Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Medical Tunnel Vision
- Margaret Bark (8 February 2008)
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Evidence?
- David S. Mallett (22 February 2008)
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Predicting the subject prone to develop back pain
- Carlos A Selmonosky (23 February 2008)
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Throwback
- Michael F Vagg (24 February 2008)
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Back Pain and Heavy Work, training may be of no benefit
- Brian J Sweetman (27 February 2008)
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Prevention of Back Pain
- Noel B Thomas (1 March 2008)
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Let's not throw the baby out with the bathwater
- G. Lorimer Moseley, Jaap van Dieen, Michael Thacker, David Butler, and Johan Vlaeyen. (5 March 2008)
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Back pain is complex and not restricted to manual workers.
- Jacqueline H Gracey, Dianne Liddle, George Kernoghan, Marlaine Sinclair, Lynn Dunwoody, Danny Kerr (15 March 2008)
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Margaret Bark, medico-legal consultant Leeds LS1 2AX
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It never ceases to amaze me that doctors continue to ignore universes of discourse other than their own. Anyone who like myself who has been fortunate enough to be treated by expert physiotherapists will know of the symptomatic relief and improvement in back function which can be achieved by using the McKenzie exercises, and if necessary submitting to the Maitland manipulations. Robin A McKenzie's book "Treat your own back" is in its 6th edition, has sold more than 3 million copies world wide and has been translated into 17 different languages. I have lost count of the number of copies I have purchased to replace those given to friends and colleagues who have gained symptomic relief after I have introduced them to his exercise regime. Competing interests: None declared |
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David S. Mallett, Occupational Physician James Cook University Hospital
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It is interesting that the authors of this article quite rightly highlight the lack of a pathological model, the lack of a reliable diagnostic test and all the old chestnuts relating to the assessment and treatment of back pain. This is not news. The fact that the same authors then go on to make specific recommendations that ignore the well established epidemiologicial evidence (flawed as it is)is surprising. How did this get past the editor? Competing interests: None declared |
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Carlos A Selmonosky, Physician Inova Fairfax Hospital. Falls Church,VA.USA
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The dissapointing diagnosis and treatment of patients with back pain reveals the confusion about symptoms and disease.We and the patient know when back pain start but we have no clue what the disease is and how to diagnose it cost effectibly.The epidemiological value of MRI or Cat Scan images is not significant because the well know fact that very positive pathology is frequently associated with no symptoms;the predictive value is insignificant and costly.A very common manifestation, and mainly ignored,of nerve compression is sympathetic hyperactivity that can be detected by digital (Toes) pneumatic plethysmography tracings.The radicular origin(dermatomes)can be detected by thermography or unexpensible by skin thermometry.The use of these very low cost tests should be implemented in asymptomatic subjects to asess their value for predicting who will developed back pain and its origin. Competing interests: None declared |
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Michael F Vagg, Consultant in Rehabilitation and Pain Medicine Geelong Australia 3220
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It is old news to pain specialists that the patho-anatomical model is not particularly helpful in diagnosing LBP, especially chronic LBP. Given the proven usefulness of psychosocial risk factors in prognosticating the outcome of acute LBP, it is unsurprising that an intervention such as modifying lifting techniques is not particularly effective when viewed through a meta-analysis. This is because it simply doesn't address the known factors which are important in maintaining high levels of disability in LBP sufferers. The rationale for this intervention is based on the simplistic assumption that mechanical loads are the cause of most undifferentiated LBP. Newer treatment approaches address the known risk factors more comprehensively, so we have learned from the errors of the past. For a minute there, until I checked the date on the webpage, I thought I was reading an editorial from the 1980s rather than the 21 st century. Competing interests: None declared |
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Brian J Sweetman, Consultant Rheumatologist Morriston Hospital, Swansea. SA6 6NL
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The editorial by Wedderkopp and Leboeuf-Yde and the systematic review by Martimo et al question the evidence for training and use of handling equipment in the workplace and the editorial also comments on remaining active and early return to work following back pain sickness absence (1,2). There was really no support for practices that have almost become the norm and they seek explanations for this dilemma. In particular they point out that there is little guidance in the literature as to how to distinguish different types of the common presentation of low back pain that normally get described as “non- specific” or “mechanical”. Indeed this is the main difficulty with research into back pain in industry as well as with clinical therapeutic trials. They even suggest suspending randomised controlled trials until this diagnostic problem is resolved. I would therefore wish to draw attention to a body of work that goes someway towards resolving these problems (3). This describes a classification study undertaken as part of a randomised controlled trial. A reproducible classification was demonstrated. In particular this identified two syndromes that correlated with heavy work in opposite ways. With the help of an industrial study it was proposed that some heavy work could strengthen the back muscles and protect against subsequent back injury in incidents/accidents leading to back strain. In contrast the facet joint syndrome was made worse by heavy work; and heaviness in this context involved much lumbar lateral flexion and lateral rotation. If one does not give the right advice to the appropriate industry no progress will be made, or even worse, the problem maybe exacerbated. The ability to distinguish the strain pattern and the facet joint syndrome will also help identify which parts of the various industries are leading to particular forms of back pain morbidity. Thus it is crucial to be able to distinguish the strain pattern from the facet joint syndrome. The classification studies indicate that strain injury leads to problems at the upper and lower extremities of the lumbar spine i.e. two levels and that the “leg twist test” is useful for identifying the upper dorso-lumbar junction involvement. The facet joint syndrome is indicated when a patient bends or twists in one direction and this induces pain on the opposite side of the back. The detailed statistical analysis is summarised in the above mentioned monograph (3). Now that the clinical features that distinguish these syndromes have been identified, it may be that occupational health intervention will be more useful. This would apply to the design of the workplace, advice on the handling of loads in industry, and the rehabilitation of the injured, and also help in the study of back pain treatment in general practice and in the hospital setting. Brian Sweetman consultant rheumatologist, Morriston Hospital, Swansea. SA6 6NL. Brian.Sweetman@swansea-tr.wales.nhs.uk Competing interests: None declared. 1 Wedderkopp N, Leboeuf-Yde C. Preventing back pain. BMJ 2008; 336:398. 2 Martimo K, Verbeek JH, Karppinen J, Furlan AD, Takala EP, Kuijer PPFM, et al. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ 2008; 336:429-31. 3 Sweetman BJ. Low back pain, some real answers. 2005. tfm Publishing Limited, Harley, SY5 6LX, UK. Competing interests: None declared |
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Noel B Thomas, GP, semi retired. Measteg, Wales CF34 9AL
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Many and varied attempts to prevent recurrent low back pain in a working class industrial practice loom large in happy memories of four decades in primary care. The confusion and despair a novice practitioner must feel on first acquaintance with the challenge may be increased rather than lessened by studying the variety of the excellent responses already posted. Is there no simpler approach ? Perhaps we should remember that only specific exercises, and not exercise per se, help in two other situations where multitudes of people endure needless chronic disability for want of being taught the necessary simple exercises. Namely, the wobble board method for recurrent ankle instability, and regular life-long static quads exercises for those with osteoarthritis or post traumatic problems affecting their knees. If people can be persuaded to sit bolt upright on a firm chair, for a minute or two initially, increasing to a total of thirty minutes or more daily, their paraspinal muscle strength will benefit. Their posture and their ability to survive flexion stress will improve.They may notice marked reduction of chronic backache, and fewer exacerbations. Motivation is all. It must be a long term practice. People of all ages, who take up meditation to befriend their mind or maker, and who sit appropriately, may be surprised that their chronic backache resolves. You very rarely meet a Buddhist with a bad back. Competing interests: Ex backacher, buddhist. |
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G. Lorimer Moseley, Research Fellow Oxford University OX1 3QX, Jaap van Dieen, Michael Thacker, David Butler, and Johan Vlaeyen.
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Dear Editor We write regarding the Editorial Preventing back pain (BMJ 2008: 336:398; 23 February; Wedderkopp & Leboeuf-Yde). First, we commend the BMJ for soliciting an Editorial, by world leaders in this field, on the article describing a robust review on the effect of training for prevention of back pain. We think that the Editorial made an important point in highlighting the relative lack of sound diagnoses for back pain and the possibility that this may explain why most RCTs of treatment or prevention of back pain show relatively inconclusive results. However, we think that the recommendations made in the Editorial should be reconsidered. For example, Wedderkopp & Leboeuf-Yde contend that clinical trials of back pain should be suspended on the grounds that our diagnostic strategies are not precise enough to identify which structure is causing the pain. We think this is too drastic because it implies that if we can’t find a tissue-based ‘source’ of pain, it is because our investigative strategies are limited. We agree that better diagnostic strategies may lead to more diagnoses but we disagree that we should simply stop doing clinical trials until that day arrives – let’s not throw the baby out with the bathwater. An alternative, perhaps more positive angle, would be to suggest widening our search for causes, to consider different contributors to back pain, for example beliefs, neuropathic mechanisms, motor control abnormalities, psychosocial influences, immune-related factors & cortical changes. Is it possible that by focussing only on structural diagnoses, we miss common threads that would permit subgrouping and then promote the likelihood that clinical trials will yield positive results? Alternatively, is it possible that the studies that are available are often poorly conducted, or the rationale for training is flawed? (e.g. we know that bending the knees does not reduce back load, so why would it reduce the probability of injury?) Is it possible that the training programs are good, but the compliance with them is not? Are some of the problems of RCTs overcome by different clinical trial designs, for example replicated case series driven by clear rationales and testing clear hypotheses. Our reservations extend to the recommendation made by Wedderkopp & Leboeuf-Yde, that patients should simply be told to change job but stay active. This would seem to imply to concerned patients: ‘your back is ruined but we don’t know exactly where’. That implication is clearly not consistent with the evidence, nor is it helpful for patients who are already anxious about the state of their back. In summary, we advocate an alternative, more hopeful, response to the review. We are reminded that nociception is neither sufficient nor necessary for any pain and that there may be many contributors to back pain, contributors beyond the tissues of the back. We think the review demonstrates why good clinical trials, with sound rationale and a wide scope, are required and we think there are several promising directions such clinical research is taking. G. Lorimer Moseley, Oxford University UK;
Competing interests: None declared |
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Jacqueline H Gracey, Lecturer Physiotherapy University of Ulster BT30 OQB, Dianne Liddle, George Kernoghan, Marlaine Sinclair, Lynn Dunwoody, Danny Kerr
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Response to back pain editorial on preventing back pain (Wedderkopp and Leboeuf-Yde, BMJ 2008). In response to the editorial by Wedderkopp and Leboeuf-Yde (2008) on preventing back pain in manual workers we, as a group of researchers involved in establishing both the causes and management of low back pain, are concerned that the messages conveyed will promote both misattribution as to the cause of injury, and does nothing to discourage the ethos of learned helplessness. Whilst we agree with the authors that ‘staying active in daily life may be the best way for these patients to regain command of their back and their occupation’, we question the role of ‘a change of job’. What type of job do the authors recommend, as back pain is not restricted to manual workers? Since it is also common in sedentary workers, surely advice to change job is overkill as a preventive strategy? The suggestion that ‘the disorder cannot be reversed once it becomes established, so that no treatment could be effective’, disregards the highly regarded biopsychosocial approach to management. Keeping your back safe and preventing further harm is all about motivating people to strengthen, condition and maintain the health of their backs through targeted physical exercise. We prefer a message promoting the benefits of physical activity, by encouraging collaboration, inviting people to take some responsibility for their health as opposed to the defeatist attitude propagated by Wedderkopp and Leboeuf-Yde (2008). With regard to the cited review (Martimo et al., 2008) we ask what role adherence to the prescribed protocol may have played in the outcome of included studies? There is a need to identify the level of adherence to advice, training in working techniques and (most crucially) what components need to be incorporated into a prevention programme in order to engage each individual. We agree that, before prevention can be addressed, the causative factors of back pain in manual workers must be identified. The authors highlight the disappointing results of the review by Martimino and colleagues however what they fail to highlight is the content of back prevention programmes and advice provision and the lack of evidence regarding effectiveness of individual components in the form of longitudinal studies. We propose work to examine the effects of alternative methods of prevention such as daily conditioning programmes in the work place; and programmes to enhance motivation, self-efficacy and behavioural change. In emphasizing the biomedical model of back pain management this editorial fails to recognise the value of a biopsychosocial approach, which acknowledges amongst other factors, the influence that individual beliefs and experiences can have on outcomes (Liddle et al., 2007). Such an approach to both prevention and management of back pain needs to be taken in future research and practice development in this field. References: Liddle SD, Baxter GD, Gracey JH. Chronic low back pain: Patients' experiences, opinions and expectations for clinical management. Disability and Rehabilitation 2007 doi: 10.1080/09638280701189895 Martimo K, Verbeek JH, Karppinen J, Furlan AD, Takala EP, Kuijer PPFM et al. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ 2008 doi: 10.1136/bmj.39463.418380.BE Wedderkopp N, Leboeuf-Yde C. Preventing back pain. Advice to stay active may not be appropriate for people in manual jobs. BMJ 2008 doi: 10.1136/bmj.39464.656007.80 Competing interests: None declared |
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