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Back pain—Knowing is half the battle
Physiotherapy 90 (2004) 173
Editorial
Back pain—knowing is half the battle
A decade on from the study by Meade et al [1] the profession again finds itself at the centre of a controversy on the management of back pain. The flurry of rapid responses in the BMJ and media coverage following publication of Frost et al’s paper [2] illustrates the interest and heated debate surrounding the management of back pain. The paper compares the effect of two interventions provided by physiotherapists and concludes that there is little difference between the outcomes for the two groups. Sadly, the results have been misinterpreted by many as a lack of evidence of efficacy in the physiotherapeutic management of back pain. The confusion highlights the importance of avoiding the generic term “physiotherapy” to describe a doctrine of treatment, a specific technique or group of techniques. To draw a parallel, if a course of medication given by a general practitioner was found to be no more effective than advice and reassurance by the same, one would not conclude that the GP had no place in that area of medicine. Comparative and controlled studies will always expose those who are stakeholders in the technique or approach under consideration, to a degree of vulnerability. However, this is no reason for failing to test tried and trusted approaches. The increasing willingness to question our understanding suggests maturation within the profession. What is then important is interpretation and generation of novel theories and ways of thinking that this new knowledge stimulates. Anyone familiar with the nature and body of literature on back pain would admit that there is uncertainty in its treatment and management. Yet, ironically, some stakeholders have sought to benefit from the findings of this study. One rapid response hosted on the BMJ website stated “It has been proven beyond any reasonable doubt that chiropractic is the treatment of choice for low back pain [3].” Aside from the controversial nature of this statement, it again falls foul of the generic use of the name of a profession to represent a group of techniques. Surely the techniques are used in various forms by the spectrum of manual therapists? There is much mutual benefit to be gained from the sharing of knowledge between professions in a symbiotic fashion. The results of Frost et al’s work provide a stimulus to all manual therapists (be they Physiotherapists, Osteopaths, Chiropractors or Orthopaedic Physicians) to unpack the black box of interventions, looking further at the basic science of how these techniques and other confounding variables, influence back pain. It is also crucial to determine which patients benefit from which forms of treatment, which show no benefit and which recover in a timely fashion without intervention. It is easy to identify the main limitations of any study, particularly those of a pragmatic nature. However, the question must be ’ in light of these limitations, what can be learnt from the results’ In the work reported by Frost et al [2], the authors clearly recognise the limitations of their study, thus the reader can draw their own conclusions within the framework of pragmatism. No pragmatic trial can hope to attain the scientific purity of the laboratory-based model. However, as a picture of real life, the results
are believable. This study stimulates more questions for future work than the multitude of underpowered studies, of questionable methodological rigor, which claim treatment success on the back of marginal or small effect sizes undertaken by many professions involved in the management of back pain. Despite an increase in the number of manual therapists of all professions and ever increasing resources directed towards the management of back pain, although the incidence of back pain remains relatively constant, disability due to back pain continues to rise. Add this to evidence from the recent Cochrane reviews [4,5,6] and it suggests that a radical change in approach to the management of many sub-groups of patients with low back pain may be required. Frost et al’s [2] study should be acknowledged for what it’s worth, recognising, as with all research, its strengths as well as its limitations, providing a stepping stone for what are the next questions to be addressed. These issues will be debated in the next issue of Physiotherapy where further commentaries have been invited.
References [1] Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. BMJ Aug 1995;311:349–51. [2] Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ Sep 2004;329:708–80. [3] Nehrlich, H., Ooooops, is most treatment unnecessary intervention? Rapid Responses: 25th September 2004. http://bmj. bmjjournals.com/cgi/eletters/329/7468/708 [4] Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. [5] van Tulder MW, Ostelo RWJG, Vlaeyen JWS, Linton SJ, Morley SJ, Assendelft WJJ. Behavioural treatment for chronic low-back pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. [6] Schonstein E, Kenny DT, Keating J, Koes BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain (Cochrane Review). In: The Cochrane Library,Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Michele Harms The Chartered Society of Physiotherapy London WCIR 4ED, UK Tel.: +44-207-306-6156 E-mail address: [email protected]
0031-9406/$ – see front matter © 2004 Published by Elsevier Ltd on behalf of Charted Society of Physiotherapy. doi:10.1016/S0031-9406(04)00170-1
Editorial
Back pain—knowing is half the battle
A decade on from the study by Meade et al [1] the profession again finds itself at the centre of a controversy on the management of back pain. The flurry of rapid responses in the BMJ and media coverage following publication of Frost et al’s paper [2] illustrates the interest and heated debate surrounding the management of back pain. The paper compares the effect of two interventions provided by physiotherapists and concludes that there is little difference between the outcomes for the two groups. Sadly, the results have been misinterpreted by many as a lack of evidence of efficacy in the physiotherapeutic management of back pain. The confusion highlights the importance of avoiding the generic term “physiotherapy” to describe a doctrine of treatment, a specific technique or group of techniques. To draw a parallel, if a course of medication given by a general practitioner was found to be no more effective than advice and reassurance by the same, one would not conclude that the GP had no place in that area of medicine. Comparative and controlled studies will always expose those who are stakeholders in the technique or approach under consideration, to a degree of vulnerability. However, this is no reason for failing to test tried and trusted approaches. The increasing willingness to question our understanding suggests maturation within the profession. What is then important is interpretation and generation of novel theories and ways of thinking that this new knowledge stimulates. Anyone familiar with the nature and body of literature on back pain would admit that there is uncertainty in its treatment and management. Yet, ironically, some stakeholders have sought to benefit from the findings of this study. One rapid response hosted on the BMJ website stated “It has been proven beyond any reasonable doubt that chiropractic is the treatment of choice for low back pain [3].” Aside from the controversial nature of this statement, it again falls foul of the generic use of the name of a profession to represent a group of techniques. Surely the techniques are used in various forms by the spectrum of manual therapists? There is much mutual benefit to be gained from the sharing of knowledge between professions in a symbiotic fashion. The results of Frost et al’s work provide a stimulus to all manual therapists (be they Physiotherapists, Osteopaths, Chiropractors or Orthopaedic Physicians) to unpack the black box of interventions, looking further at the basic science of how these techniques and other confounding variables, influence back pain. It is also crucial to determine which patients benefit from which forms of treatment, which show no benefit and which recover in a timely fashion without intervention. It is easy to identify the main limitations of any study, particularly those of a pragmatic nature. However, the question must be ’ in light of these limitations, what can be learnt from the results’ In the work reported by Frost et al [2], the authors clearly recognise the limitations of their study, thus the reader can draw their own conclusions within the framework of pragmatism. No pragmatic trial can hope to attain the scientific purity of the laboratory-based model. However, as a picture of real life, the results
are believable. This study stimulates more questions for future work than the multitude of underpowered studies, of questionable methodological rigor, which claim treatment success on the back of marginal or small effect sizes undertaken by many professions involved in the management of back pain. Despite an increase in the number of manual therapists of all professions and ever increasing resources directed towards the management of back pain, although the incidence of back pain remains relatively constant, disability due to back pain continues to rise. Add this to evidence from the recent Cochrane reviews [4,5,6] and it suggests that a radical change in approach to the management of many sub-groups of patients with low back pain may be required. Frost et al’s [2] study should be acknowledged for what it’s worth, recognising, as with all research, its strengths as well as its limitations, providing a stepping stone for what are the next questions to be addressed. These issues will be debated in the next issue of Physiotherapy where further commentaries have been invited.
References [1] Meade TW, Dyer S, Browne W, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. BMJ Aug 1995;311:349–51. [2] Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ Sep 2004;329:708–80. [3] Nehrlich, H., Ooooops, is most treatment unnecessary intervention? Rapid Responses: 25th September 2004. http://bmj. bmjjournals.com/cgi/eletters/329/7468/708 [4] Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. [5] van Tulder MW, Ostelo RWJG, Vlaeyen JWS, Linton SJ, Morley SJ, Assendelft WJJ. Behavioural treatment for chronic low-back pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd. [6] Schonstein E, Kenny DT, Keating J, Koes BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain (Cochrane Review). In: The Cochrane Library,Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Michele Harms The Chartered Society of Physiotherapy London WCIR 4ED, UK Tel.: +44-207-306-6156 E-mail address: [email protected]
0031-9406/$ – see front matter © 2004 Published by Elsevier Ltd on behalf of Charted Society of Physiotherapy. doi:10.1016/S0031-9406(04)00170-1