Physiotherapy for neck and back pain
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7482.53 (Published 06 January 2005) Cite this as: BMJ 2005;330:53All rapid responses
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We thank Professor Galasko for his comments on our editorial. We would like to point out, however, that his interpretation of our statement "Only a small proportion of patients with so called red flag signs indicating serious underlying pathology should be referred without delay to specialist services" is somewhat different from our intended meaning. Our intention was to communicate the idea that those patients with red flag signs should be referred urgently to specialist services, but that this patient group is simply a small proportion of all back-pain sufferers.
We are confident that the majority of readers will have interpreted the statement as intended, but do accept that it could have been phrased more convincingly.
Professor Cyrus Cooper and Dr Nicholas Harvey
Competing interests: None declared
Competing interests: No competing interests
Dear Sir
I am concerned by the Editorial by Nicholas Harvey and Cyrus Cooper (Physiotherapy for neck and back pain, BMJ.2005,330;53-4.) In this Editorial they recommended ‘ only a small proportion of patients with so called red flag signs indicating serious underlying pathology should be referred without delay to specialist services’. This is dangerous and may result in patients being left with significant weakness, sensory loss, bladder disturbance, loss of bowel control and impotence (in a male) if a cauda equina syndrome is missed. The purpose of the red flags are to detect patients who may be developing spinal cord or cauda equina compression and other serious spinal pathology. All the evidence is that early decompression gives the patient the best opportunity of obtaining a good recovery and maintaining neurological function.
Doctors who follow the advice of Harvey & Cooper may find that they are being sued for medical negligence, the delayed diagnosis of cauda equina syndrome resulting in several such claims every year.
I am surprised that the BMJ allowed such a sentence to be published without demanding from the authors that they define which ‘small proportion of patients with so called red flag signs indicating serious underlying pathology should be referred without delay to specialist services’ and which patients with such red flags do not need to be referred urgently.
Yours sincerely
Charles S B Galasko
Competing interests: None declared
Competing interests: No competing interests
The outcome of a particular trial or treatment of neck pain or back pain cannot be predicted well unless we are very much sure about the cause of pain. While every book or article does mention various causes of neck pain or back pain but when it comes to practice we almost always put our emphasis on intervertebral disc or gross bony abnormalities. And the cause of pain is almost certain when we find such abnormalities on x-rays or CT- or MRI scans. But then we prescribe physiotherapy. All the physiotherapy methods like heating, ultrasound exercises or spinal manipulation should be contraindicated if we are only to consider the disc lesions. The only treatment should be to rest immobilization and wait. But in practice we see physiotherapy methods are beneficial to many patients and there is quicker recovery than we are expecting from the cartilage damage. The major part of pain in most of the patients with or without discal lesions is in the soft tissues. Although there is much debate about true nature and history of such lesions. For every sciatica and numbness or sharp pain the neck or arm with or without numbness the our first diagnosis radiculopathy but any structure near the vertebral column can produce such symptoms. Sciatica is a symptoms and not sciatic root compression, we should always try to find out the origin or pain and most of time it is just a few centimeter from the surface. So if we try to locate the local tender spots and treat them by physiotherapy without giving too much attention to the bones, joints or discs(except patients with red-flag symptoms) we can not only better results and more specific physiotherapy methods. If the total pain is a commutative pain then too making the superficial soft tissue structures pain free grossly reduces the overall pain. Excessive and wrong physiotherapy like manipulation or massage or counter- irritated substances exasperate the pain and also too much heating worsen the pain. Although cold is first line of treatment in musculoskeletal pains it is seldom used in physiotherapy departments. So the outcome of physiotherapy do depend upon the following factors.
1-Exclude fractures, infections or neoplasm and red-flag symptoms.
2-Give more attention to soft tissues then to deeper structures.
3-Knowing the referred pain patterns.
4-Identifying the source of pain.
5-Applying not all but specific physiotherapy methods and avoiding too frequent or too excess.
6-Above all assurance as vast majority of neck pain and back pain do get resolved sooner of later and avoid all sort of self therapy.
Competing interests: None declared
Competing interests: No competing interests
This weeks journal contained two rays of hope for those of us who look forward to more Medicine Based Evidence. The first was the comment in Harvey and Cooper’s editorial that “further research into the subgroups of patients who respond best to particular treatments is warranted.” The UK BEAM trial was a trial of broad treatment strategies for “back pain”. One only needs to consider a similar hypothetical trial for “chest pain” to see the problem. It is overwhelmingly likely that the residual “back pain” actually consists of a heterogeneous group of conditions and different treatments work differently for each.
The second ray of hope was the whole area of questions and issues opened up by the article arguing for the need for expertise based randomised controlled trials. At last, an admission that the skills, aptitude and attitudes of practitioners can impact the efficacies of treatments under trial.
This all brings out two really important points frequently overlooked in the discussions of EBM, and in the design and discussion of trials. Firstly, before you can conduct statistically finessed trials on treatments for conditions, a great deal of rather different research has to have been completed correctly. Vital work that is apparently is a long way down the “hierarchy of evidence”. Modern EBM rests on the product of a historical process of clinical and basic scientific enquiry that took place largely in the 19th and early 20th centuries. There are probably numerous areas in which this process is incomplete. How many inconclusive trials actually hide the fact that an as yet undisclosed sub-group of patients actually derived marked benefit, whilst others did not?
The second point relates to operator dependent therapies, which certainly include physiotherapy and surgery, but perhaps also more subtle forms of treatment such as general practice, talking therapies and homeopathy. Trials which pay no heed to the expertise of practitioners (as internally defined within the parameters of their discipline) must surely be held to be flawed? RCTs for drug therapy represent probably one of the few areas of medical practice where such considerations are minimised.
Personally I believe these considerations represent some of the mechanisms that produce the marked disparity we see between the evidence and our day-to-day experience in medicine. Patients fail to respond to “best treatment” and benefit from “useless treatments” every day. It is indefensibly lazy to put all the improvements down to a “mere placebo” and effectively dismiss the non-responders as regrettably untreatable. Please can we look forward to more research that is alive to the heterogeneity of both patients and practitioners?
Competing interests: None declared
Competing interests: No competing interests
Apologies: patient information booklet referred to is from the Arthritis Research Campaign, and not the Arthritis and Rheumatism Council as stated in my original rapid response to this article
Competing interests: None declared
Competing interests: No competing interests
A personal view on what the authors refer to as the "quagmire that is the management of spinal pain"
The past year has given me the opportunity to sample a wide range of physiotherapeutic techniques for a non-surgical cervical spinal problem. I discovered that if symptoms do not improve after a few sessions with a therapist,then it may be worthwhile changing to someone else, recurrently, if necessary. An Arthritis and Rheumatism Council booklet on neck pain states that all that may be needed is manual physiotherapy. It may be extremely difficult to locate someone with this expertise. Perhaps the Chartered Society of Physiotherapists should identify practitioners trained to provide the full range of treatment options for spinal conditions. Currently, obtaining help is something of a postcode lottery. I believe that it is unrealistic to hope that ultrasound, massage, TENS machines or Bowen technique, might help anything but the mildest symptoms, but at least they should do no harm. In contrast, neck exercises, may exacerbate symptoms in some individuals. Some hyperextension exercises would appear to be rather dangerous. Agreed, we need to know who will benefit from which intervention. Whilst this is being elucidated, there is a more pressing need to alert both doctors and physiotherapists to the potential adverse effects of common interventions.
Competing interests: None declared
Competing interests: No competing interests
EDITOR-Harvey and Cooper make a most important statement when they say “We need to know who will benefit from which intervention”. This was the subtitle to their editorial on the topic of treatment of back pain (1). This certainly needs to be emphasised as studies of unselected or unstratified groups of back or neck pain patients invariably leads to little or no useful discovery. However past attempts to tease out such distinctions failed to help and so some sought psychosocial explanations as to why the outcome could be so variable.
Some tried to select using basic discriminators such as age, sex, mode of onset, or duration of pain. Some thought cruralgia or sciatica would distinguish cases, and yet again some thought pain exacerbated by lumbar (or cervical) spine extension would yield the posterior column component envisaged as the elusive facet joint syndrome. Others tried to find structure in their clinical data but again did not select the right questions. The rest have failed to recognise the challenge or simply given up! Finally the sceptics truly believe the presentation of common low back pain to be indivisible.
But if there are different patterns, researchers need to incorporate the required detail into their studies from the outset. Afterwards is too late. Work that offers suggestions is linked to a series of articles including one on the leg twist test” (2) which has already helped to recognise those who respond to traction therapy. It is even claimed that the facet joint syndrome can be recognised if bending or twisting to one side exacerbates pain on the opposite side. Analysis of variance has ranked a useful selection of such clinical variables for consideration, and at the same time shows which of the seemingly plausible options that experts have recommended in the past would be poor bets. With such prior knowledge the chances of making real progress with therapeutic trials would hopefully be considerably enhanced.
Brian Sweetman consultant rheumatologist
Department of Rheumatology, Morriston Hospital, Swansea SA6 6NL
Competing interests: None
declared.
1. Harvey N, Cooper C. Physiotherapy for neck and back pain. BMJ 2005;330:53-4. (08 January).
2. Sweetman BJ. Low back pain and
the leg twist test. J Orthop Med 1998;20:3-9.
Competing interests: None declared
Competing interests: No competing interests
Re: A personal view on what the authors refer to as the "quagmire that is the management of spinal pain"
You may find the below information helpful.
http://www.macpweb.org/home/index.php?&textOnly=off
The Manipulation Association of Chartered Physiotherapists (MACP) is a group of over 1000 physiotherapists, who are members of the Chartered Society of Physiotherapy.
In addition to their undergraduate training they have all undertaken extensive postgraduate study and reached a recognised standard of excellence in neuromusculoskeletal physiotherapy. Their knowledge and practical skills ensures that all MACP Physiotherapists are able to provide an excellent standard of care in examination, treatment and management for people with neuromusculoskeletal problems.
In the UK the MACP is recognised as the specialist manipulative therapy group by the International Federation of Orthopaedic Manual Therapists (IFOMT). To obtain membership of the MACP clinicians have to complete a recognised postgraduate course of study, many of which are at a Master of Science level. The association has over 800 full members (members who have passed a stringent examination process) and almost 200 associate members (members undertaking post-graduate education leading to membership).
Competing interests: Student member of MACP
Competing interests: No competing interests