treated by physiotherapists with manipulation. At two months 67% were back at work compared with 27% in an exercise therapy group. This clinically important difference, which was mirrored in pain and disabilty scores, was significant at P = <0.01 and was maintained throughout the one-year follow-up period. Recognition of new findings used to be delayed until they could be published. Are they now to be ignored even by BMJ authors until they have found their way into reviews of evidence, a delay that will often be over a year? The scarcity of good quality trials of manipulation has demonstrated for decades that a treatment that cannot be licensed and has no commercial value to a manufacturer will not be adequately investigated no matter what potential benefit it may have for the Health Service and patients. Should the treatment fail to conform to, or be developed within, the conventional medical paradigm the liklihood of adequate investigation declines further. When expert authors then rely on evidence reviews rather than being abreast of their field, our aspirations for evidence-based medicine are further thwarted. References : [1] MacAuley,D. Back pain and physiotherapy. BMJ 2004; 329 : 694-5. [2] Frost, H et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004; 329: 708 - 11. [3] Ferreira, M et al. Does spinal manipulative therapy help people with chronic low back pain ? Aust J Physiotherapy 2002; 48 : 277 - 84. [4] Assendelft, WJ et al. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004; (1) : CD000447. [5] Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain : A Randomized, Controlled Trial With 1 - Year Follow-up. Spine 2003; 28(6) : 525 - 31. Competing interests: None declared |
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Bronwyn F Thompson, Clinical Senior Lecturer University of Otago, New Zealand
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The thoughtful response from Dr MacAuley highlights something I am finding even with 5th year medical students - they leap into diagnosis without first listening to what the patient is saying about their back pain. It is tempting in the 15 minutes or less set aside to examine and treat a patient in the community to decide that the priority is to identify/diagnose the illness first, then rely on evidence or experience to determine the intervention. However, there is research to support the recognition that patients with back pain first of all want to know what their back pain is NOT (ie the 'red flags'), then what they CAN do for themselves. This involves identifying the problems that have arisen for them because of their pain - that is, how they drive to and from work, how they are sleeping, how they are managing with self cares, how they are managing their work, their worries, their expectations for the future. Von Korff and colleagues have identified a number of positive options for primary care practitioners. In the argument that traditional physiotherapy modalities provide little or no benefit, we forget that physiotherapists and occupational therapists can provide coaching and self management information that help a patient experiencing back pain return to normal activity. In the case of a patient who is fearful, the support of a 'knowledgable coach' who provides consistent, nonmedical reassurance that returning to activity is safe is a critical ingredient in the process of a person recovering. Unfortunately, as the article referred to describes, this has not been clearly studied, in that all manner of physiotherapy approaches has been combined. It is important that medical, physiotherapy and occupational therapy practitioners are fully versed in the research on how to provide coaching to people experiencing nonspecific low back pain - this typically should include knowledge of motivational interviewing, a clear model of acute and chronic pain including the gate control theory, and some knowledge of the psychosocial factors that influence return to normal activity. I don't believe that at this stage exercise instructors have good awareness of this - and they may in fact reinforce the 'let pain be your guide' approach that used to be the mainstay of nonspecific low back pain management. Korff MV. Pain management in primary care: An individualised stepped- care approach. In: Gatchel RJ, Turk DC, editors. Psychosocial Factors in Pain: Critical Perspectives. New York: The Guilford Press; 1999. p. 360 - 373. Competing interests: None declared |
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Gabriel Symonds, General Practitioner Tokyo
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What a counsel of despair! Dr McAuley no doubt speaks for a large section of the medical profession when he says that for the patient suffering six weeks back pain, ‘physiotherapy was the obvious option’, and ‘For one of the most common and debilitating conditions...we have no real answer’. He is too pessimistic. Of course physiotherapy for back pain is ‘no better than advice’. Back pain is a symptom, not a diagnosis. It is unfair and disheartening for all concerned to expect a physiotherapist to treat patients with undiagnosed pain. In practice, for those who take the trouble to learn, it is possible in most patients to diagnose the cause of the pain and determine the tissue from which it arises. The only tools that are needed are the ability to take a proper history and to carry out a systematic clinical examination. In most cases, laboratory test and imaging techniques are not needed. Diagnoses such as displaced lumbar intervertebral discs, sacro-iliac joint subluxation and ligamentous insufficiency can regularly and confidently be made. Treatment can then be directed to the tissue at fault in such a way that the lesion can be beneficially affected. Such methods include lumbar spine and sacro-iliac joint manipulation, lumbar spine traction, epidural local anaesthesia, lumbar nerve root blocks and ligamentous sclerosis. Forget about alternative practitioners and ‘specially trained fitness instructors’. (Who will instruct the instructors?) For doctors who are interested, there are three current textbooks where these diagnostic methods are described, and where these entirely orthodox treatments, with their indications and contra-indications, are set out: 1.Cyriax J. Textbook or Orthopaedic Medicine, Volume I, 8th edition, Bailliere Tindall, London, 1982 2. Cyriax J. Textbook of Orthopaedic Medicine, Volume II, 11th edition, Bailliere Tindall, London, 1984 3. Ombregt L, Bisschop P, ter Veer H J. A System of Orthopaedic Medicine, 2nd edition, Churchill Livingstone, 2003 Competing interests: None declared |
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Ian P Stevens, Physiotherapist Forth Valley Scotland Stirling FK
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Dr McCauley et al, It is timely to question the role of intervention for costly problems and often needless suffering . Back pain and indeed many musculoskeletal problems are an enigma . Some may argue that the explosion in disability due to relatively benign problems is not a real medical problem at all see the link here http://www.rheuma21st.com/archives/ cutting_edge_hadler_muscul_injuries.html I disagree with the last Physiotherapist I don't feel it is easy to diagnose problems . (I have 'done the courses' suggested and take a different tack after looking at the bigger picture of pain and disability ). There is extremely poor correlation with imaging and back pain . There is little to no correlation with 'manual therapy' probing and diagnosing of sensitive soft tissues. This in many cases may provide some kind of answer . If success with an intervention, whether it be manipulation/soft tissue therapy/acupuncture or whatever can be gained relatively quickly in many chronic problems perhaps the pain issues are less tissue based but more to do with processing of sensory information ...the fault may lie anywhere in the system..... This may explain the mechanism behind the success and failures of many approaches..repeated manipulation/operations etc in a highly sensitised state may cause further 'wind up' at the DHorn and lead to ongoing disability ......However careful therapy(whatever one feels comfortable doing) with neurological explanations ,graded movement and re-exposure to tasks that have been avoided may reverse the situation....... This can be the experience in pain management and also recent research done in Australia utilisiing education based on pain physiological explanations.This may shed light on useful ways to practice. There are an A-Z of approaches available and every tissue in the spine has its favourite brand of practitoner and band of adherants. It seems the one feature of musculosekeletal medicine that marks it out from many other areas is the cult like following and belief amongst practioners . Perhaps one has to believe for a thing to work ??This is one factor that often marks the difference between success and failure; belief/ relationship/understanding and time spent in the treatment room........This is no bad thing to admit in the rushed and pressuried clinical environment . (For those that may be interested in this area a controversial but well written book is Touch and Emotion in Manual Therapy by an Osteopath Bevis Nathan). However ,in GP clinc land the spinal pain problem is often the tip of the iceberg when a comperehensive health questionnaire is obtained. Adopting a more comprehensive bio psych social approach to the spinal pain complaint may elicit a plethora of issues which a Physiotherpist has little chance of influencing ...this is often a reality of practice .... Co-existing blood pressure /employment/ relationship,pain avoidance and somatoform issues are very common co existing problems ......I challenge any practioner to influence a large group of Scottish taxi drivers as an example! Dr MacAuley singled out the Meade study as an example of how one group may offer superior treatment .....As Patrick Wall suggested in Pain the Science of Suffering (p126) the difference in the study was stark -patients were treated in the private clinic v's routine physiotherapy- probably akin to compariing Peckhams Deli v's Poundstrechers(discount supermarket with little in the way of vitamin supplements)....... People often don't do well in NHS hospitals due to rushed case loads,often the environments are quite impersonal and often there is an obsession with biomechanical and mechanical issues rather than the often dominant physiological and behavioural issues relating to excessive spinal sensitivity and pain behaviour ? Ian Competing interests: None declared |
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Brian J Marien, Associate Specialist, Psychological Medicine St Bartholomew's Hospital, William Harvey House, West Smithfield, London EC1A 7BE
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Dear Sir Back Pain – effective interventions are available I hope that MacAuley’s editorial on back pain1 is just a reflection of his own confusion about how best to manage back pain. His therapeutic nihilism does not reflect the research evidence. MacAuley states that ‘For one of the most common and debilitating conditions in the community, we have no real answer’. To be unaware of effective interventions in back pain is understandable, but to write a misleading editorial, in a leading medical journal, is iatrogenic. It perpetuates the myth that nothing works. Actually, there is room for optimism. Effective, evidence based, treatments for patients with back pain are available.2 3 4 5 Over ten years ago the CSAG Report 6 observed ‘traditional medical treatment had failed to halt the epidemic of back pain and may even have contributed to it’. They recognised that early management very largely determines the final outcome. They strongly recommended the assessment of psychological and social factors in all patients who are off work after six weeks. Subsequent research has confirmed that psychological and behavioural responses to pain and social factors are the main determinants of chronic pain disability. 2 7 8 Pain management programmes are effective in treating chronic pain. A systematic review of the literature shows that psychological factors are related to neck and back pain and efforts should be made to incorporate this information better into clinical practice to enhance both assessment and treatment7. Effective health care, a bulletin published by the NHS Centre for Reviews in Dissemination, concluded that there is strong evidence that exercise therapy may help chronic low back pain. They found that multidisciplinary treatment programmes improve long-term outcomes for pain, functional status, and sick leave compared with other treatments for chronic back pain 4. A Cochrane Systematic Review found that the multidisciplinary functional restoration approach improved pain and function in patients with chronic low back pain. Less intensive interventions did not show improvements in clinically relevant outcomes5. MacAuley asks ‘can we make referral decisions based on subjective measures?’ Research consistently shows that 30% of all consultations are for ‘medically unexplained symptoms’- subjective symptoms. Pain is subjective it is private data. Pain cannot be objectively measured or quantified. Measurement relies on the individual’s personal report, and ‘yes’ we should make referral decisions based on subjective measures when effective interventions are available. Pain management begins with acknowledgement of the reality of the patient’s symptoms. It is important to identify the principal factors that maintain musculoskeletal pain in each patient and then develop an appropriate management plan.2 It is unfair to make physiotherapy the scapegoat. In back pain, identifying the patients concerns, allaying anxieties, providing advice and encouraging a graded exercise programme with pacing and goal setting are all part of an effective treatment package.2 3 5 Many physiotherapists are well informed about the, evidence based, biopsychosocial model of back pain and the importance of appropriate early interventions. Specialist ‘back pain’ physiotherapists, often work within a multidisciplinary back pain team. They can identify the factors associated with chronicity, that may include the patient’s specific concerns and beliefs about their back pain, misunderstandings about the meaning of the pain, psychological distress, coping strategies and fear avoidance. Specialist physiotherapists can help the patient with back pain: to improve their understanding of pain and the factors that influence their pain; to reduce levels of emotional distress; to develop a level of active control over their pain; to reduce reliance on medication and other health care; to set realistic and achievable goals; to change patterns of under and over activity – pacing; to improve levels of fitness, mobility and activity tolerance; to encourage a graded return to normal activities and where possible, a graded return to work. This integrative approach to back pain involves the interaction of physiological processes, psychological factors and the socio-occupational context.2 A biopsychosocial model of back pain makes MacAuley’s question ‘Is back pain an occupational health, a lifestyle, or even a medical problem?’ meaningless. There is good evidence that changes in clinical practice and service provision could radically improve outcomes for patients with back pain. BUPA established an evidence based approach to back pain over two years ago.10 The Department of Work and Pensions are using a number of evidence based pain management strategies in their return to work programmes. Patients with back pain have long been aware of the inadequacy of NHS services and many have voted with their feet. Perhaps it is not physiotherapy that is at fault but the persistence of the traditional model of back pain care that, despite the evidence, remains prevalent in the NHS. We need to be sending a realistic positive message to patients with back pain. The traditional model of care, along with therapeutic nihilism, can create a sense of hopelessness and helplessness, in both the doctor and the patient, that often contributes to chronic pain disability. We could do better. There is evidence that effective interventions are available. The risk of chronicity can be reduced. We have an integrated evidence-based model of care for back pain. The challenge is its widespread dissemination. There are real obstacles to progress. Back pain care is a Cinderella service and the implementation of an evidence based back pain service across the NHS requires firm political will along with changes in medical practice and the organisation of services. In the meantime, when seeking treatment for back pain, either acute or chronic, it is worth identifying a specialised service offering a multidisciplinary approach in line with the research evidence. The outcome data demonstrates improved physical functioning, improved psychological well-being, return to a more normal lifestyle and productive activity and reduced healthcare costs.3 4 5 We know that this approach can provide each individual with the best chance of a reduction in pain, improved function and recovery. To suggest we have no real answer is wrong. However, to tell doctors and patients there is no multidisciplinary back pain service, in line with evidence based guidelines, at a hospital near you is probably right. Brian Marien Department of Psychological Medicine,
St Bartholomew’s Hospital,
William Harvey House,
West Smithfield,
London EC1A 7BE
Competing interests: none declared References: 1. MacAuley D. Back Pain and Physiotherapy: NHS treatment is of little value. BMJ 2004; 329:694-5 (25 September). 2. Main CJ. Williams A. Musculoskeletal Pain. ABC of Psychological Medicine. BMJ 2002; 325:534-7. 3. Morley SJ, Eccleston C, Williams A. Systematic review and meta- analysis of randomised controlled trials of cognitive behavioural therapy for chronic pain in adults, excluding headache. Pain 1999; 80:1-13. 4. Effective Healthcare. NHS CENTRE FOR REVIEWS AND DISSEMINATION. Acute and chronic low back pain. Nov 2000 Vol 6. No: 5. ISSN:0965-0288 5. Guzman et al. Multidisciplinary Bio-psycho-social Rehabilitation for chronic Low Back Pain. The Cochrane Database of Systematic Reviews, 2002. 6. Clinical Standards Advisory Group. Clinical Standards Advisory Group report on back pain. London:HMSO, 1994. 7. Linton SJ. A Review of psychological risk factors in back and neck pain. Spine 2000; 25:1148-56. 8. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychological yellow flags in acute low back pain: risk factors for long term disability and work loss. Wellington NZ. Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee, 1997. 9. Burton AK, Waddell G, Tillotson KM, Sommerton N. Information and advice to patients can have a positive effect. A randomised controlled trial of a novel educational booklet in primary care. Spine 1999; 24: 2484 -91 10. BUPA. Evidence Based approach to Back Pain. August 2002. Competing interests: None declared |
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Vera Neumann, President, British Society of Rehabilitation Medicine BSRM, c/o Royal College of Physicians, St Andrews Place, London NW1 4LE, Andrew Frank
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The direct health care costs resulting from sick leave and early retirement due to back pain are huge, over three times higher than corresponding costs for all cancers. Against this background, it is remarkable that research on back pain relief and rehabilitation is so limited. Frost and colleagues1 are right to challenge the assumption that “routine physiotherapy” is effective. In his editorial in the same issue of the BMJ, Domhnall MacAuley2 concludes that “For one of the most common and debilitating conditions in the community, we have no real answer”. With respect to treatment of back pain, this is probably true. However, Dr MacAuley also asks “Is back pain an occupational health, a lifestyle or even a medical problem?” This is a question to which we do have some answers. As described in our recently published working party report on Musculoskeletal Rehabilitation3 there is a significant body of evidence that aspects of work and lifestyle may predispose to back pain, and interventions which address these factors can be effective in ameliorating the problem. When a GP or another health professional is faced with a patient with persistent back pain, the workplace, psychological and/or other factors which predispose to chronicity need to be addressed. Our report discusses how this might be approached. The real hope for the future is that health professionals will become more adept at tackling these issues. In cardiovascular disease, diabetes and many other areas of clinical practice, the emphasis is now on prevention. Why is the management of musculoskeletal diseases and research in this area lagging behind and still so focussed on cure? Isn't it time to pay more attention to prevention of these painful and disabling conditions? 1, Frost H, Lamb SE, Doll HA, Taffe Carver P, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004; 7468:708-711 2. MacAuley D, Back pain and physiotherapy. BMJ 2004; 7468: 694-695 3. British Society of Rehabilitation Medicine. Musculoskeletal Rehabilitation - Report of a working party (Chair: Neumann V) BSRM, London 2004 Competing interests: None declared |
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Stanley W. Wisnioski, III, Osteopahic Physician West Palm Beach, FL 33401
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Dear Friends and Colleagues, I have read this article and the responses to it. You are not alone. I hear many physicians across all specialities groan when they hear there is a Low back pain patient waiting to see them. I make my living by seeing these patients. They usually find me after having been through a litany of practictioners. The patients have had plain films, MRI, medication and been sent to Physical Therapy where they were given the standard 'Shake and Bake' treatments. Or they have been treated by chiropractors for a length of time were either they have had no decrease in pain or are worse off. I welcome these patients because I know that every practioner who has seen this patient has made the same fundamental error. They have "chased the pain." Focused on the low back and forgotten basic anatomy. The low back is where, thorough multiple facial layers and ligaments,muscular insertions and origins ties the four quadrants of the body together. (Netter's Atlas of Human Anatomy, third edition, plate 167) To focus on the low back as the cause of the pain completely ingnores any other anatomical cause. You are in essence treating the symptoms and not the cause of the pain. This we know is a recipe for failure. I have found that 80-90% of the time the cause of the pain is in areas other than the low back. I find lower extremity,shoulder and ribcage dysfuntions are the usual suspects. In cases where there are discreet somatic dysfuntions in one of these areas the treatment is simple and the results dramatic. The way I explain this to my patients is with a simple analogy. If you have water leaking in through your ceiling. You can go up on the roof and you may find a hole directly above the ceiling leak. Or you may find the hole is elsewhere in the roof and the rain has simply followed a path to where it eventually finds a place to leak through the ceiling. The next time you see a Low back pain patient observe what the range of motion is in the arms,shoulders, legs and rib cage. When taking the history think about how the anatomy elsewhere ties into the low back. The low back is the anatomical location where multiple areas are anchored. It makes perfect sense that this is the location where the majority of pain would show up. Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Dr. Wisnioski. I read with rapidly fading interest your comments on low back pain. The gist of your remarks appears to be the implied information that osteopathic physicians, and in particular you, would be the treatment of choice for low back pain. Osteopathy has experienced a drastic decline in number of practitioners and the average person does not know what an osteopath does. I realise that the American Medical Association was instrumental in this drastic reduction, through their "absorb and eliminate" tactics some decades ago but it is rather universally known that public acceptance of osteopathy has been less than noteworthy overall. Re-reading your comments, I find nothing of interest or conducive to further enlightenment for the continuing discussion concerning back pain and its treatment. You will excuse me for suffering from such a lack of perception, but, try as I might (and I did) I am at a total loss. What, dear doctor, are you saying? While I realise that all the professionals who deal with this kind of problem would tend to claim results that are at least predictable and acceptable, if not always spectacular, I find the dishonourable mention of chiropractic treatment somewhat of an undeserved blow into the sacroiliac region. If I had a low back pain I would see a chiropractor first, having found over the years that their track record is good or better, chances are that I wouldn't have to look for treatment beyond this approach. I consider myself fairly open-minded and would be happy to look at what your magic fingers can do but it would be helpful if you could elaborate. Competing interests: None declared |
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Stanley W. Wisnioski, III, DO, Osteopathic Physician West Palm Beach, FL 33401S
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Dr. Nehrlich, Judging from your response I have apparently located a tender point. It was my impression that this forum was a place to intellectually discuss experiences which would be helpful to one another. I see no reason to personally attack a fellow physician though the use of sarcasm. You are absolutely correct in your assessment of what the AMA has done to the Osteopathic profession. I might add that many of the Osteopaths have willingly gone along joyfully. This is however a seperate topic for discussion and in part why I wrote my original response. It is my hope that by utilizing every opportunity to stand up for the profession the word will get out that there are still DOs who stick close to the original philosophy. What I claim is that for those patients who have had the conventional six weeks of care and not improved one should simply look elsewhere for the problem. I see these patients all the time. If the problem had been located in the back, then the MD or the DC would have located it and effectively treated it. Lets face it both fail to help many patients. What I am saying in essense is that as a physician you can not ignore other areas as a cause for low back pain. I simply point out the anatomical facts that the low back is where many areas of the body are anchored. This is not magic. It is to those who are not thinking anatomicaly. I agree with you that because of the current state of the Osteopathic profession and its training in many of its schools an average patient has probably had better results with DCs as the majority of DOs treat as an MD would. Again these are broad sweeping statements and not ment to offend any specific profession or practitioner. Low back pain is a common complaint we all see daily. I would think that we would each welcome any help from any licensed practitioner who had experience and ideas which might be helpful in the alleviation of pain for our patients. Especially, if it could be explained in a rational manner. Not magic I assure you. Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Dr. Wisnioski: You are mentioning "rational manner", you state: "If the problem had been located in the back ....would have located it and effectively treated it." You might have pointed out the general lack of effective, active practitioner-centred treatment for many back conditions. Yet you then ask us to focus onto other areas as causes of the symptoms if we want to avoid treating the symptoms only. Yes, we can look at the low back as an "anchor point", or as a foundation of a building. Your remarks remind me of a doctor who is unable to help his patient through something out of his usual bag of tricks and therefore sends the patient to a psychiatrist. But far be it from my current interest to enter into a discussion on this aspect of the subject. My "sarcasm" was intended to point out that -to this reader- you are saying that you know how but are keeping it to yourself. That kind of thing never sounds very promising. You talk about explaining things in a rational manner and about the need to use 'licensed practitioners'. In your first letter you mention the "litany of practictioners" (sic), also the "multiple facial (sic) (???) layers", then you talk about how every "practioner"(sic) has made the same fundamental error. So, I must say, forgive the sarcasm if IT offended you, but after reading your second letter I am no wiser than before. Competing interests: None declared |
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