Multidisciplinary rehabilitation for chronic low back pain: systematic review
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7301.1511 (Published 23 June 2001) Cite this as: BMJ 2001;322:1511
All rapid responses
Guzman et al, (1) have shown evidence that intense multi-disciplinary
rehabilitation programmes will produce improvements in pain and function
for patients suffering chronic low back pain. Certainly this should be the
preferred model of care. However do chronic pain sufferers need to receive
a minimum of 100 hours of therapy as indicated by the authors?
This paper
has prompted a retrospective review of outpatient activities in our own
public hospital setting. An audit of 176 non-admitted patients attending
our allied health services (July 2000 - June 2001), demonstrated that the
average total length of treatment was only 2.8 hours/patient (SD 2).
Physiotherapy intervention occurred most frequently with only three
patients receiving multi-disciplinary care. This intervention consisted of
specific back exercises (2), including general fitness instructions. The
main outcome measure used in this service was the achievement of patient
negotiated goals. Patients discharged from the service reported achieving
their goals (35%) with a larger proportion (36%) being discharged due to
their failure to contact the service, either before therapy started or
during their episode of care. Some patients were deemed inappropriate for
therapy (10%) while others “plateaued” on discharge (10%). The remaining
patients (9%) were discharged due to transfer to another centre or being
deemed as non-compliant.
Until recently our service had no defined chronic pain programme. We
have recently introduced a programme that has been agreed upon by
individual health professionals, including referring general
practitioners, that suits the individual needs of the client. This
includes a range of interventions; cognitive - behavioural therapy (3),
hydrotherapy (4), exercises (5) and a multi-disciplinary case management
model. Early indications suggest we are improving the goals achieved for
our patient with an estimated 15 hours of therapy per patient, this is
much less than the 100 hours suggested.
1. Guzman J, Esmail R. Multidisciplinary rehabilitation for chronic
low back pain: systematic review. BMJ 2001:322:1511-1516.
2. Hansen FR, Bendix T, Skov P, et al. Intensive , dynamic back-
muscle exercises, conventional physiotherapy or placebo-control treatment
of low-back pain. Spine 1993:18:98-107.
3. Linton SJ and Anderson T. A randomized trial of a cognitive-
behavioural intervention and two forms of information for patients with
spinal pain. Spine 2000: 21: 2825-2831.
4. McIlveen B and Robertson VJ. A randomised controlled study of the
outcome of hydrotherapy for subjects with low back or back and leg pain.
Physiotherapy 1998: Vol 84: No 1: 17-26
5. Manniche C, Lundberg E, Christenson I, Bentzen L, Hesseloe G.
Intensive dynamic back exercises for chronic low back pain: A clinical
trial. Pain 1991:47:53-63.
Competing interests: No competing interests
Re: Multidisciplinary rehabilitation for chronic low back pain:
systematic review
We have some serious misgivings about the conclusions drawn by Guzman
and colleagues on multidisciplinary rehabilitation for chronic low back
pain .1 Low back pain problems are as heterogeneous as the wider category
of chronic pain, and in disregarding systematic reviews and meta-analyses
of multidisciplinary rehabilitation in chronic pain 2 the authors have
missed a large body of relevant evidence, including trials of cost-
effectiveness 3.
Standard quality criteria used for RCTs cannot be applied unmodified
to psychological treatments which constitute important components of
multidisciplinary rehabilitation. The impossibility of blinding patients
and therapists need not lower standards: several trials reviewed employed
recognised methods for establishing treatment equivalence: patient rating
of treatment credibility or expectations; manualised treatments, blind
rating by experts of therapy excerpts, and close supervision of
therapists. It is disappointing to see the Cochrane Back Review Group
continuing to apply inappropriate criteria and thereby misjudging
methodological quality of trials.
Variability in outcome arises from heterogeneity among patients,
treatment differences, and their interaction, not only from treatment
length. Treatment content is far more important than total programme time.
Physical therapy alone, as the authors state, is a weak way to change
behaviour, particularly in relation to work and health care use. Patients
who have become fearful of further pain and damage, and are disabled as
much by their fears and misapprehensions as by the pain itself 4, need
psychologically-based treatment which is still in woefully short supply.
The emphasis on return to work as the primary outcome is
inappropriate when the population includes homemakers, as did several of
the trials reviewed. Disability or function is a broader issue, and
includes the important but neglected issue of change in use of health care
resources. An undue focus on return to work to define effectiveness leads
to restricting access to treatment for non-workers, particularly among
older patients.
The authors acknowledge that their conclusions may not apply in
primary care, but patients are better defined by their level of disability
than by the setting in which they are seen, and their treatment defined
not by hours but by its adequacy to restore as near as possible normal
function, whether in secondary prevention of recently injured workers 5 or
in chronically disabled non-workers. Unfortunately, this review offers
clinicians little help in selecting the right level of treatment for
patients with low back pain.
Yours sincerely,
Cathy Price
Consultant in Pain Management,
Southampton University
Hospitals NHS Trust, Southampton
cathyprice@freeuk.com
Amanda C de C Williams ,
Senior Lecturer in Clinical Health Psychology,
Guy's, King's & St Thomas' Medical School & INPUT Pain Management
Programme, St Thomas’ Hospital,London
Chris J Main,
Professor in Behavioural Medicine,
Salford Behavioural
Medicine Research Unit, Hope Hospital, Salford, United Kingdom.M6 8HD
1.Guzmán J,Esmail R, Karjalainen K, Malmivaara A, Irvin E, and
Bombardier C. Multidisciplinary rehabilitation for chronic low back pain:
systematic review
BMJ 2001; 322: 1511-1516 (23 June)
2.Morley SJ, Eccleston C, Williams ACdeC (1999). Systematic review and
meta-analysis of randomised controlled trials of cognitive behaviour
therapy and behaviour therapy for chronic pain in adults, excluding
headache. Pain 1999 ; 80:1-13.
3.Goossens ME, Rutten-Van Molken MP, Kole-Snijders AM, Vlaeyen JW, Van
Breukelen G, Leidl R. Health economic assessment of behavioural
rehabilitation in chronic low back pain: a randomised clinical trial.
Health Econ 1998;7(1):39-51
4.Vlaeyen, J.W.S. and Linton, S.J. (2000) Fear-avoidance and its
consequences in chronic musculoskeletal pain: a state of the art. Pain
2000; 85: 317-332.
5.Marhold C, Linton SJ, Melin L A cognitive-behavioral return-to-work
program: effects on pain patients with a history of long-term versus short
-term sick leave. Pain 2001; 91(1-2):155-63.
Competing interests: No competing interests
As a consultant anaesthetist involved in an integrated back pain
service that struggles for existence in a District General Hospital, I
read this with interest. Sadly this paper indicates that we may have got
it all wrong. How I wish that I had even 10% of >100 hours of clinical
resources to apply to a patient!
If Health services where realistic, planned and equitable they would
be using such resources to either prevent back pain or at a minimum, treat
it aggressively at its outset. Sadly there seems to be no political will
in the UK to do this.
Until we get the front end of back pain we will continue to get it
back to front.
(No conflicts of interest)
Competing interests: No competing interests
Chronic Low Back Pain - The Foot Connection
ETIOLOGY OF FOOT HYPERPRONATION – AN EMBRYOLOGICAL PERSPECTIVE
Hola,
My research questions the validity of the traditional definition of
forefoot varum [metatarsals 1-IV inverted relative to the midline of the
calcaneus in STJ NP]. Embryological studies suggest/indicate that forefoot
varum is limited to the first metatarsal only. Published clinical studies
done at the Bellevue Foot and Ankle Center and GRD BioTech Laboratory,
using postural insoles, collaborate this embryological viewpoint. Based
on embryological studies, I propose that hyperpronation in the adult
[gaiting] foot is the result of an ontogenetic retention of talar torsion
[termed talar supinatus] seen during weeks 6pf-8pf in the developing
embryo. Clinically, talar supinatus is visualized as an elevation of the
medial column of the foot [termed Primus Metatarsus Elevatus], in the
standing/neutral positioned foot. I have devised a way to measure PME
using microwedges with confirmed high interrator reliability. I have
introduced a way to reduce hyperpronation resulting from PME using
postural insoles [not orthotics which weaken the feet]. Postural insoles
are based on Proprioceptive Feedback Stimulation, and are not used as
supportive devices [e.g., arch supports/metatarsal bars or pads, etc].
My work has been published in the Journal of Bodywork and Movement Therapy
[Harcourt Publishers, Leon Chaitow Editor, January 2002].
If you would like an electronic [Email] copy [Acrobat Reader 4.0 format],
visit the following website [under white papers], run and maintained by
Bjorn Svae:
www.PostureDyn.com
This website describes my research [in laymen’s terminology] and offers a
channel for the technology to be used in the medical community.
Your comments regarding my research would be most welcomed.
With Best Regards,
Brian A. Rothbart DPM, PhD, FACFO
Competing interests:
None declared
Competing interests: No competing interests