Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Negative investigations are useful
- Graeme M Mackenzie (19 June 2006)
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Low back pain management need not be guesswork
- Brian J Sweetman (26 June 2006)
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Clinical Review of diagnosis and treatment of low back pain: an omission
- Gavin PR Clunie (30 June 2006)
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Why do we get back pain?
- Mark J Turtle (5 July 2006)
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Non-specific diagnoses lead to non-specific results
- Owen D Moore (6 July 2006)
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Suicide and high frequency of Low Back Pain at final General Practitioner Contact
- Keith R Linsley, Jessica Martin (7 July 2006)
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Back Pain- Think of Tuberculosis
- Lavanya Diwakar, Sarah Logan, Nadia Ghaffar, Andrew Hare, William Lynn, Steve Ash (9 July 2006)
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Diagnosis and treatment of low back pain
- Louis I Jones (21 August 2006)
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Spinal manipulation, therapeutic massage and acupuncture for low back pain: an update
- Vincent Chung, Prof Sian Griffiths (28 August 2006)
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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We live in times when investigation is seen as the way doctors do business. Not to investigate often threatens the patient-doctor relationship. That relationship is of course crucial in managing chronic back problems. A negative XR (i.e. degeneration changes at the most) of course proves little in the minds of the doctor. As doctors we know the limitations of plain radiographs. However a negative MRI enables us to start moving the patient on, using much of the advice in this article. Spinal Schwannoma has been found on MRI in chronic low back pain with no red flags. It only takes one such case in a practice to make it difficult to be confident in excluding all progressive disease. It is difficult to be in diagnostic mode and management mode at the same time. Negative MRIs enable us to move into management mode. I know that with a negative MRI there is little need for me, as a GP, to involve any sedcondary care sector other than physiotherapy and in the ideal world CBT type services. That reduction in referrals could in time make MRIs the cheap option in all back pain investigation. Competing interests: None declared |
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Brian J Sweetman, Consultant Rheumatologist Morriston Hospital Swansea SA6 6NL
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EDITOR- For back and neck pain it seems that the rarer and nastier the cause, the easier it is to diagnose. Conversely, the common presentation of back pain is curiously difficult to characterise and this has led to all sorts of problems. In this journal Dillane, Fry and Kalton as early as 1966 (1) were to help make us aware of this pervasive impediment, with about 80% of patients failing to receive a meaningful diagnosis for their back pain. If one assesses the “Clinical review of diagnosis and treatment of low back pain” by Koes, van Tulder and Thomas in the journal more recently (2), it can be seen that this concept of “diagnostic difficulty” is generally true. Indeed they emphasise this early on, but do not use it to explain why so much of treatment effectiveness is regarded as “unknown”. However there are some well-established rules for managing the less common cases. Beware of fracture, inflammation, infection, and cancers (primary or secondary). But there is no guarantee that you will catch every such case at first encounter. Be precise in identifying nerve root signs, and be praised for thinking of things like spinal canal stenosis and abdominal aortic aneurysm. Such review articles are very good on these aspects, though generally one might expect medical students to already be aware of these sorts of things. We would perhaps be hoping for deeper insights from an intensive review of the literature. For example it proves more perplexing to explain why even the greatest experts have had such difficulties in distinguishing the different sorts of “ordinary” back pain presenting daily in general practice, in industry, and even percolating through to hospital. Indeed some experts would seem to be in denial, refusing to believe that there are any such subdivisions of common back pain, and side step the problem by lumping all such cases into the “non-specific” dustbin category. They often arrive at this nihilistic state of mind having learnt how to disbelieve all those pseudo diagnoses that have plagued the literature. They have also observed the poor correlation of many types of x-ray anomaly with symptoms and signs. So then they suspect that patient presentation differences are primarily psychosomatic. Luckily for doctors who get back pain, they can be sure that their pain is not imaginary; theirs is for real! Where does that leave us? More therapeutic trials will still give minimalist answers if conducted in their present format. The evidence base is not ripening. No end of searching the old literature would seem to help other than to confirm the lack of progress. There are however ways of “stratifying” cases using particular tests so that we can find which patients variously respond to different treatments. These few tests have been selected from hundreds of contenders and been shown to describe “structure” in a repeatable manner, and are easily performed in practice. They have been described elsewhere and have recently been reviewed (3). If the patients are not segregated, the cases that have one syndrome who get worse with a given treatment will cancel out those with a different syndrome who get better, and those with yet other syndromes who show no response at all will dilute out any evidence of either bad or good response in terms of numerical outcome criteria. We found that overall there was no significant difference between treatments and control when looking at all back pain together, but showed that hidden in this there was a particular subgroup who responded very nicely to traction therapy (4). This sort of phenomenon probably explains why most other trials in this field have tended to give little in the way of useful information though Koes et al have referenced one attempt at such specificity. It should now perhaps be the duty of ethical committees and project funders to press for more accent on classification procedures as part of treatment trials. In the mean time, it seems that if one does anything at all, one mainly guesses which patient needs which treatment. Brian J Sweetman consultant rheumatologist Department of Rheumatology, Morriston Hospital, Swansea SA6 6NL Competing interests: None declared 1 Dillane JB, Fry J, Kalton G. Acute back syndromes- a study from general practice. BMJ 1966; 82-4. 2 Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4. (17 June.) 3 Sweetman BJ. Low Back Pain, some real answers. 2005. tfm Publishing, Castle Hill Barns, Harley, Nr Shrewsbury SY5 6LX, UK. Web site: www.tfmpublishing.com 4 Sweetman BJ, Heinrich I, Anderson JAD. A randomised controlled trial of exercises, short-wave diathermy and traction for low back pain, with evidence of diagnosis-related response to treatment. J Orthop Rheumatol 1993;6:159-66. Competing interests: None declared |
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Gavin PR Clunie, Consultant Rheumatologist The Ipswich Hospital NHS Trust
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There was little mention of ankylosing spondylitis (AS) or axial spondylarthropathy (SpA) in the clinical review by Koes (1). Reliable screening suggest these conditions account for 1 in 20 cases of chronic back pain in the community (2). Also unfortunately, a 5-10y delay in the diagnosis of these conditions is common (3). The clinical and financial burden of these conditions should not be under-estimated given the relatively high prevalence of AS/axial SpA in men of working age (4). The issue of diagnostic delay is recognised commonly by Rheumatologists.
The hallmark feature of AS and axial SpA is inflammatory back pain (IBP) characterised by morning stiffness (>30min), improvement with exercise not rest, waking at night and alternating buttock pain (5). IBP was not mentioned in Koes’ article (1). Typical features that associate with AS and axial SpA - although not necessarily temporally - include anterior uveitis, enthesitis, psoriasis, peripheral arthritis and inflammatory bowel disease. There needs to be greater awareness of AS and axial SpA in Primary Care and inclusion of the condition in reviews of chronic back pain. Given the likely shift in implementing musculoskeletal services through ‘early access’ and triage (6), screening for IBP and AS/axial SpA needs particular focus if morbidity from undiaganosed AS/axial SpA is to be lessened rather than worsened. I am particularly concerned by the advice that 'only in cases with red flag conditions might imaging be indicated' (1). AS and axial SpA require imaging for diagnosis. 1. Koes, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. Br Med J 2006; 332: 1430-4. 2. Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol 1995; 34(11): 1074-7. 3. Feldtkeller E, Khan MA, van der Heijde D, van der Linden S, Braun J. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int. 2003 Mar;23(2):61-6 Epub 2002 Sep 3. 4. Boonen A. Socioeconomic consequences of ankylosing spondylitis. Clin Exp Rheumatol 2002; 20(6): S23-6. 5. Rudwaleit M, Metter A, Listing J, Sieper J, Braun J. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum. 2006 Feb;54(2):569-78. 6. Maddison P, Jones J, Breslin A et al. Improved access and targeting of musculoskeletal services in Northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme. BMJ 2004; 329: 1325-7. Competing interests: None declared |
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Mark J Turtle, Consultant Anaesthetist specialising in Pain Management West Wales General Hospital, Carmarthen SA31 2AF
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By and large I found this a well organised and helpful paper. However, it is necessary to challenge some of the statements concerning diagnosis, particularly those referring to specific low back pain and the pathophysiological mechanisms behind them. Let us look at some of the examples given. Osteoporosis per se is not a cause of pain. If it was, the majority of people over 70 would complain of pains in their legs. Rheumatoid arthritis is principally a disease involving the sinovial membrane, not a structure well represented in the spine. Few would argue against the detrimental effects of a true protusion of a nucleus pulposus with unequivocal neurological deficit, but this is of course rare. A far more common allegation, admittedly not made in this paper, is that a radiologically observed irregularity, descibed as an annular tear or other feature of non - specific disc degeneration, is responsible for the pain. This does not withstand critical examination however; how do we explain the identical appearance in the absence of pain? It is only reasonable to assume that the two are causally related if this feature is unique to those people with pain. Spondylolisthesis, even of a marked degree, is not uncommonly diagnosed as an incidental finding in a symptomless patient. This also is therefore a causal relationship which is problematic. One could go on….. It is difficult to avoid the conclusion that when it comes to understanding the mechanisms leading to low back pain, the truth is that in most cases, we do not know. If we were able to shed some light on it, we would surely have found our principal guide to management. Denial of this knowledge vacuum on the other hand, is responsible for the huge waste of valuable resources that is spent on the ubiquitous search by both health professionals and lay people for an elusive structural solution to the back pain problem together with it's equally futile surgical consequence. I have always found it surprising that so little attention appears to be given to a concept that underpins the whole subject; it is an area of profound ignorance which we unfortunately seem to ignore. Competing interests: None declared |
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Owen D Moore, Clinical Specialsit Physiotherapist Ilkeston Hospital DE7 8LN
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EDITOR: the publication of this clinical review in the BMJ presents all clinicians involved in the diagnosis & treatment of low back pain (LBP) with our greatest challenge; can we reliably detect sub-categories of low back pain? My physical therapy colleagues in all parts of the globe have for decades classified LBP within the context of identifying physical stresses that elicit spinal pain. Examples of this include the Mckenzie Institute's methods (http://www.mckenziemdt.org/), the recent Brennan et al (2006) paper cited in the article and also the work published by Linda Van Dillen and her colleague Shirley Sahrmann of the same faculty. There is a consistent theme amongst all these investigators and I feel the concept to be one of identifying a direction susceptible to movement (DSM) in the forms of extension, rotation or flexion stresses. Combinations of movements do, of course, occur. However the DSM (some authors refer to directional preference) becomes a primary focus for movement scientists to research and treat during practice. Importantly when the DSM is corrected, mechanical pain CAN be alleviated. This does not diminish the importance of other factors in the chronicity of LBP; it does however identify those professionals responsible for physical therapy and those responsible for psychosocial management. I am not and will never be in a position to treat pathological or psychological factors. However kinesiophobia, which is amenable to physical therapy, can be adequately addressed. An example from my own practice may help clarify the point. When patients have undergone triage and red flags ruled out (see http://evolve.elsevier.com/greenhalgh/redflags/ for new text on this subject) with nerve root pain also considered, what then? It is customary to record a patients account of what aggravates and eases their pain and then contemplate whether physical stresses play a role in the aetiology of their pain. My recent experience with overweight patients reporting pain in standing at rest and further aggravated by prolonged walking or supine lying could make one wonder about allied diagnoses of stenosis, pathological labels of discitis or a whole myriad of "diseases". With an MRI having ruled out significant pathology, a neurological exam failing to detect a nerve root syndrome I have been left with the sinking feeling associated with the CSAG guidelines - Non Specific LBP as a diagnosis. When I have systematically examined patients' movement systems, and not used the CSAG guidance alone, patients have been able to leave the consultation in charge of managing their LBP. Had we allowed patients to continue being treated under the non- specific category of "heart disease", I doubt many advances in cardiac science would have occured. I feel the time has come for physical therapists to identify their role as diagnosticians so far as movement- related impairments are concerned and communicate case-studies & RCT's on this important work. Sahrmann SA: Diagnosis by Physical Therapist - a prerequisite for treatment. A special communication. Physical Therapy. 68:1703-1786, 1988 Van Dillen LR, Sahrmann SA, Norton BJ, McDonnell MK, Fleming DA, Caldwell CA, Woolsey NB. Reliability of physical examination items used for classification of patients with low back pain. Physical Therapy, 78(9):979-988, 1998. Harris MH**, Sahrmann SA, Van Dillen LR: Classification, treatment, and outcomes of a patient with lumbar extension syndrome. Physiotherapy Theory and Practice, 21(3):181-196, 2005 Stith JS, Sahrmann SA, Dixon KK, Norton BJ, Wolsey NB. Curriculum to Prepare Diagnostician in Physical Therapy. J Phys Ther Educ 1995;9:46-53. Competing interests: None declared |
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Keith R Linsley, Consultant Psychiatrist County Hospital, Durham DH1 4ST, Jessica Martin
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It was pleasing to read a comprehensive review including psychosocial interventions for this common problem. In County Durham and Darlngton we have been looking at suicide prevention within a number of agencies. One of these areas was contact with primary care in the 3 months before suicide. Out of 205 'probable' suicides, we were able to get General Pracitioner (GP) records for 147 cases. Of these, 98 (66.7%)had seen their GP in the 3 months before suicide. A suprising finding was that of these 98 attendances, 76 (77.6%) were for low back pain. We feel it is important to ask about mental wellbeing (especially depression) in any ongoing medical condition; and if pertinent sensitive enquiry about suicide thoughts. Ours finding suggests low back pain to be a particular symptom that should alert practitioners to enquire about how they are coping and if any concerns ask about suicide thoughts and consider if any other suicide risk factors exist. Competing interests: None declared |
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Lavanya Diwakar, Research Fellow in Infectious Diseases Ealing Hospital , Uxbridge Road, Middlesex, UB1 3HW, Sarah Logan, Nadia Ghaffar, Andrew Hare, William Lynn, Steve Ash
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We read with interest the clinical review on low back pain by Koes et al identifying some red flags which may indicate underlying spinal pathology in individuals presenting with back pain. (1) We are however concerned that the authors advise referral for imaging only in the presence of these red flags. We recently completed a retrospective study of patients with spinal tuberculosis (TB) at Ealing hospital. Of 29 adult patients diagnosed between 2002 and 2005, 23 (80%) were aged between 20 and 50 years (mean age 38.5 years). All were originally from the Indian subcontinent or Africa. Most patients had been in the UK for more than 5 years (range 1-26 years). None were HIV positive, gave a history of carcinoma or steroid use. Only 4 (14%) had a history of previous tuberculosis or close TB contact. Almost all of the patients gave a history of constitutional symptoms (fever, night sweats, weight loss or loss of appetite). Lumbar and cervical back pain was seen more commonly than thoracic. The ESR was greater than 35mm/hr on presentation in almost all of them (96%). Many of the patients had repeatedly sought healthcare advice from their general practitioners or the accident and emergency department before diagnosis was made. A delay in the diagnosis of tuberculosis exposes young patients with a treatable condition to the risk of permanent disability. Non-pulmonary tuberculosis accounts for around 40% of all TB notifications in the UK. (2) The incidence of tuberculosis in London has reached 48/100,000 and in areas such as Ealing with a large immigrant population, the rates are as high as 82/100,000. (3) Spinal TB is, therefore, a diagnosis that needs to be considered early by attending physicians. The red flags mentioned in the review could not have been used to identify most of these patients. We therefore suggest that patients from countries with high TB prevalence presenting with back pain in association with constitutional symptoms and a high ESR should be investigated to exclude tuberculosis. In the context of a normal spinal X-ray and a high clinical suspicion, further cross-sectional imaging may be warranted. This is irrespective of their age or duration of stay in the UK. 1. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. Bmj 2006;332(7555):1430-4. 2. Health Protection Agency. Annual report on tuberculosis cases reported in England, Wales and Northern Ireland in 2003; http://www.hpa.org.uk/infections/topics_az/tb/pdf/2003_Annual_Report.pdf 3. Health Protection Agency. London Surveillance Bulletin. May 2006 No.7 Competing interests: None declared |
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Louis I Jones, Retired G.P. 6.A.Folleigh Drive,Long Ashton.Bristol,BS 41 9JDD
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Koes et al quote the standard attitude to low back pain.But G.P's should note that alternative stategies do exist. Diagnosis:-Ask the patient if the pain is worse on sitting or lying or worse on standing or walking.The former is indicative of a soft tissue lesion such as muscle or ligament strain. Half will be bilateral, the rest equally left or right. The latter is indicative of a bony lesion such as prolapsed disc,nerve trapped, facet joint displacement,etc. Most will be unilateral.Many will need referral). It is clearly right to look out for serious disease but in 25 years (1973-1998)I had only one patient with multiple myelomatosis and two with spinal secondaries(out of 300 back pain patients a year). Treatment:-Patients want relief of pain and return to work within a few days and this is achievable.Telling someone that 90% will be better in 6-12 weeks is of little comfort. Without considering referral to physio etc.I found 3 treatments to be effective :-(1)prescribe ibuprofen 800mg 8-hourly(or cocodamol when NSAID contraindicated) (2)manipulation of lumbar spine (3) a single injecion of local anaesthetic & steroid to tender area(I used 5ml 1% lignocaine+80mg depomedrone). Results:-each of these helped some patients but using all three in every patient caused relief of symptoms in 90% in 3-6 days. Two further points:-(1)Many low back pain patients have an associated cervical spine lesion so manipulation should include this.(2)Many develop pain during a common cold, suggesting that a viremia might predispose the back muscles to strain. Competing interests: None declared |
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Vincent Chung, Chinese Medicine Practitioner, PhD Student School of Public Health, Chinese University of Hong Kong, China, Prof Sian Griffiths
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Editor: We are pleased to read this excellent review on the clinical management of low back pain (LBP) by Koes and colleagues. Whilst the clinical evidences for spinal manipulation and acupuncture have been mentioned briefly in the effectiveness table (table 2) along with various conventional therapies, we believe CAM should have higher profile and include effectiveness of therapeutic massage. Two systematic reviews mapped the evidence of acupuncture for LBP (Furlan et al 05, Manheirmer et al 05). Furlan et al suggested that acupuncture reduces pain and improves functions for chronic LBP when compared to no treatment or sham therapy, but this evidence originated from short term observation. Manheirmer et al have quantified acupuncture’s short term benefit in their meta-analyses, which reported the standardized mean differences between acupuncture vs. no treatment (0.69 {95%CI, 0.40 to 0.98, 8 trials}) and acupuncture vs. sham treatment (0.54 {95%CI, 0.35 to 0.73}).Evidence also showed that acupuncture effectively augments conventional treatment. For its longer term benefit for chronic LBP, a recent pragmatic randomized controlled trial (RCT) (Thomas et al 05) has reported that acupuncture was significantly more effective in reducing bodily pain than usual care at 24 months. It is also found that GP referral to acupuncture service is cost effective over a 2 year period. The present data is insufficient for reaching firm conclusions regarding its effectiveness for acute low back pain additively. A recently updated systematic review (Assendelft et al 04, updated Feb 06) reported that spinal manipulative therapy is superior to sham intervention, and its effectiveness is clinically and statistically equivalent to GP care, analgesics, physical therapy, exercise and back school. The results hold for both acute and chronic low back pain. In a three year pragmatic trial, spinal manipulation provided a 29% higher improvement compared hospital outpatient care in terms of total Oswestry scores and patient satisfaction. It is highlighted that the effect of chiropractic on pain reduction was particularly clear (Meada et al 95). For chronic low back pain, a systematic review of eight RCT (Furlan 02, updated Aug 05) (of which only 5 are of high quality) has suggested that massage’s effectiveness is equal to corsets and exercise, and superior to relaxation, acupuncture and self care education. However it is inferior when compared to manipulation and TENS. A comparatively longer term benefit is observed, with beneficial effects lasted at least one year after the end of the treatment. Potential for augmenting exercise and education’s effect is highlighted. However, evidence from high quality RCT for massage is rather limited and more research on the topic is warranted. In conclusion, current evidences suggested that acupuncture and therapeutic massage may effective CAM modalities for chronic LBP, while spinal manipulation may be useful for both acute and chronic LPB. References: Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2. Manheimer E. White A. Berman B. Forys K. Ernst E. Meta-analysis: acupuncture for low back pain. Annals of Internal Medicine. 142(8):651-63, 2005 Apr 19. Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, Fitter M, Roman M, Walters S, Nicholl JP. Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technol Assess. 9(32): iii-iv, ix-x, 1-109, 2005 Aug. Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000447. DOI: 10.1002/14651858.CD000447.pub2. Meade TW. Dyer S. Browne W. Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. BMJ. 311(7001):349-51, 1995 Aug 5. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain. The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD001929. DOI: 10.1002/14651858.CD001929. Competing interests: None declared |
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