Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Treatments for low back pain
- Nick G Mann (11 January 2009)
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Quality of read
- Nicholas J Devine (12 January 2009)
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Cauda Equina Syndrome and the Rectal Examination
- Chrishan A Thakar, Elaine Buchanan, Nasir A. Quraishi, Chris Lavy and Jeremy Fairbank. (15 January 2009)
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Management of low back pain: test for vitamin D deficiency
- Peter J Lewis (15 January 2009)
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To PR or not to PR
- Richard Bartley (17 January 2009)
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Management of low back pain: person and spine
- Andrew O. Frank (19 January 2009)
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Reserve soldiers
- Richard E Deacon (19 January 2009)
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Management of low back pain
- Louis I Jones (21 January 2009)
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Another option-Pain Management Programme
- Helen M Firth (30 January 2009)
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Nick G Mann, GP Well St Surgery, 52b Well St, london E9 7PX
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This latest review highlights the many treatments available for mechanical back pain. We know that conventional treatment appears to make little difference to outcomes and that - so far - few of the various treatments appear to be much better. The most encouraging evidence for successful treatment appears to come from the recently published, well-conducted RCT and subsequent health economics paper of Alexander Technique (ATEAM trial). Compared to conventional and other treatments, Alexander Technique significantly reduced both disability and days in pain; an effect which was sustained one year following treatment. The effect size was much larger than we are used to seeing for exercise alone or hitherto for other treatments for back pain. Alexander Technique was also shown to be very cost-effective; even more so if one were to include industrial losses due to back pain. I have personally experienced the benefits of Alexander Technique and would hope that we are not too conventional to herald this technique as a genuine example of therapeutic progress and seek to embrace it as mainstream in the NHS. I would certainly hope to see it referenced in future reviews of treatments for back pain. Competing interests: None declared |
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Nicholas J Devine, gp sk7 3ep
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An article containing useful information but with little thought for the reader; with tables and pictures inserted with little thought as to where they were relevant in the text. Not an unusual occurence in the BMJ which increasingly seems to written for reference rather than reading. Competing interests: None declared |
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Chrishan A Thakar, Spinal Registrar Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, Elaine Buchanan, Nasir A. Quraishi, Chris Lavy and Jeremy Fairbank.
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Letter to Editor of BMJ Dear Sir, We read with great interest Cohen et al’s1 recent clinical review article on the “Management of low back pain”. We wanted to raise the issue with regards to the necessity of rectal examination as stated by the authors to evaluate possible cauda equina syndrome (CES) or conus medullaris dysfunction. Rectal examination is not only invasive but can be awkward to perform for both doctor and patient alike. Furthermore, it is not always straightforward to conduct this examination in a busy practice. Patients can treat it with suspicion and a chaperone has to be found causing delays and hassle. In some instances GPs have been left vulnerable to assault charges. The symptomology of cauda equina syndrome is complex and can present in a number of ways with delayed diagnosis and intervention possibly leading to permanent neurological damage. We analysed prospectively collected data between 2006 and 2008 of all patients undergoing urgent operative intervention for the diagnosis of cauda equina syndrome secondary to a disc prolapse. Out of the cohort of 33 patients only 11 had reduced anal tone and two of these patients were incontinent of stool. The most pertinent finding was the presence of both saddle anaesthesia and abnormal urinary symptoms in 28 patients (including the 11 patients with reduce anal tone). This would suggest that the diagnosis of cauda equina syndrome can be made with a higher sensitivity by the presence of saddle anaesthesia and abnormal urinary symptoms (85%) compared to reduced anal tone alone (33%). While we accept that these numbers are relatively small it has become the practice of our spinal triage service not to routinely perform a rectal examination on patients whom cauda equina syndrome is suspected. Instead, emergency MRI is employed for patients presenting with radicular pain, saddle anaesthesia and/or relevant urinary symptoms. We do not feel rectal examination adds additional clinical value in making the decision to order MRI. In those with radiologically confirmed CES there may be a medicolegal argument for anal tone testing pre-surgery. Additionally, our study evaluated the best question to assess saddle anaesthesia. The following terms were reported: ‘numb feeling around my bottom’ (28/28; 100%), ‘strange feeling when sitting’ (12/28; 43%) and ‘altered sensation when wiping bottom with toilet paper’ (10/28; 36%). We conclude that asking patients with possible cauda equina syndrome if their ‘bottom feels numb’ to be the best question for evaluating saddle anaesthesia. This effectively assists non specialists in making the possible diagnosis of cauda equina syndrome and minimises the requirement for invasive rectal examination. Yours faithfully, Chrishan Thakar, MRCS Specialist Registrar in Orthopaedics, Nuffield Orthopaedic Centre, Oxford Elaine Buchanan, MSc, MCSP Consultant Spinal Physiotherapists, Nuffield Orthopaedic Centre, Oxford Nasir A. Quraishi, FRCS Consultant Spinal Surgeon, Queen’s Medical Centre, Nottingham Chris Lavy, MD FRCS Hon Professor, Nuffield Orthopaedic Centre, Oxford Jeremy Fairbank, MD FRCS Professor of Spinal Surgery, Nuffield Orthopaedic Centre, Oxford References: 1.Cohen SP, Argoff CE, Carragee EJ. Management of low back pain. BMJ 2008;336:a2718 Competing interests: None Competing interests: None declared |
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Peter J Lewis, Integrative physician YourHealth, 15 South Steyne, Manly, NSW 2095, Australia
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It appears that the importance of testing for vitamin D deficiency in patients with back pain - as discussed in my letter 4 years ago (1) - is still not widely appreciated; Cohen and colleagues fail to make any mention it in their recent review article on the management of low back pain (2). Many studies have shown the high prevalence of vitamin D deficiency in various populations. In my own practice in Sydney, the majority of the patients that I investigate have suboptimal levels of vitamin D. Plotnikoff and Quigley evaluated both children and adults presenting to a university affiliated inner city primary care clinic in Minneapolis with persistent, non-specific musculoskeletal pain, and found that 93% had deficient concentrations of vitamin D (100% of patients younger than 30 years and older than 60 years had vitamin D deficiencies) (3). Most patients (83%) attending spinal and internal medicine clinics in Saudi Arabia over six years who had experienced low back pain that had no obvious cause for more than six months had abnormally low levels of vitamin D (4). After treatment with vitamin D supplements, clinical improvement in symptoms was seen in all of those who had a low initial concentration of vitamin D. The authors concluded that screening (of patients with chronic low back pain) for vitamin D deficiency should be mandatory. A report in the Medical Journal of Australia described two patients with failed spinal fusion for chronic low back pain who were subsequently found to have severe vitamin D deficiency (5). Both responded positively to vitamin D supplementation. The authors highlight the need for attending surgeons and physicians to be aware of the potential for vitamin D deficiency in their patients since failure to recognise this easily reversible problem may result in complications of treatment, including failure of spinal fusion surgery, additional morbidity, and the substantial costs of further surgery and hospitalisation. In a recently published article, Schwalfenberg reviewed 6 cases of improvement/resolution of chronic back pain or failed back surgery after vitamin D repletion in a Canadian family practice setting (6). There are a number of reasons for the current worldwide epidemic of vitamin D deficiency. These include inadequate sun exposure, use of sunscreen (which can reduce the body’s vitamin D production by almost 100%), dark skin, ageing (by 70 years of age, an individual’s capacity to synthesise vitamin D is only around 20% of that of a 20-year old), excess body fat (which ‘soaks up’ [fat-soluble] vitamin D), and global dimming (due to atmospheric pollution). In assessing a patient's vitamin D status, it is important to emphasise that a laboratory reference range for 25-hydroxy-vitamin D (25(OH)D) is not an optimal range, which is probably around 100-175 nmol/L (40-70 ng/ml). As a general rule of thumb in calculating an appropriate dosage for vitamin D supplementation, 1,000 IU of vitamin D3 (cholecalciferol) per day will raise 25(OH)D levels by around 10 nmol/L over about 3 months. So, for example, a patient with an initial 25(OH)D level of 40 nmol/L would require a dose of at least 6,000 IU/day to attain a blood level above 100 nmol/L. Vitamin D toxicity (causing hypercalcaemia) from supplementation is extremely rare, probably requiring an intake of at least 40,000 IU/day for a prolonged period, and a 25(OH)D level somewhere above 375 nmol/L; the consequences of undiagnosed and untreated (or under-treated) vitamin D deficiency (including increased risk of osteoporosis, insulin resistance, diabetes, high blood pressure, heart disease, multiple sclerosis, autoimmune diseases, depression, and 17 different cancers, as well as a low back pain and a variety of musculoskeletal problems) are of much greater concern. Current clinical guidelines for managing chronic low back pain should include assessment of vitamin D status, together with advice on appropriate vitamin D supplementation in those found to be deficient. References 1. Lewis PJ. Vitamin D deficiency may have role in chronic low back pain. BMJ 2005; 331:109 2. Cohen SP, Argoff CE, Carragee EJ. Management of low back pain. BMJ 2009;338:100-106 3. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78: 1463-70 4. Vitamin D deficiency and chronic low back pain in Saudi Arabia. Spine 2003;28: 177-9 5. Plehwe WE, Carey RPL. Spinal surgery and severe vitamin D deficiency. Med J Austr 2002;176: 438-9 6. Schwalfenberg G. Improvement of chronic back pain or failed back surgery with vitamin D repletion: a case series. JABFM 2009;22(1):69-74 Competing interests: None declared |
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Richard Bartley, Physiotherapist Denbigh, Wales
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Despite a small cohort size, the Rapid Response by Thakar et al makes a valuable observation. The questions you list could also include asking whether the patient can tell the difference between flatus and defecation, using local slang whenever possible. However, I have come across patients reporting a numb bottom in the absence of urinary retention, where they are referring to numb buttocks after prolonged sitting, rather than a numb anus. The devil is in the detail I suppose. Competing interests: None declared |
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Andrew O. Frank, Consultant in Rehabilitation Medicine and Rheumatology Northwick Park Hospital, Harrow, HA1 3UJ
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I greatly welcome the authoritative review by Cohen et al [1] on low back pain which, however, is highly unlikely to be the leading cause of occupational disability in the UK. Although it is the commonest cause for long-term sickness absence among manual workers [2], they are a diminishing proportion of the UK workforce. Stress and mental ill health are the commonest cause for sickness absence in non-manual workers [2]. Mental ill health is also the commonest reason for individuals receiving Incapacity Benefits [3]. (Incapacity Benefits are given by the state to those who have been absent from work due to sickness for 6 months or more). It is helpful to classify patients into those whose back pain has or has not a traumatic origin. Those with post-traumatic back pain may have post-traumatic stress symptoms - often missed in primary and secondary care settings - that are amenable to specific therapies. Low back and neck pain may co-exist in this situation [4;5]. Vitamin D deficiency is common as noted by Lewis [6]. In a cohort of 657 patients referred to a rheumatology department, 15 (2.3%) were found to have metabolic bone disease, more than infections, ankylosing spondylitis and malignancy combined [7]. In North West London, the combination of vegetarian peoples with dark skins and the English climate (together with some patients dressing with clothes that cover most of the body) seem to be common factors. In this population osteomalacia is often present in the absence of a raised alkaline phosphatase and may be missed unless Vitamin D and parathyroid hormone levels are requested [8]. The section on the importance of the history and physical examination was regrettably short. The challenges relating to the management of chronic low back pain are more related to ‘person management’ than to ‘disease management’ as there is no disease to manage! The management of the patients’ emotions, fears and anxieties early – by obtaining a careful history, may elicit important areas for exploration with the patient [9], including the need to reassure them about unfounded fears [10]. 'Yellow flags' are widely believed to be helpful in eliciting potential areas for psychological exploration [9]. As the majority of individuals with spinal pain have a mechanical problem without simple solutions, appropriate psychological management is important from the initial onset of pain. This should include sufficient physical examination in primary care to ensure that patients feel that their problems have been taken seriously [11]. Reference List (1) Cohen SP, Argoff CE, Carragee EJ. Management of low back pain. BMJ 2009; 338:100-106 (2) Chartered Institute of Personnel and Development. Absence management. London: Chartered Institute of Personnel and Development; 2006. (3) Black C. Working for a healthier tomorrow: Dame Carol Black's review of the health of Britain's working age population. London: TSO; 2008. (4) Frank AO. Understanding back injuries and back pain. In: Barnes MP, Braithwaite B, Ward A, editors. Medical Aspects of Personal Injury Litigation. Oxford: Blackwell Science; 1997. 164-209. (5) Frank AO. Psychiatric consequences of road traffic accidents - often disabling and unrecognised. BMJ 1993; 307:1283. (6) Lewis PJ. Management of low back pain: test for Vitamin D deficiency. http://www bmj com/cgi/eletters 2009; 337(15 January):3-5. (7) Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross- sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force Classification. Int J Clin Pract 2000; 54(10):639-644. (8) Frank AO. Back Pain. Rheumatology 2002; 4:1069-1070. (9) Kendall N, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Wellington, New Zealand: Accident Rehabilitation and Compensation Insurance Corporation of NZ and the National Health Committee; 1997. (10) Grogan E, Frank AO, Keat A. Patients in rheumatology clinics need reassurance. BMJ 2000; 321(29 July):300. (11) Roland MO. Back pain in General Practice. Taking a positive view. Musculoskeletal Medicine 1994; 1(3):2-4. Competing interests: Andrew Frank is also Medical Director of Kynixa, a rehabilitation company |
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Richard E Deacon, GP Haslingden Health Centre BB4 5SL
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It is a shame the authors chose reserve soldiers as their excuse for low reporting. As I understand it, a condition such as back pain can have a detrimental effect on their career if they even mention it - hence why it goes unreported. Competing interests: None declared |
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Louis I Jones, Retired G.P. BS41 9JDI
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In an article aimed at primary care physicians, listing so many rare causes which most will never see once in a lifetime of practice is not very helpful. The inexperienced practitioner needs to know the various presentations, the two commonest being (1)pain on sitting & lying, helped by movement, (2) pain on standing & walking, helped by resting.The first is most likely in simple mechanical pain. Early activity will help (1) but may aggravate (2). Treatments used are frequently helpful in a minority only.Specialising in low back pain for 30 years (1968-1998) I found that quick recovery i.e. 3- 5 days,was best achieved by giving three treatments together ,namely (1) analgesia such as ibuprofen or cocodamol, (2)manipulation of the spine, especially both sacro-iliac areas & the cervical spine, (3) injection of local anaesthetic plus steroid,e.g.Depot Medrone with Lidocaine, if there was a localised tender area (left or right or both sacro-iliac areas being by far the commonest.) Competing interests: None declared |
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Helen M Firth, Physiotherapist Manchester and Salford Pain Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD
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We read with interest the clinical review ‘Management of low back pain’. The stated aim of this clinical review was to provide an evidence based overview of low back pain aimed at primary care physicians. The review of publications involved searches of low back pain crossed with various categories for each of the subsections including pharmacotherapy, nerve blocks, surgery and alternative therapies. However one treatment modality in the management of chronic low back pain (CLBP) not mentioned in the review and available via referral from primary care physicians is a pain management programme (PMP). Whilst we are in agreement with the summary points including the fact that most treatments for chronic low back pain have a small effect and/or afford transient benefit we felt it important to highlight other options available within the NHS setting which are recommended in the European evidence based guidelines and more recently in the draft NICE guidelines for the management of low back pain. The European evidence based guidelines on preventing and managing acute and chronic low back pain state that the most promising approaches seem to be cognitive behavioural interventions encouraging activity/exercise. Further to this they state that there is strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with a functional restoration approach reduces pain and improves function in patients with chronic LBP. To this end the approach of PMP’s are recommended for CLBP. A PMP is a rehabilitation programme delivered in a group setting. The PMP differs from many treatments in that pain reduction is not the primary goal. People living with chronic pain will already have developed some skills to manage their pain. The PMP aims to develop these skills further by introducing psychological, physical and practical techniques to help manage pain better. PMPs were developed because of the need to address both the physical and psychological impact of living with chronic pain. After a programme, many people say that although they still have pain they have learned that it is safe to keep active and they can manage and cope with their pain better. They also often say they can take part in activities that are important to them and as a result, they feel happier and less concerned about their pain. Reflecting on the case study used in the review demonstrating a patient’s perspective it highlights the pathway that many patients take before embarking on a pain management programme and the treatment of choice for this lady having not found a cure for her pain through the traditional route could be a pain management programme. We would encourage primary care physicians in the UK to review current guidelines and the option of referring patients into NHS services which offer this approach of pain management when treatments fail to cure or lessen the pain. Relevant links include the British Pain Society website www.bps.co.uk and the physiotherapy pain association www.ppaonline.co.uk. Reference List Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26:1-9. Morley S, Williams S, Hussain, S. Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: Evaluation of a CBT informed pain management programme. Pain 2008;137:670-680. Morley S, Eccleston C, Williams A. Systematic review and meta- analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999;80:1-13. Flor H, Fydrich T, Turk DC. Efficacy of multidiscplinary pain treatment centers:a meta-analytic review. Pain 1992;49:221-230. Competing interests: Employed at the Manchester and Salford Pain Centre and involved in the delivery of Pain Mangement Programmes |
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