Managing low back pain
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7555.0-a (Published 15 June 2006) Cite this as: BMJ 2006;332:0-aAll rapid responses
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I would like to comment on the Clinical Review – Diagnosis and
treatment of low back pain by Koes, van Tulder and Thomas (BMJ;332: 1430-
1434).
I am in total agreement with their statement that “much research is
focused on detecting relevant sub-groups of patients with low back pain
with a different prognosis and susceptibility to specific treatments”.
However they fail to acknowledge the research that has been done on
the prognostic value of centralisation. In a systematic review of
centralisation published in 2004 (Aina et al) (1) six studies were
described that had investigated the prognostic value of centralisation
(4,6,7,9,10,11) The conclusion of this review was that centralisation was
consistently associated with better outcomes and that non-centralization
was an important predictor of poor outcomes. Since this review a further
study (George et al 2005) (5) has demonstrated that centralisation was a
significant predictor of both pain and disability at 6 months post
treatment whereas fear avoidance only predicted disability.
The authors do describe the identification of subgroups of patients
who are amenable to specific treatments as “promising developments”. They
acknowledge studies by Brennan et al (2) and Childs et al (3) both of
which demonstrate better outcomes when patients were provided with
treatment that matched their classification than when unmatched treatment
was provided. Again however they fail to acknowledge a key study, which
supports the importance of sub-classification of patients before
treatment. A important RCT (Long et al) (8) published in the same year as
the Childs et al study,(3) demonstrated significantly better outcomes in
patients who were treated with exercises appropriate for their
classification based on directional preference than those patients who
were treated with the exercise that was considered opposite to their
directional preference.
It seems inappropriate in a clinical review, which seeks to provide a
summary of the current evidence for the diagnosis and treatment of low
back pain that such key evidence is overlooked
Helen Clare, PhD
References
1. Aina A, May S, Clare H. The centralization phenomenon of spinal
symptoms – a systematic review. Manual Therapy 2004; 9:134-143
2. Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of
patients with acute/subacute “nonspecific” low back pain. Results of a
randomized clinical trial. Spine 2006;31:623-31.
3. Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to
identify patients with low back pain most likely to benefit from spinal
manipulation: a validation study. Annals of Internal Medicine 2004;141:920
-8.
4. Donelson R, Silva G, Murphy K. The centralization phenomenon: its
usefulness in evaluating and treating referred pain. Spine 1990;15:211-13.
5. George SZ, Bialosky JE, Donald DA. The centralization phenomenon
and fear-avoidance beliefs as prognostic factors for acute low back pain:
a preliminary investigation involving patients classified for specific
exercise. J Orthopaedics Sports Physical Therapy 2005;35:580-588.
6. Karas R, McIntosh G, Hall H, et al. The relationship between non-
organic signs and centralization of symptoms in the prediction of return
to work for patients with low back pain. Physical Therapy 1997;77:354-60.
7. Long A. The centralization phenomenon: its usefulness as a
predictor of outcome in conservative treatment of chronic low back pain.
Spine 1995;20:2513-21.
8. Long A, Donelson R, Fung T. Does it matter which exercise? A
randomized controlled trial of exercise for low back pain. Spine
2004;29:2593-602.
9. Sufka A, Hauger B, Trenary M, et al. Centralization of low back
pain and perceived functional outcome. Journal of Orthopaedics and Sports
Physical Therapy 1998;27:205-12.
10. Werneke M, Hart DL. Centralization phenomenon as a prognostic
factor for chronic low back pain and disability. Spine 2001;26:758-65.
11. Werneke M, Hart DL, Cook D. A descriptive study of the
centralization phenomenon. A prospective analysis. Spine 1999;24:676-83.
Competing interests:
None declared
Competing interests: No competing interests
The Editor,
I would like to comment on the Clinical Review entitled “Diagnosis
and Treatment of Low Back Pain” by Koes and van Tulder (BMJ 2006;332; 1430
-1434).
These authors provide an overview of the current evidence relating to
the diagnosis and treatment of low back pain. While there is nothing new
in their paper to excite the average clinician, the authors continue to
state that there is strong evidence that specific exercises have no
benefit. To their credit they make the point that promising developments
suggest that “identifying subgroups of patients more amenable to specific
treatments,” is an important step forward. Indeed the International Forum
on Low Back Pain in 19981 emphasised that identification of subgroups is
seminal to better management of non-specific low back pain. Despite this
recommendation however, little has been done since that time to identify
systems that have that potential. The authors cite two studies, Brennan
et al 2 and Childs et al3 that demonstrate superior outcomes following
treatment matched to suit the patient’s symptomatic responses. Indeed,
the two studies cited contain the key element of centralisation as
described by McKenzie in 1981.13
The authors, for some reason, have chosen to ignore the much earlier
system of classification commonly referred to as Mechanical Diagnosis and
Therapy13 now in widespread use in over 35 countries. This simple,
inexpensive and low-tech clinical assessment procedure consists of
repeatedly moving the patient to lumbar end-range in loaded and unloaded
positions and recording the resultant patterns of symptomatic responses.
Directions of movement (usually extension) that cause symptoms to cease,
reduce in intensity or change location towards the mid line
(centralisation) are described as the patient’s mechanically determined
directional preference. This enables an immediate (in some cases only a
few minutes) and reliable determination of appropriate specific exercise
and posture for each individual. Conversely, such patients, when moved in
the opposite direction (usually flexion), will experience symptoms that
appear, increase in intensity, or peripheralise.
Studies have shown that clinically induced centralisation of pain
based on patient’s directional preference is a reliable predictor of
favourable outcome.5,6,11,12 Conversely, failure to achieve
centralisation is now known to be indicative of poor outcome.16,17
Exercises specific to the patients’ directional preference can easily and
commonly be identified. Koes and van Tulder continue to ignore this
evidence for classification by symptomatic response.
The findings of this assessment and the assignment of patients to
their matching classification have demonstrated in multiple studies to
have interexaminer reliability if the exam in conducted by properly
trained clinicians.4,9,14 And in various ways, numerous cohort
studies7,8,10,15-17 and one randomized clinical trial11 all demonstrate
that specific exercises matched to the patients’ directional preference
provide superior outcomes and consistently identify subgroups.
A key randomized clinical trial demonstrated that a significant
majority of patients improved when assigned the specific direction of
exercise that matched their directional preference, whereas a majority of
those who exercised in a direction opposite to their directional
preference were either unimproved or were even worse. 11
With all this evidence published in the spinal research mainstream,
it is difficult to understand how Koes and van Tulder continue to argue
that specific back exercises are of no benefit.
It is disappointing that twenty-five years after the first
publication of the classification system that bears my name,13 the
significance of centralisation and directional preference continues to be
lost, misunderstood, or misapplied by those responsible for guiding the
care and management of patients with low back pain as well as by those
involved in back pain research.
Robin McKenzie, CNZM, OBE, FNZSP (Hon), FCSP (Hon).
Raumati Beach
New Zealand.
References
1. Borkan J, Koes B, Reis S, et al. A report from the second
international forum for primary care research on low back pain:
reexamining priorities. Spine 1998;23:1992-6.
2. Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of patients
with acute/subacute “nonspecific” low back pain. Results of a randomized
clinical trial. Spine 2006;31:623-31.
3. Childs J, Fritz J, Flynn T, et al. A clinical prediction rule to
identify patients with low back pain most likely to benefit from spinal
manipulation: a validation study. Annals of Internal Medicine 2004;141:920
-8.
4. Clare H, Adams R, Maher C. Reliability of the McKenzie spinal pain
classification using patient assessment forms. Physiotherapy 2004;90:114-
9.
5. Clare H, Adams R, Maher C. A systematic review of efficacy of McKenzie
therapy for spinal pain. Australian Journal of Physiotherapy 2004;50:209-
16.
6. Cook C, Hegedus E, Ramey K. Physical therapy exercise intervention
based on classification using the patent response method: a systematic
review of the literature. JMPT 2005;13:152-62.
7. Donelson R, Silva G, Murphy K. The centralization phenomenon: its
usefulness in evaluating and treating referred pain. Spine 1990;15:211-13.
8. Karas R, McIntosh G, Hall H, et al. The relationship between non-
organic signs and centralization of symptoms in the prediction of return
to work for patients with low back pain. Physical Therapy 1997;77:354-60.
9. Kilpikoski S, Airaksinen O, Kankaanpää M, et al. Interexaminer
reliability in low back pain assessment using the McKenzie method. Spine
2002;27:E207-14.
10. Long A. The centralization phenomenon: its usefulness as a predictor
of outcome in conservative treatment of chronic low back pain. Spine
1995;20:2513-21.
11. Long A, Donelson R, Fung T. Does it matter which exercise? A
randomized controlled trial of exercise for low back pain. Spine
2004;29:2593-602.
12. Machado L, de Souza M, Ferreira P, et al. The McKenzie Method for Low
Back Pain: A Systematic Review of the Literature With a Meta-Analysis
Approach. Spine 2006;31:E254-62.
13. McKenzie R. The lumbar spine: mechanical diagnosis and therapyed.
Waikanae, New Zealand: Spinal Publications, 1981.
14. Razmjou H, Kramer J, Yamada R. Inter-tester reliability of the
McKenzie evaluation of mechanical low back pain. Journal of Orthopedic
& Sports Physical Therapy 2000;30:368-83.
15. Sufka A, Hauger B, Trenary M, et al. Centralization of low back pain
and perceived functional outcome. Journal of Orthopedics and Sports
Physical Therapy 1998;27:205-12.
16. Werneke M, Hart DL. Centralization phenomenon as a prognostic factor
for chronic low back pain and disability. Spine 2001;26:758-65.
17. Werneke M, Hart DL, Cook D. A descriptive study of the centralization
phenomenon. A prospective analysis. Spine 1999;24:676-83.
Competing interests:
None declared
Competing interests: No competing interests
I would like to respond to the recent clinical review article by
Koes, van Tulder, and Thomas that addressed the diagnosis and treatment of
low back pain (Koes B, van Tulder M, Thomas S. Clinical review: diagnosis
and treatment of low back pain. British Medical Journal 2006; 332:1430-4).
Their statement that “at present no reliable and valid classification
system exists for most cases of non-specific low back pain” is quite
problematic. While compatible with the position taken by most clinical
guidelines, this position nevertheless continues to ignore the growing
list of studies that strongly establish the interexaminer reliability of
identifying the clinical findings of the centralization pain response and
directional preference, that single direction of repeated end-range lumbar
bending that centralizes and/or abolishes so many patients’
pain.2,8,11,12,16,18,22,24 The presence or absence of these two findings
enable classification of patients into distinct pain response subgroups
that are at the heart of the Mechanical Diagnosis and Therapy (MDT)
paradigm, better known to many as the McKenzie methods of low back care.15
Overlooked as well is a second lengthy list of studies providing
substantial preliminary validation of these same two clinical findings and
subgroups as predictors of good and excellent outcomes, especially when
centralizers are treated with exercises and posture strategies that match
patients’ directional preference.3,6,10,13,17,19,21,22
Most important are two randomized clinical trials that further
validate centralization and directional preference.1,14 Long et al
reported that 74% of those presenting with acute, subacute and chronic
back pain were found during their baseline assessment to have a
directional preference.14 Only this large subgroup was then randomized.
Ninety-five percent of those assigned to exercises that directionally
matched their directional preference improved or fully recovered in just
two weeks, with no one worsening or withdrawing. This is in remarkable
contrast to the outcomes of those subjects (also with a baseline
directional preference) randomized to guideline-consistent care (assurance
of recovery and advice to remain active) and non-specific exercises. Only
42% of this latter group improved or recovered, 15% actually worsened, and
33% withdrew early due to little or no improvement. It was the ethics
committee that limited the study to only two weeks based on their insight
and concern about treating patients with exercises that did not match
their directional preference. Even they understood the validity of
directional preference in treatment selection.
How comprehensive is this classification? A large number of studies
report that most non-specific low back pain can be centralized and
abolished using directional exercises (70-87% in acutes and up to 50% in
chronics).3,5-7,10,13,14,17,19,21-23. The alternative and much smaller
non-centralizing subgroup also has good evidence that non-centralization
strongly predicts poor or non-recovery, apparently even more so than
psychosocial factors when these two predictors have been compared head-to-
head.21 This MDT classification is indeed quite comprehensive.
So the statement that “no reliable and valid classification system
exists for most cases of non-specific low back pain” resembles a consensus
view rather than an evidence-based statement. This is quite disappointing
coming from prominent guideline and systematic review experts whose
familiarity with the low back literature would be expected to be far
greater than this.
These authors also repeat another familiar guideline conclusion that
there is “strong evidence that specific back exercises are not effective,”
perpetuating the conclusions of van Tulder et al’s 2000 systematic review
of exercise.20 I wrote a similar letter-to-the-editor at that time for
which there was no response from the authors.4 Persisting with this same
view disregards the findings of the Brennan et al, and especially the Long
et al randomized clinical trials. Both report that specific exercises,
when matched to patients’ baseline subgrouping, bring superior, perhaps
far superior, treatment outcomes.1,14
Despite these many oversights, it is encouraging that Koes et al at
least recognized the Brennan et al study1 as a “promising development”
that documents the value of matching treatment selections to validated
subgroups determined by examining and classifying patients at baseline.
It seems that Koes et al are unaware that, not only does this study
directly contradict their position that specific exercises are not
effective, but members of the “specific exercise” subgroup in this
classification system are solely determined by patients’ baseline clinical
findings of centralization and directional preference.
Finally, nearly all clinical guidelines, as well as this article by
Koes et al, perpetuate the perceived importance of psychosocial factors as
obstacles to recovery despite acknowledging the absence of any evidence
that addressing these factors improves outcomes. Reviewing one such
negative study at some length9 seemed odd in light of the authors’ failure
to recognize so many positive reliability, prognostic, and randomized
clinical trials targeting centralization and directional preference.
So the fundamental question becomes whether this clinical review
article, and most low back pain clinical guidelines for that matter, are
as evidence-based as their authors portray them to be. Consensus-based
recommendations can be helpful in the absence of evidence, however they
become quite problematic, even misleading, when the consensus ignores
existing relevant evidence.
I apologize for my lengthy list of references yet, given the topic,
this seems justified and will hopefully be helpful to readers.
Ron Donelson, MD, MS
References
1. Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of
patients with acute/subacute “nonspecific” low back pain. Results of a
randomized clinical trial. Spine 2006;31:623-31.
2. Clare H, Adams R, Maher C. Reliability of the McKenzie spinal
pain classification using patient assessment forms. Physiotherapy
2004;90:114-9.
3. Delitto A, Cibulka M, Erhard R, et al. Evidence for an extension-
mobilization category in acute low back syndrome: a prescriptive
validation pilot study. Physical Therapy 1993;73:216-28.
4. Donelson R. Letter to the editor. Spine 2001;26:1827-9.
5. Donelson R, Aprill C, Medcalf R, et al. A prospective study of
centralization of lumbar and referred pain: A predictor of symptomatic
discs and anular competence. Spine 1997;22:1115-22.
6. Donelson R, Silva G, Murphy K. The centralization phenomenon: its
usefulness in evaluating and treating referred pain. Spine 1990;15:211-13.
7. Erhard R, Delitto A, Cibulka M. Relative effectiveness of an
extension program and a combined program of manipulation and flexion and
extension exercises in patients with acute low back syndrome. Physical
Therapy 1994;74:1093-100.
8. Fritz J, Delitto A, Vignovic M, et al. Interrater reliability of
judgments of the centralization phenomenon and status change during
movement testing in patients with low back pain. Archives of Physical
Medicine and Rehabilitation 2000;81:57-61.
9. Jellema P, van der Windt D, van der Horst H, et al. Should
treatment of (sub)acute low back pain be aimed at psychosocial prognostic
factors? Cluster-randomised clinical trial in general practice. British
Medical Journal 2005;331:84-90.
10. Karas R, McIntosh G, Hall H, et al. The relationship between non
-organic signs and centralization of symptoms in the prediction of return
to work for patients with low back pain. Physical Therapy 1997;77:354-60.
11. Kilby J, Stigant M, Roberts A. The reliability of back pain
assessment by physiotherapists, using a "McKenzie algorithm".
Physiotherapy 1990;76:579-83.
12. Kilpikoski S, Airaksinen O, Kankaanpää M, et al. Interexaminer
reliability in low back pain assessment using the McKenzie method. Spine
2002;27:E207-14.
13. Long A. The centralization phenomenon: its usefulness as a
predictor of outcome in conservative treatment of chronic low back pain.
Spine 1995;20:2513-21.
14. Long A, Donelson R, Fung T. Does it matter which exercise? A
randomized controlled trial of exercise for low back pain. Spine
2004;29:2593-602.
15. McKenzie R, May S. Mechanical Diagnosis and Therapy. Second ed.
Waikanae, New Zealand: Spinal Publications New Zealand Ltd., 2003.
16. Razmjou H, Kramer J, Yamada R. Inter-tester reliability of the
McKenzie evaluation of mechanical low back pain. Journal of Orthopedic
& Sports Physical Therapy 2000;30:368-83.
17. Skytte L, May S, Petersen P. Centralization - its prognostic
value in patients with referred symptoms and sciatica. Spine 2005;30:E(293
-9).
18. Spratt K, Lehrmann T, Weinstein J, et al. A new approach to the
low back physical examination: behavioral assessment of mechanical signs.
Spine 1990;15:96-102.
19. Sufka A, Hauger B, Trenary M, et al. Centralization of low back
pain and perceived functional outcome. Journal of Orthopedics and Sports
Physical Therapy 1998;27:205-12.
20. van Tulder M, Malmivaara A, Esmail R, et al. Exercise therapy
for low back pain. Spine 2000;25:2784-96.
21. Werneke M, Hart DL. Centralization phenomenon as a prognostic
factor for chronic low back pain and disability. Spine 2001;26:758-65.
22. Werneke M, Hart DL, Cook D. A descriptive study of the
centralization phenomenon. A prospective analysis. Spine 1999;24:676-83.
23. Williams M, Hawley J, McKenzie R, et al. A comparison of the
effects of two sitting postures on back and referred pain. Spine
1991;16:1185-91.
24. Wilson L, Hall H, McIntosh G, et al. Intertester reliability of
a low back pain classification system. Spine 1999;24:248-54.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir 23.06.06
Koes, van Tulder, and Thomas(1) present an interesting review of
lower back pain. However, they emphasise multidisciplinary care only in
the context of conservative care.
There is a clear agenda in UK healthcare to emphasise primary care
management for common conditions such as back pain. This is partly at
least to try and control costs of investigation and intervention
associated with secondary or tertiary referral. However, with respect to
lower back pain, sciatica and spinal claudication, this has often resulted
in an overly jaded presentation of the possible benefits of spinal surgery
– sometimes based on an unrealistic presentation to patients of outcomes
and complication rates of spinal surgery by primary care health
professionals who have had little training in the assessment and treatment
of musculoskeletal disease, and may have no ongoing access to MRI or links
to spinal surgery services.
The authors go some way to reinforce that misconception by a flawed
statement on spinal stenosis surgery. There is clear evidence from well
constructed randomised controlled and prospective observational studies
that in spinal stenosis, decompressive surgery can confer safe, rapid and
early symptomatic relief for patients suffering from sciatic and
claudicant symptoms(2,3). The authors may have wished to imply that
decompressive surgery is not helpful for lower back pain – a statement
that the spinal surgery fraternity would generally support – but they do
not make this clear, and dismiss surgery, proven to be often helpful, in a
single sentence.
The important principle in the management of patients with lower back
pain and leg pain is that although spinal surgery probably only has
something to offer to 8-10% of patients, that is a small percentage of a
very large number of patients – and it means that primary care
organisations must ensure competent and close collaboration with a spinal
surgery service if they are to offer their patients a truly
multidisciplinary approach.
Yours faithfully,
Mr Paul L P J Thorpe MB ChB FRCSEd(Orth)
Consultant Spinal Surgeon
Somerset Spinal Surgery Service
Level 1 Queens Building
Musgrove Park Hospital
Taunton TA1 5DA
1. Koes BS, van Tulder MW, Thomas S, Diagnosis & treatment of low
back pain BMJ 2006;332:1430-4
2. Amundsen T, Weber H et al, Lumbar Spinal Stenosis: Conservative or
Surgical Management – a prospective 10 year study Spine 2000;25(11):1424-
1436
3. Long-term outcomes of surgical & nonsurgical management of Lumbar
Spinal Stenosis: 8-10 year results from the Maine Lumbar Spine Study Spine
2005;30(8):936-943
Competing interests:
None declared
Competing interests: No competing interests
Clinicians' frustration
To the Editor
Koes, van Tulder and Thomas presented the Clinical Review – Diagnosis
and treatment of low back pain (BMJ, 332, 1430-4) however some recent
evidence is not included which may have altered some of their concluding
remarks and influenced future back pain guidelines.
The statement that “at present no reliable and valid classification
system exists for most cases of non-specific low back pain” is of concern.
Two recent papers have provided evidence of reliability of Mechanical
Diagnosis and Therapy (MDT) for classifying patients with so-called non-
specific low back pain (1, 2). This system uses the symptomatic and
mechanical responses to repeated end range lumbar movements &/or static
postures to classify patients into clinically separate and meaningful
subgroups that helps to guide their management. Treatment is predicated on
these responses and emphasises self-care.
A key component of this assessment is the centralisation phenomenon
(3). A systematic review of high quality studies of centralisation (4)
concluded that the presence of centralisation was consistently associated
with better clinical outcomes, and non-centralisation was an important
predictor of poor outcomes. Centralisation is a useful and reliable
clinical tool to classify those patients requiring directional specific
exercises and postures. A recently published randomised clinical trial
(5), referred to by Koes et al, using principles of MDT showed superior
outcomes when subjects in the specific exercise group exercised according
to their matched treatment (directional preference) compared with an
unmatched treatment (opposite direction). An earlier study, which was not
reviewed by Koes et al, also showed superior outcomes in the directional
matched group when compared to the unmatched exercise group and the group
randomised to usual (current guideline based) care (6).
Had Koes et al included additional evidence in their review they may
not have concluded that there is “strong evidence that specific back
exercises are not effective.” An alternative conclusion was made by the
Danish back pain guidelines in 1999 (7). If reliable and clinically useful
tools are not recognised by reviews and guidelines why should we be
surprised that clinicians do not implement the recommendations in the
clinical environment?
1. Clare H, Adams R, Maher C. Reliability of the McKenzie spinal pain
classification using patient assessment forms. Physiotherapy 2004;90:114-
9.
2. Kilpikoski S, Airaksinen O, Kankaanpää M, et al. Interexaminer
reliability in low back pain assessment using the McKenzie method. Spine
2002;27:E207-14.
3. McKenzie R, May S. The Lumbar Spine. Mechanical Diagnosis and Therapy.
Second ed. Waikanae, New Zealand: Spinal Publications New Zealand Ltd.,
2003.
4. Aina A, May S, Clare H. The centralization phenomenon of spinal
symptoms – a systematic review. Manual Therapy 2004; 9:134-143
5. Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of
patients with acute/subacute “nonspecific” low back pain. Results of a
randomized clinical trial. Spine 2006;31:623-31.
6. Long A, Donelson R, Fung T. Does it matter which exercise? A
randomized controlled trial of exercise for low back pain. Spine
2004;29:2593-602.
7. Danish Institute for Health Technology Assessment; Low-back pain.
Frequency, management and prevention from an HTA perspective. Danish
Health Technology Assessment; 1-106, 1999.
Competing interests:
None declared
Competing interests: No competing interests