It is encouraging to see that a package of manipulation and or a back
to fitness exercise approach to the treatment of non-specific low back
pain (NSLBP) has some clinical effectiveness. It is also encouraging that
the provision of these treatment packages was cost effective and
considerably below recommended thresholds of "willingness to pay". The
UKBEAM team are to be congratulated on running an excellent trial, it is
however disappointing that the results, although positive, are only
marginally sized and of questionable clinical significance.
Those of us involved in the treatment of NSLBP will recognise that
"back to fitness" programmes and manual therapy approaches are appropriate
and clinically beneficial in particular subgroups of NSLBP and not
appropriate in others. The decisions used by clinicians in deciding what
therapy is likely to be beneficial in certain "types" patients are complex
and grounded in our clinical reasoning abilities. Within the complexities
of our diagnostic reasoning process only one thing is clear, the vast
majority of clinicians do not provide “non-specific” treatment for non-
specific low back pain. Unfortunately, whilst our reasoning processes are
infinitely adaptable to all patient presentations the diagnostic labelling
that results from this process can be as diverse. In the face of this
diversity the challenge of diagnosing valid “types” of NSLBP has been
unmet and indeed has been all too often forgotten.
It has been recognised that the greatest priority facing the NSLBP
community is the need to develop valid subcategories of NSLBP(1). This
recommendation, developed during the international forum for primary care
research in low back pain (1995) has been in the public domain since the
mid nineties with little change in diagnostic practice being evident as a
result. It is possible that if that recommendation had been addressed and
subcategories of NSLBP had been established prior to the commencement of
this seminal study, we would be viewing data of an all-together more
convincing nature. It is entirely reasonable to believe that certain sub-
groups of patients are more suited to manual therapy approaches than
"back to fitness" exercise classes however until we establish a valid
mechanism of sub-classifying NSLBP we can only hypothesize. It is time we
addressed our own recommendations and developed trial designs that will
have greater chance of demonstrating clinically significant differences
between interventions in subgroups of this heterogeneous syndrome.
Reference
(1)Borkan J, Koes B, Reis S, Cherkin D. A report from the second
international forum for primary care research on low back pain. Spine
1998; 23(18):1992-1996.
Competing interests:
None declared
Competing interests:
No competing interests
03 December 2004
Dr Chris McCarthy
Research physiotherapist / Chair of the Manipulation Association of Chartered Physiotherapists
Rapid Response:
Which treatment for whom?
Dear Sir,
It is encouraging to see that a package of manipulation and or a back to fitness exercise approach to the treatment of non-specific low back pain (NSLBP) has some clinical effectiveness. It is also encouraging that the provision of these treatment packages was cost effective and considerably below recommended thresholds of "willingness to pay". The UKBEAM team are to be congratulated on running an excellent trial, it is however disappointing that the results, although positive, are only marginally sized and of questionable clinical significance.
Those of us involved in the treatment of NSLBP will recognise that "back to fitness" programmes and manual therapy approaches are appropriate and clinically beneficial in particular subgroups of NSLBP and not appropriate in others. The decisions used by clinicians in deciding what therapy is likely to be beneficial in certain "types" patients are complex and grounded in our clinical reasoning abilities. Within the complexities of our diagnostic reasoning process only one thing is clear, the vast majority of clinicians do not provide “non-specific” treatment for non- specific low back pain. Unfortunately, whilst our reasoning processes are infinitely adaptable to all patient presentations the diagnostic labelling that results from this process can be as diverse. In the face of this diversity the challenge of diagnosing valid “types” of NSLBP has been unmet and indeed has been all too often forgotten.
It has been recognised that the greatest priority facing the NSLBP community is the need to develop valid subcategories of NSLBP(1). This recommendation, developed during the international forum for primary care research in low back pain (1995) has been in the public domain since the mid nineties with little change in diagnostic practice being evident as a result. It is possible that if that recommendation had been addressed and subcategories of NSLBP had been established prior to the commencement of this seminal study, we would be viewing data of an all-together more convincing nature. It is entirely reasonable to believe that certain sub- groups of patients are more suited to manual therapy approaches than "back to fitness" exercise classes however until we establish a valid mechanism of sub-classifying NSLBP we can only hypothesize. It is time we addressed our own recommendations and developed trial designs that will have greater chance of demonstrating clinically significant differences between interventions in subgroups of this heterogeneous syndrome.
Reference (1)Borkan J, Koes B, Reis S, Cherkin D. A report from the second international forum for primary care research on low back pain. Spine 1998; 23(18):1992-1996.
Competing interests: None declared
Competing interests: No competing interests