We need to rethink front line care for back painBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3260 (Published 25 May 2011) Cite this as: BMJ 2011;342:d3260
All rapid responses
In back pain, as in most other musculoskeletal conditions, assessment
from the outset needs to consider [i] the possibility or contribution of a
disease process, [ii] the psychosocial impact, actual or potential, on the
sufferer; and [iii] the present function of the neuro-musculoskeletal
system and level of disability.
We must not forget that no other professional group has the general
practitioners' level of training and experience in [i] and [ii]. At the
same time, their training in [iii] is accepted as inadequate considering
the community's burden of musculoskeletal morbidity and so many GPs lack
confidence in managing these conditions. But there is no other group
better placed to bring the required range of competence to those who fail
to resolve with individual therapies or have significant co-morbidities so
an urgent enhancement of general practitioners skills in assessment of the
locomotor system is required. At the British Institute of Musculoskeletal
Medicine we have a decade of experience in educating general practitioners
to enhance their role in this area but, while being gratified at the
enthusiasm and achievement of those who take part, we are also concerned
that this training, involving considerable practical skills, requires
small group hands-on work while the present funding scarcity pushes
postgraduate courses towards the economy of large lecture audiences or
Of course the majority of treatment will and should continue to be
delivered by physiotherapists and targeted according to their own
However, with some quite limited training in assessment of musculoskeletal
function, GPs can improve their immediate management of back pain often
throughout an episode or with timely referral to : secondary care
specialist, interface musculoskeletal service or physiotherapy
department. As they gain experience in this role some will extend it
further towards the functions of a medical specialist: many have taken
this route and are providing clinical partnership or leadership in
Where patients perceive their problem to be a straightforward
physical problem they may well be happy to refer themselves directly to a
therapist and the outcomes from services pioneering this are likely to be
good. However the cost-savings of such a pathway could lead to it being
commissioned as the one of choice. The consequent progressive de-skilling
of general practitioners would reduce their effectiveness in the many
situations where so-called "simple back pain" turns out to be far from
simple in its effects on an individual.
It would be a regrettable if, due to a remediable gap in training, UK
general practice, with its strong espousal of the bio-psychosocial model
of care, were to abandon responsibility for sufferers from back pain which
is the condition par excellence requiring holistic care. The degree of
impairment is dependent on so many factors, the condition can extend
disability into so many aspects of life, and optimal management requires
the employment of so many interventions. Handing over complete
responsibility to practitioners lacking the GP's breadth of training would
be nothing short of abdication. It is heartening to hear that the RCGP is
recognizing the urgent need for enhanced training.
Competing interests: The author has a strong interest in providing musculoskeletal training to general practitioners
The present "red flags" seem to fail to detect certain common
conditions. Last year my wife had major problems with back pain and was
referred to the local assessment service. Apparently she had none of
the current "red flag" conditions, so treatment was given without
investigation or x-ray. She had in fact severe osteoporosis which had
been undetected and the pain was due to compression fracture of one
vertebra. During treatment she sustained a second fracture. It was
only after pressure from myself that appropriate investigations were made
and the condition diagnosed. Given the delays built in to the system
she suffered six months of sevre disability before the correct diagnosis
was made. One patient only but her experience suggests that for elderley
female patients a "red flag" for the possibility of osteoporosis is badly
Competing interests: No competing interests
I agree with Britton that the GP is the most appropriate gate-keeper
for managing low back pain in the community.
Many GPs across the UK these days have rapid access to NHS
physiotherapy run triage services which are able to assess patients in a
timely fashion. These
physiotherapists undergo specialist training and many have direct access
to advanced imaging when required. It is a system that works well,
especially as GPs are often able to sift out patients they know are
motivated enough to self manage.
Snelling makes a valid point that physiotherapists, osteopaths and
chiropractors often over medicalise due to their enthusiasm to employ non-evidence-based treatments. This may well be a common feature in the
private sector, but NHS physiotherapists are increasingly abandoning guru-taught treatment techniques in favour of evidence-based combined physical
exercise and cognitive behavioural remedies.
Competing interests: No competing interests
Triage is one of the safest and most effective ways of dealing with
many forms of back pain. Most importantly, in many cases early and
accurate diagnosis of its cause can save extended periods of discomfort
and fruitless interventions for patients. Also,any serious underlying
pathologies must be excluded prior to treatments with manual therapies.
Many GPs will have scant knowledge of what can be achieved by
physiotherapists based on accurate initial diagnosis. However, triaging
patients in primary care settings would be expensive. But could the
benefits possibly outweigh the costs?
Competing interests: No competing interests
Re Britton's response: "The proposed alternative would attempt to
cure the back pain without addressing the overall context of how the pain
fits into the fullness of the patients life." Dear me, someone
threatening to cure people without addressing the fullness of their lives.
Can't have any of that nonsense, can we?
Seriously, I completely lose interest in how a pain fits into the
fullness of my life just as soon as it's been cured. My good experiences
of private physiotherapy are such that in future it will always be my
first port of call for any condition I assume to be musculo-skeletal but
more than a simple sprain suitable for self-management. This includes
having been cured in a single session of a chronic problem that had been
worsening for months, but also on other occasions of having been reassured
that no treatment or follow-up is needed (contrary to Snelling's concern
about the pressures of private practice).
The reality is that primary care is already fragmented, because the
public has long since twigged that GPs aren't much use for back pain. Non-medical practitioners can make a dramatic difference in some cases, and,
as Snelling suggests, what is needed is to bring them into a more
structured and evidence-based model of NHS provision.
Competing interests: Satisfied occasional patient of physiotherapists in private practice.
Hartvigsen, Foster and Croft argue that healthcare professionals such
as physiotherapists, chiropractors and osteopaths might be more
appropriate gatekeepers to health services than GPs where back pain is
concerned. As a patient and as formerly active in The National
Back Pain Association (now BackCare) - www.backcare.org.uk - I disagree.
The authors fail to make the important distinction between 'low back
pain' and other forms of back pain.
The great majority of cases seen in primary care are of (mostly
muscular) low back pain. As they say, this can be treated reasonably
effectively by patients remaining active, taking appropriate exercise and
by the use of analgesia. All GPs know this, and that is why their standard
response to a patient presenting with low back pain is to advise him or
her appropriately, prescribe simple analgesics and suggest they come back
in six weeks if the problem persists. Their hope, of course, is that this
patient will not be one of the few who do return and who will therefore
require specialist intervention. The difficult cases are those in which
the pain is not, in fact muscular, and may be far more serious. It is not
good enough to dismiss such cases as 'rare' as the authors do; the
consequences for those 'rare' patients can be very serious indeed.
In the summer of 2008, I suddenly developed a severe pain, apparently
in my stomach. Two GPs, at separate consultations about a fortnight apart,
diagnosed it as being caused by muscular back pain, and started me on the
ritual described above. The prescribed analgesics reduced the pain almost
not at all. We were due to go abroad on holiday for a fortnight towards
the end of July, so I rang the first GP and explained that if nothing more
could be done for the pain, we would be unable to go. He suggested I see a
chiropractor and gave me the contact details for what he understood to be
a respectable practice. The chiropractor sent me for x-rays. Once he had
seen them, he proceeded to manipulate my back very violently and
painfully. He repeated the manipulation on, I think, three further
We went on holiday but returned home after only five days because the
pain was intolerable.
The GP referred me to a specialist who ordered CT and bone scans. The
CT scan showed a wedge fracture of the thoracic vertebra T7. I was
diagnosed as having osteoporosis and started on appropriate medication.
The following January (2009), I had a spontaneous fracture of another
thoracic vertebra, this time T10. Two months later, one of my ribs broke
as I reached across to take a book from a book shelf.
It might be supposed that I blame the GPs for their initial mis-
diagnoses. I do not. Where doctors are concerned, I am acutely conscious
of the uncertainties they face across a range of conditions, back pain
being one of the most difficult. In my estimation, the two GPs concerned
are both highly competent doctors who simply responded as would almost any
of their colleagues, nationwide. It may have been a little incautious to
recommend that I see a chiropractor when the cause of the pain was
unknown. Equally, though, I may unwittingly have put the GP in question
under moral pressure to 'do something' and he, for his part, may have
hoped that the chiropractor might be able to diagnose the problem.
I do wonder why, when I had taken the trouble to have x-rays taken,
the chiropractor failed to spot the wedge fracture, and why he persisted
with such violent manipulation when it was so obviously so painful. We
will never know whether the he did further damage to my back.
Also, and as an aside, no doctor should ever tell a patient with
fractured vertebrae that they will 'heal within six to eight weeks'. My
fractured vertebrae took over a year to reach the point at which they
From this account, it may seem that I should support Hartvigsen's,
Foster's and Croft's argument that physiotherapists, chiropractors and
osteopaths might be more appropriate gatekeepers to health services than
GPs where back pain is concerned. I adamantly do not.
I do not envy GPs the difficulties they face when confronted with
patients with all sorts of common conditions in which they are not
specialists; indeed, I have the greatest admiration for their commitment
and for the range of knowledge they must have at their disposal. And I
could certainly support the concept of the GP with a Special Interest
(GPwSI) in back pain, just as we already have GPwSIs in, e.g., dermatology
One of GPs' chief assets is that they know their way around the
healthcare system better than almost any other heath professionals, and
the best of them maintain excellent working relationships with their
colleagues in secondary care. Perhaps mine was a statistically 'rare'
case, but that would not have justified consigning it to triage by people
with little or no breadth of medical training.
Competing interests: None.
I totally agree with the reasoning of Hartvigsen and colleagues. In my
opinion there is room for effective self-referral to a physiotherapist and
Given the relevance of "mobility" problems in the ageing
population, GPs should receive much more training in diagnosis of MSK
diseases and their management, more specifically in physiatry.
GPs should have direct access to imaging, including MRI and CT scan. Probably, physiotherapists and chiropractors would benefit from precise guidelines on when to refer to a GP or a Specialist.
We cannot forget about the issue of "notification of sickness". I am afraid, I often find myself dealing with chronic backache and backache following MVTA with a patient openly requesting a new sick note and wondering about why exactly the patient is coming to me. Is it really because of the backache?
The possibility of financial incentives associated with chronic backache leading to long-term certification of illness may affect negatively the core of doctor-patient and doctor-system relationship, which is based on mutual trust.
I feel the time has come to re-think the role of GPs in the notification of sickness.
Occupational Health Physicians may be more qualified and could be called on
to do extra-work to reverse this socially unacceptable problem.
Competing interests: No competing interests
There is better optional treatment in Ayurveda for back ache. Our
mode of treatment involvse manipulation of the vertebral column without
surgery. Ayurvedic treatments include internal medicine and external
application, massage, exercises and yoga for curing back aches and
avoiding re-occurrence. Common cases of back aches are due to human
postural defects, only a few are considered as referral pain.
Back aches are either due to degenerative changes in between the vertebrae
or due to inflammatory conditions; there are also cases due to traumatic
After a proper diagnosis and evaluation of the condition the Ayurveda
physician will be able to advise a treatment.
There are specific drugs to strengthen the back muscles and specified yoga
and mechanical massage to re-ensure the default may not re- occur.
Competing interests: No competing interests
Frontline care for back pain
Hartvigsen et al comment on the poor training in medical school for
the management of back pain, and argue for using physiotherapists,
osteopaths and chiropractors as a first port of call for back pain.
Having trained first as an osteopath and then going through medical
school, I can indeed attest to the fact that training in musculoskeletal
medicine is generally poor at medical school and beyond. These
aforementioned healthcare providers do spend much longer studying
musculoskeletal pain syndromes, and could well provide a useful service to
However, my main caveat would be that the training of these clinicians is
very much in the private sector, and whilst things are slowly changing
there is still not an environment of evidence based medicine anything like
that which exists in the NHS. There can still be an emphasis on almost
medicalising back pain, with intricate biomechanical diagnoses given with
long treatment programmes, with limited evidence to back them up. It would
be extremely rare to visit an osteopath or chiropractor and for them to
say that your back is strong, this is a simple sprain which is likely to
improve on it's own if you keep mobile, and you do not need any hands on
manual treatment. As most of these professions work in the private sector,
the pressures are very different to those of the NHS. This can make it
very difficult to challenge entrenched beliefs (for example most patients
attending a chiropractor might expect manipulation, and a chiropractor
will have invested considerable time and money in training in
manipulation, thus making it difficult for the chiropractor to challenge
this approach, particularly if it is paying his mortgage). Complex
biomechanical diagnoses and manipulative treatments can risk making
patients feel over reliant on manual therapies. It is therefore vital that
any inclusion of these professions is accompanied by adequate training in
critical thinking and incorporation of evidence based medicine. However on
this basis I would be wholeheartedly in favour of their greater
integration into frontline musculoskeletal management.
Dr NJ Snelling
Hartvigsen et al. BMJ 2011;342:d3260 doi: 10.1136/bmj.d3260
Published: 25 May 2011
Competing interests: The author is a qualified osteopath and a GP specialist trainee, currently working in emergency medicine.
Again another biased opinion where GPs are touted as being
incompetent of managing a particular subset of medical problems. GPs are
supposedly terrible at managing back pain, depression, diabetes etc. And
everyone else should have a go at gate keeping their particular system of
medicine. In this article the authors suggest that others should gate keep
the Muskuloskeltal system without acknowledging the fact that GPs are
there for more than managing the problem the patient presents with. We
manage the patient, not their problems, placing all symptoms all in
context, synthesising the anguish of pain in conjunction with their other
medical history, social and actual cognitive/spiritual view of life's
expectations. The proposed alternative would attempt to cure the back pain
without addressing the overall context of how the pain fits into the
fullness of the patients life.
I know this sounds grandiose, but GPs are the only specialists with
the opportunity to see the patient as a person in the fullest sense. we ar
the only specialty with specific training to do inside the medical
profession and alongside nursing.
If we can do things better please suggest how to help us.
The suggestion of partitioning out one physiological system to be managed
elsewhere subverts the power and benefit of a wholistic primary care
practitioner, one of the key diamonds (in the rough) of the British Health
Competing interests: I am a GP