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Rapid Responses: Rapid Responses published:
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Modern acute back pain management
- Dr A Breck McKay (10 July 2008)
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Discrepancy between protocol and publication
- Lorna M Gibson (12 July 2008)
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Authors' reply
- Robert D Herbert, Nicholas Henschke, Christopher G. Maher, Kathryn M. Refshauge, Robert G. Cumming, Jane Bleasel, John York, Anurina Das, James H. McAuley (18 July 2008)
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Prognosis of low back pain: depends on the methods and also on conceptual and nosological approach
- Joel Coste, Jean-Baptiste Paolaggi, Académie Nationale de Médecine, Paris (18 July 2008)
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I Did Not Realise......
- GRAEME MACKENZIE (19 July 2008)
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Could Early Skeletal Fluorosis Account for This?
- Peter J Mansfield (21 July 2008)
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Low back pain: positive optimistic management required
- Richard M Whittington (23 July 2008)
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Dr A Breck McKay, Director Victoria Point, Brisbane, Australia
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Dear Editor, Henschke et al (1) do not appear to be aware of the modern approach to acute back pain (especially work related)as published by McGurk B, Bogduk N,(2)and also presented to the World Pain Congress in 2005. McGuirk B Bogduk N (3)have now published an article covering the simple exercises with explanations, used originally by Indahl A et al(4) and also promoted by McKenzie R (5)for all back pain management. I have used these in my primary care/physiotherapy and musculoskeletal practice very successfully for many years and our musculoskeletal group has reviewed the basic anatomy of the lumbar spine and recognised the importance of the Psoas/Erector-Multifidus muscles around the lumbar spine as the true core spinal muscles, (which are directly moderated by the mentioned exercises) and the activated sacro- coccygeal entheses. For moderate to chronic back pain we also use our modification of Blomberg's injection of localised entheses under paravertebral dorsal nerve root anaesthesia(6) When will primary care and others catch up with and use the proven successful methods of managing acute back pain,(and now moderate to chronic back pain), instead of rehashing older, but less useful methods for research? References: 1. Henschke et al, "Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study" BMJ 2008; 337: a171 2. McGuirk B, Bogduk N," Evidence-based care for low back pain in workers eligible for compensation." Occup Med (Lond). 2007 Jan;57(1):36- 42.) 3. McGuirk B, Bogduk N, "The "Indahl" exercises for low back pain" Australasian Musculoskeletal Medicine Journal13;1:8-14 May 2008 4. Indahl A, Velund L, Reikeraas "Good prognosis for low back pain when left untampered. a randomised clinical trial" Spine. 1995 Feb 15;20(4):473 -7) 5. McKenzie R "Treat your own back" 5th Edition Lower Hutt Spinal Publications 1997 pp42-52)B 6. McKay B, 'Cheese and Chalk? Missing the real anatomy 'Letters to the Editor Pain 137 (2008) 229-231. Competing interests: None declared |
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Lorna M Gibson, Medical Student University of Edinburgh
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Dear Editor, Discrepancies often exist between protocols and later publications, although this evidence mainly comes from studies of clinical trials and systematic reviews(1,2). Henschke et al. aimed to recruit 1000 patients with acute low back pain into their cohort study(3) but their final recruitment figure fell short of this at 969 patients(4). Although this is a small difference, Henschke et al. provided no information on why their target sample size was not reached when they were so close, or if falling short of their target by 31 patients had any effect on their results. Lorna Gibson. 1. Chan AW, Hróbjartsson A, Haahr MT et al. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. JAMA. 2004;291(20):2457-2465. 2. Silagy CA, Middleton P, Hopewell S. Publishing protocols of systematic reviews: comparing what was done to what was planned. JAMA. 2002;287(21):2831-2834. 3. Henschke N, Maher CG, Refshauge KM et al. Prognosis of acute low back pain: design of a prospective inception cohort study. BMC Musculoskelet Disord 2006, 7:54. 4. Henschke N, Maher CG, Refshauge KM et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008:337:a171 Competing interests: None declared |
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Robert D Herbert, Senior Research Fellow The George Institute for International Health, Camperdown NSW 2050, Australia, Nicholas Henschke, Christopher G. Maher, Kathryn M. Refshauge, Robert G. Cumming, Jane Bleasel, John York, Anurina Das, James H. McAuley
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Dr McKay is concerned that participants in our cohort study did not receive 'the modern approach to acute back pain as published by McGuirk B, Bogduk N'. He may find it re-assuring that Professor Bogduk was an executive author of the clinical practice guidelines that we asked participating clinicians to use(1). Lorna Gibson asks why there were discrepancies between the sample specified in the protocol (N = 1000)(2) and the paper (N = 973, of whom baseline data were available for 969)(3). The explanation is that we sampled patients with radiculopathy but, because we were interested in the prognosis of non-specific low back pain, we did not include those patients’ data in the analysis. References 1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence- Based Management of Acute Musculoskeletal Pain. Brisbane: Australian Academic Press, 2003. 2. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prognosis of acute low back pain: design of a prospective inception cohort study. BMC Musculoskeletal Disorders 2006;7:54 (Epub). 3. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prognosis of recent onset low back pain in primary care. BMJ 2008;337:a171. Competing interests: None declared |
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Joel Coste, Professor of Biostatistcs University Paris Descartes 75014 Paris France, Jean-Baptiste Paolaggi, Académie Nationale de Médecine, Paris
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Dear Editor, Henschke et al. [1] repeatedly compare the results of their study of “recent onset” low back pain (LBP) to those of our own study published in the Journal in 1994 [2] and apparently fail to explain the marked difference in the results in terms of delay before recovery. In our opinion, the different results are a consequence of the study methods, which were much more dissimilar than that acknowledged by Henschke et al., and also of conceptual and nosological approaches, which were even more dissimilar. Henschke et al. stated they conducted an “inception cohort” study, as we did both in 1991 [2] and also in 1999 [3]; however, it appears that they included subjects who had been suffering for up to two weeks, a delay which was associated with 90% recovery in our studies (we are thus very surprised that they found “a recovery rate virtually unchanged at two weeks” when considering the subset of subjects whose back pain lasts only for up to 3 days). It also appears that they only required a one-month symptom-free interval for including patients in the cohort (three months in our studies): this lax definition of “recent onset” LBP allows the inclusion of “relapsing- remitting” chronic LBP subjects and may therefore result in the observed prognosis being worse. It also appears that up to 20% of the subjects of their study presented with leg pain (although it was stated patients with radiculopathy were excluded). Obviously this subgroup of patients with mild sciatica or “borderline” LBP did have a worse outcome than the population as a whole. It also appears that 81% of patients were included by physiotherapists or chiropractors. These professionals may provide inadequate and worrying information about LBP and possibly even harmful therapeutic manoeuvres (and, at least, are much more “stigmatizing” than acetaminophen prescribed by GPs); this design is also open to huge selection biases as self- referral to physiotherapists or chiropractors indicates that the subjects are familiar with, and probably even have long-lasting experience of, LBP. We also note that practitioners were encouraged financially to discover “serious pathology”, which necessarily increased the burden of investigation, anxiety and thereby delayed recovery. These are major differences with respect to our studies regarding the selection of patients. Furthermore, it appears that recovery was defined using a question such as “how much LBP have you had during the past week” asked during the first follow-up interview which took place at 6 weeks (in our study we used a diary including standardized instruments which patients filled in prospectively). In the light of these differences, we disagree with the conclusion of Henschke et al. that “prognosis is not as favourable as claimed in patients with acute LBP in primary care” and we disapprove this rhetoric of fear constructed on results from a cohort of subjects accumulating bad prognosis factors, irrespective of whether it is motivated by laudable reasons (fund raising for research) or less laudable ones (defending corporative interests of “professionals of LBP”). We agree with Henschke et al. that “further studies are warranted”, but we believe further studies should make use of optimised methods and appropriately defined concepts. Indeed, it is remarkable that conceptual and nosological thinking has almost disappeared from current clinical research in LBP. Using a “black box” approach instead of refining current classifications [4] and thereby not distinguishing between established nosological entities such as back pain and sciatica (with quite different natural history and kinetics of recovery [5]) and concepts such as “recent onset” and “acute”, can only be detrimental both to medical science and the care of (millions of) patients with these conditions. J. Coste
J.B Paolaggi
References 1. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008 Jul 7;337:a171. 2. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Delecoeuillerie G, Paolaggi JB. Clinical course and prognostic factors of acute low-back pain. An inception cohort study in primary care practice. BMJ 1994; 308 : 577-580. 3. Coste J, Lefrancois G, Guillemin F, Pouchot J. Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study. Arthritis Rheum. 2004; 51: 168-76. 4. Coste J, Spira A, Ducimetière P, Paolaggi JB. Clinical and psychological diversity of non-specific low-back pain. A new approach towards the classification of clinical subgroups. J. Clin. Epidemiol 1991; 11 : 1233-45. 5. Paolaggi JB. Natural history of non specific neuralgias of the limbs. Exponential kinetics of the root pain recovery in sciatica and femoral neuralgia; uncertain kinetics for brachial neuralgia. Bull Acad Natl Med. 2003; 187: 1631-45. Competing interests: None declared |
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GRAEME MACKENZIE, GP OUT OF HOURS NORTH CUMBRIA
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That so many of us whingeing Poms had moved over there to the point of affecting medical research. Competing interests: None declared |
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Peter J Mansfield, Aviation Medical Examiner 21 Brewers Wharf, Newark on Trent NG24 1ET
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Recent data from the British National Diet and Nutrition Survey of adults 2000 shows that in the UK some 20-25% of the population receive more fluoride daily than the safe intake defined in 1996 by The Committee on Medical Aspects of Food Policy. Since in this survey only 5.5% of the population receive water fluoridated at 1 part per million, the majority of fluoride is now derived from food and cosmetics - most notably fluoridated toothpaste. We now know that in Britain fluoride consumption extends to well above 10mg/day in the highest consumers, most of whom have little fluoride in their water supply. This is quite sufficient, according to authorities such as Roholm and Hodge, to produce skeletal fluorosis within 10-20 years of regular exposure at that level. I understand that most water in Australia is fluoridated, and has been for some decades. Given a similar pattern of use of food and cosmetics but higher water consumption and less tea, British data suggests most Australians are now receiving above 5mg fluoride per day with 1% or more consuming twice that. Sooner or later a proportion will begin to experience the early stages of skeletal fluorosis, which is not discernible on radiography. The symptoms include vague skeletal aches and pains and joint stiffness. These will not disperse without drastic reduction of fluoride consumption. The index of clinical suspicion regarding fluorosis seems to be zero everywhere but South and East Asia. Perhaps it is time to change that. Competing interests: Independent reviewer of National Diet and Nurtitional Survey 2000 fluoride data |
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Richard M Whittington, retired general practitioner 3, Moreton Road, Oxford OX27AX
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I am surprised at the pessimistic findings of this review of recent onset low back pain. A positive immediate management outlook, in my experience, produced much better results. Thus if there was evidence of nerve root involvement, after careful assessment, manipulation often produced dramatic and almost immediate relief. If the pain appeared to be muscular, extensive elastplast strapping - after eliminating the possibility of allergy to elastoplast - provided the necessary temporary support to obtain pain relief in a few days and prevention of chronic symptoms. Simple analgaesia might be prescribed if required. Follow up in a few days would be used to advise on suitable work practices to protect the back, together with simple exercises, particularly directed at strengthening the erector spinae muscles. What seemed important was to convey to the patient an optimistic outlook, without any expectation of long term symptoms and unemployment, together with advice and measures that could be taken to prevent recurrence. Competing interests: None declared |
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