Outcome of low back pain in general practice: a prospective study
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7141.1356 (Published 02 May 1998) Cite this as: BMJ 1998;316:1356
All rapid responses
Mr. Steve's Lockhart's reaction calls for an invitation to visit the
next website: www.mckenziemethod.com (click on "Low Back Pain"). After reading the stories
of patients of just one (!) practice (in Texas), you will probably want to
surf to: www.mckenzie.nl/literatu.html (it's a Dutch site, but this
page is in English), to see that new insights and a new (working!)
approach to LBP have come up in the last few years, backed by literally
dozens of scientific studies and papers (it's not just a "here today, gone
tomorrow" method!).
Spinal problems largely untreatable? No sir, not anymore.
Are
physiotherapy/chiropractic/osteopathy still in their growing years: yes,
very much so. Try reading McKenzies book "The Lumbar Spine, mechanical
diagnosis and therapy" (ISBN: 0 473 00064 4), and see if it will arouse
the same reaction as it did in me: "We didn't even learn the most basic
principles of the functional anatomy of the spine in college!" After years
of (trying to) treat(ing) patients with so-called "Non-specific low back
pain", with -amongst others- manipulation of the spine, I'm willing to say
that we as orthopedic (para)medics never really knew what we were doing,
or at least thought we knew but didn't. That has changed lately, as
pertains to the availability of an effective, evidence-based and very cost
-effective therapy. (Not that the respective colleges have incorporated it
yet: they remain way behind).
Just look at the sites (and read his book if
you like), and judge for yourself: it's all a matter of insight on how the
spine really works!
Competing interests: No competing interests
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.
Competing interests: No competing interests
I really have to question the statements of Jeffery M Sherr on the
bases that it has already been found that the majority of back pain
sufferers still have their pain 12 months after it started even though
they haven't gone back to their GP. I'm sure a study would find that those
sufferers have in that time consulted chiropractors, oesteopaths and
physical therapists still with no solution to their pain. The notion that
these modalities can provide any sort of long term solution to back pain,
by my logic, is totally floored by the fact that pain is still present 12
months on and back pain is a topic that warrants all this discussion as a
largely untreatable condition. Lets face it if chiropractors, oesteopaths
or physical therapists had the answers to solve back pain episodes we
wouldn't need to be talking about it.
Competing interests: No competing interests
I was pleased to read that someone has actually taken the time and
effort needed to begin researching the natural history of low back pain
with a scientific vein. It is a welcome first step and you are all to be
commended. I sense that North American and British patients will have a
similar pattern of findings and that the results of this study may
ultimately have influences beyond those anticipated by the authors.
Sincerely yours, Dr. Haggart
Competing interests: No competing interests
This study would suggest that the "wait and see" approach is ineffective and contributes to the large cost of back pain.
In 1993 back pain cost the UK 5.3 billion pounds, most of which was made up of Social Services and lost production costs. Only 481 million pounds was estimated as NHS costs.
The Clinical Standards Advisory Group (DEC 94) and the Royal College of General Practitioners (SEPT 96) in guidelines for the treatment of back pain in the UK recommend a shift of resources towards primary care. Skilled spinal manipulation is recommended as a beneficial and cost effective means of treatment.
Chiropractors, osteopaths and specially trained physiotherapists offer evidence based primary care which is both beneficial and cost effective. This care consist of history, appropriate physical, orthopaedic and neurological examination, diagnosis and suggested action or treatment plan outlined in a written report of findings to the GP and a verbal review of findings with the patient using models and illustrations.
Treatment consists of spinal manipulation/mobilisation, soft tissue therapy, physiotherapy modalities as indicated and advice on posture and ergonomics to facilitate recovery and early return to normal tasks of daily living. Encouragement and a positive approach to recovery accompanies an emphasis away from passive therapy to active spinal rehabilitation to promote self sufficiency and decreased dependence on treatment. A follow up report of progress is sent to the GP.
This protocol is low cost, low tech and effective for the majority of simple back pain and nerve root entrapment sufferers.
In view of this study the locality purchasing commissioners within the NHS as well as the general practitioners themselves would do well to take heed of the guidelines and seek out local reputable qualified chiropractors, osteopaths and physiotherapists skilled in spinal manipulation. The reduction of back pain costs to the nation may be substantial as would I venture patient satisfaction.
Competing interests: No competing interests
Dear Sir
The prospective study of low back pain (LBP) in general practice by Croft et al. reminds us of the important fact that non attendance for further care does not equal recovery. They measure morbidity which often remains unrecognised, and their data counter the claim that 90% of patients with LBP have fully recovered by one month.
However, this study is not methodologically robust enough to support the statement that of the non attenders 'most will still be experiencing low back pain and related disability one year after the (index) consultation'. Detailed follow up data analysing patients' experience outside the surgery was only available in a minority of the original group, 170/463 (37%), leaving considerable room for selection bias. Although an attempt was made to quantify this bias, the 'validation group' was too small (44) to be conclusive. Two further factors may have exagerated this bias. Both the original cross sectional survey and the interview process may have altered patients perceptions of their LBP (the Hawthorne effect).
Competing interests: No competing interests
I find it hard to work out what the conditions were that underlay the complaint that this paper studies. Metastatic disease, tuberculosis, and osteoporosis for example are all causes of back pain with more or less forseeable but different outcomes in time. On the other hand people who have undoubted secondary gain in the form of money, love, or avoidance of unpleasant duties through a pain that the doctors cannot cure are not likely to give up their pain. Those on Disability Benefit or other recompense for example would be much worse off if they were to recover and become unemployed instead. Without knowing something about the case mix this study does little mor than tell us that back pain is a big and chronic problem to a lot of people. I suppose that we should be glad to have our intuition supported by factual information but harder facts are needed.
Competing interests: No competing interests
Re: Non attendance and morbidity from low back pain.
As a patient with sciatica of unknown origin of 6 months standing I
can vouch for the assumption that non attendance does not correlate with
either an improvement or cessation of low back pain or sciatica. The GP's
attitude and the lack of interest in finding the causes must be a prime
factor in the non attendance, so one suffers in silence.
Competing interests: No competing interests