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  1. Different types of low back pain consequences confound the guidelines

    Brian Sweetman, NHS

    8 May 2013

    Premature return to the work place may risk aggravation or reprecipitation of the underlying back pain problem. Surely it would be best to fix the back or work place first. But that is easier said than done and gauging recovery of the back is difficult. In their study Hendrick et al (1) question current wisdom. They reveal many incongruities between measures of impairment, disability and handicap, which help explain why guidelines on back care may well be flawed.
    Why is evidence lacking or so contrary? There are perhaps three main types of reason (2). Firstly, a patient may be asked one question, but inadvertently answers another. The visual analogue pain scale is a good example. It measures different things in different circumstances. At initial interview it describes whether pain is getting worse in preference to describing actual severity of pin. At follow up, it measures handicap and correlates best with the heaviness of work to which the patient must return, i.e. their ¿normal¿ activities.
    Secondly, different types of impairment may cause different types of disability. For example exercise activity may make one type of back pain worse, have no effect on another, and help in yet other cases. Likewise different types of disability may cause more or less handicap under different work place circumstances.
    Thirdly, it seems that there are distinct types of low back pain within the common presentation of the so-called non-specifics. Their differences have profound effects. They vary in terms of activities and tests that provoke the pain, characteristic disability questionnaire scores, the tendency to persist, resolve and then recur, and in terms of which measures best gauge change in outcome.
    Taking these aspects into account probably explains varying natural prognosis and why observed effects of intervention dilute or cancel out and hide the real evidence. Guidelines will only improve when the assumption that all back pain is the same continues to be questioned.

    Brian Sweetman FRCP, MD, PhD.
    Swansea, UK.

    1. Hendrick P, Milosavljevic S, Hale L, Hurley DA, McDonough SM, Herbison P, Baxter GD. Does a patient's physical activity predict recovery from an episode of acute low back pain? A prospective cohort study. BMC Musculoskeletal Disorders 2013. 14:126. Published: 5 April 2013.

    2. Sweetman BJ. Low back pain, some real answers. 2005. tfm Publishing, Harley SY5 6LX; UK.

    Competing interests