As a practicing chiropractic physician and team physician for professional and university level athletes, I am surprised to see that the results of Croft et al.'s research are so unpalatable to so many. I agree with Dr. Addis' comments regarding the multitude of causes for LBP and the confounds and shortcomings of this study. I do not believe that he has any important data supporting his implication that malingerers and secondary gainers comprise a significant proportion of LBP sufferers. There is also no evidence in the literature to suggest that a "litigation neurosis" exists in LBP patients.

In 1976, I personally sustained a bilateral pars fracture to my fifth lumbar vertebra, visited three very respected Boston orthopedists who found nothing, the third of whom referred me for psychiatric evaluation because "there was nothing wrong". I was urged to seek alternative opinions and a friend dragged my parents and myself to a chiropractor. My parents were quite skeptical given the medicopolitical situation for U.S. chiropractors at the time. When an A-P tilt-up view (see Yochum & Rowe) of the lumbar spine on a plain film radiograph taken by the chiropractor revealed the problem, I was braced, and advised to rest. I was prescribed exercises later that still help me today.

That was 1976. Hopefully, spondylolysis is more readily recognizable to physicians today. But my example begs the question: If physicians do not adequately look for a problem, does that mean it doesn't exist? Does a lack of objective findings mean that the LBP patient does not have a reason for his subjective complaints?

Estimates of costs of LBP in the U.S. rise as high as the 50 billion dollars per annum. Studies have supposedly "proved" that "Back Schools" and other varied injury prevention programs for industrial LBP are ineffective. Malingering and secondary gain are often suspected by persons who have never themselves experienced LBP, and who have no proof that objective findings do not exist, just because they cannot (or will not) find them.

I would like to propose an easy solution: make exercise a mandatory part of the job description where lost time at work due to LBP is the problem. Make it a daily event, with exercises for trunk extensors, flexors and lateral flexors. Try videotaping different job tasks, and then designing an obstacle course for employees who must demonstrate proficiency at proper lifting, bending postures, etc. for the jobs you want them to perform. Clearly, most LBP is the result of strain injuries to muscle belly or tendon.

Mandatory, paid exercise has worked well for U.S. companies that have integrated exercise into the workplace. Most patients to whom I have prescribed home exercise do not perform the exercises properly. With office supervision, performance improves. Studies like the recent New England Journal of Medicine study comparing the McKenzie method, a one- dollar pamphlet on exercises and one or two cracks to the back are deeply flawed because most practitioners in my profession use all three of these treatment methods simultaneously, which most likely have a cumulative beneficial effect.

It takes time, perhaps 3-6 months of dedicated effort by patients, to see real strength, flexibility and balance improvements in trunk muscles. These muscles are often ignored by orthopedists, physical therapists and chiropractic physicians who are not knowledgable enough regarding rehabilitaion of LBP. Studies which do not measure exercise compliance statistics will be left behind.

Sincerely,

Gregory T. Wright, D.C.