Low back pain
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7448.1119 (Published 06 May 2004) Cite this as: BMJ 2004;328:1119
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Sir,
Effective, efficient care for patients with acute low back pain is
possible.
Following on from the success of a three year pilot into the
practicalities of implementing the then new RCGP guidelines, Greater
Glasgow Health Board put their money where their mouth was and created the
Greater Glasgow Back Pain Service in April 2002.
This is a city-wide service lead by thirteen clinical specialist
physiotherapists strategically placed throughout the city. Any patient
with a 6 week or less history of low back pain can access the service
either through self-referral or via their GP. Patients with nerve root
symptoms are seen within one week and all others within two.
The physiotherapist assesses using a biopsychosocial model and treats
according. If indicated, the physiotherapist can refer directly for MRI,
dexa scan, bone morphology, neuro or othopaedic opinion. This ensures a
smooth patient pathway of care.
A recent audit of MRI/ortho referrals has revealed a marked
improvement in the quality of referrals for further investigation and a
resultant positive impact on both orthopaedic and radiology resources.
Uniquely, where psychosocial issues are affecting recovery, there is
direct access to clinical psychology. Physiotherapy and clinical
psychology work together to provide an 'enhanced back class' for those
people requiring additional support in managing their back problem.
Patients are offered and receive a 'patient-centred' service based on
the needs of the individual, ensuring a smooth, efficient and effective
pathway of care.
Competing interests:
None declared
Competing interests: No competing interests
Editor
I read with interest Dr Speed’s review (1) including her
reference to sacroiliac joint (SI) pain due to mechanical
stresses. I do not agree with Dr Bamji (2) that
"sacroiliac strain really represents injuries of the gluteal
region". Clinicians who manipulate the SI joint,
following a careful history, physical examination and
appropriate radiology to exclude pathology, know that
patients may derive considerable, if not complete, relief
from a dysfunctional SI joint. An example of SI joint
dysfunction was documented by me (3). In summary, a
25 year old woman who fell onto her right buttock four
years previously presented with constant chronic low
back pain that included the right SI joint, with radiation
into the right buttock, the right leg posteriorly and into
the sole of the right foot. She was neurologically intact,
had a normal lumbar MRI and her right SI joint pain
could be aggravated by mechanically straining the joint.
She had obtained no relief from various NAISDs,
paracetamol, endep and a CT guided right SI joint
steroidal injection. However, she received great relief
from manipulation of the painful SI joint, although she
found the initial manipulation to be very painful. She
had one further manipulation three days later, another
one month later for a minor recurrence of right SI joint
pain, and a further manipulation two months later for a
similar occurrence – each treatment provided excellent
relief. The patient’s husband asked why several
specialists to whom she had been referred had
suggested her symptoms were in her head and he
stated that her condition had almost wrecked their
marriage. In view of this, I believe clinicians should
include manipulation as a useful management
procedure for mechanical dysfunction of the SI joint.
Also, it should be noted that SI joint pain may be
referred as far as the foot, although some authors
consider that the pain is most often referred to the
groin, buttocks, and posterior thigh and less often to the
lower extremity (4).
Lynton Giles, Consultant Clinical Anatomist
Brisbane, Queensland, Australia
(lggiles@austarnet.com.au)
(1) Speed C. ABC of Rheumatology. Low Back Pain.
BMJ 2004; 328: 1119-1121. (8 May.)
(2) Bamji AN. Low back pain. Sacroiliac joint pain may
be a myth. Letter. BMJ 2004; 329: 232 (24 July.)
(3) Giles LGF. 50 Challenging Spinal Pain Syndrome
Cases. Edinburgh, Butterworth-Heinemann, 2003:
32-35.
(4) Quon JA, Bernard NT, Burton CV, Kirkaldy-Willis WH.
The site and nature of the lesion. In Managing Low
Back Pain (Kirkaldy-Willis WH and Bernard NT (eds)),
4th edition, Edinburgh, Churchill Livingstone, 1999:
125.
Competing interests:
None declared
Competing interests: No competing interests
It is not widely known, even among Chiropractors that about 70
percent of the population does not stand on two feet. Next time you go
into a bank take a look at how most people are standing. They are shifting
their weight to one side. This throws the hips out which makes one leg
longer than the other and this of course puts pressures on the spine,
sacrem and neck. This is the primary PHYSICAL cause of lower back
problems. Of course there are emotional causes but when one throws one's
balance out gravity becomes one's enemy. It is my experience that most
doctors don't want to deal with such things because then they have to deal
with a person's resistance to change and thats not easy at all. But ones
resistance to change is at the heart of many disorders...so its the
doctors job....To ignore this factor in back problems is to ignore basic
medicical essentials.
Competing interests:
None declared
Competing interests: No competing interests
As a sufferer of intractable low back pain and bi-lateral sciatica
due to spinal stenosis, post opperative scaring following hemis discectomy
and central sensitisation etc. It is so infuriating to find that this
attitude is voiced strongly whereas I have as yet to hear the other side
from the medical profession. It is so often the case that as soon as the
situation appears difficult to deal with the psychosamatic card is played
and the patient hurried to the door. It is quite amasing to hear the
nashing of teeth when the shoe is on the other foot. A medic with severe
back pain, not a pretty sight but the problem suddenly becomes so real.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
We read Speed’s review of low back pain with interest but were
surprised that no acknowledgement was made that by far the greatest
proportion of back pain has no clear mechanical or organic cause.
There is acceptance that psycho-social factors may have a role in the
persistence of pain and that their recognition is important; the yellow
flags described in the RCGP acute low back pain guidelines can help
identify the patients in whom physical therapies alone may reinforce
illness behaviour rather than speeding recovery.
Main and Williams’ paper on musculoskeletal pain in the ABC of
psychological medicine series highlights that the vast majority of those
with back pain have no evidence of the disorders described by Speed but
nevertheless suffer troublesome symptoms and functional impairment. In
addition to yellow flags they also talk of blue (occupational) and black
(socio-occupational) flags that should influence management.
Their comment “for the vast majority of patients, however, the
identification of contributory psychological and social factors should be
seen as an investigation of the normal range of reactions to pain rather
than the seeking of psychopathology” seems to encompass an approach more
likely to be successful than that of Speed, who focuses exclusively on a
biological model of understanding of people’s symptoms.
We are currently looking at general practitioners’ management of
acute back pain and their sensitivity to a range of biopsychosocial
factors. If teaching continues to emphasise the physical causes of back
pain without also drawing attention to non organic risk factors for its
persistence, it will not be not surprising if some primary care
practitioners fail to recognise the patients in whom back pain, while
real, is augmented by distress in other areas of their lives and requires
a more inclusive approach to management.
Dr Charles Campion-Smith & Professor Alan Breen
for the Bournemouth Back Pain Study Group,
Institute for musculoskeletal research and clinical implementation
Anglo-European Chiropractic College
Bournemouth
Competing interests:
We are currently studying general practitioners management of low back pain and concordance with guidelines
Competing interests: No competing interests
Sir,
Patients with low back pain must be investigated with an abdominal
ultrasound for evidence of ureteric calculi and an urine examination for
crystalluria.
In drought affected areas people often consume 'borewell' water from
uncertified borewells which may cotain high amounts of calcium.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – Cathy Speed’s ‘ABC of rheumatology: Low back pain’ review
(1), fails to highlight the important, but frequently overlooked, role
that vitamin D deficiency may play.
A study of 360 patients attending spinal and internal medicine
clinics (in Saudi Arabia) over a 6-year period who had chronic low back
pain that had no obvious cause, found that 83% had an abnormally low level
of vitamin D. After treatment with vitamin D supplements, clinical
improvement was seen in all those that had a low level of vitamin D, and
in 95% of all the patients. The study authors concluded that vitamin D is
a major contributor to chronic low back pain, and that screening for
vitamin D deficiency and treatment with supplements should be mandatory.
An Australian report described two patients with chronic low back
pain who, subsequent to failed spinal surgery, were found to have severe
vitamin D deficiency (3). These patients were much improved after
treatment with vitamin D supplementation.
In a US study of primary care outpatients with persistent, non-
specific musculoskeletal pain syndromes refractory to standard therapies,
93% had deficient levels of vitamin D (4). The authors of the study
concluded that, because osteomalacia is a known cause of non-specific
musculoskeletal pain, screening of all patients with such pain for
hypovitaminosis D should be standard practice in clinical care.
In an accompanying editorial to the above study, Michael Holick
emphasises that physicians should be alert to vitamin D deficiency, and
recommends that all patients should have their vitamin D status tested
once a year (5).
Failure to recognise and treat vitamin D deficiency in patients with
low back pain may result in a great deal of unnecessary suffering, as well
as substantial direct and indirect costs. Vitamin D deficiency is readily
identified by measuring 25-hydroxy vitamin D levels (< 50 nmol/L =
deficiency; 50-100 nmol/L = insufficiency; 100-150 nmol/L = optimal), and
is easily and cheaply corrected with appropriate vitamin D supplementation
(which may typically require treatment with 6,000 IU (150 mcg) or more
daily, followed by maintenance doses of 2-3,000 IU (50-75 mcg) daily
and/or adequate exposure to sunlight).
References
1. Speed, C. ABC of rheumatology: Low back pain. BMJ 2004;328:1119-
21.
2. Al Faraj S, Al Mutairi K. Vitamin D defiency and chronic low back
pain in Saudi Arabia. Spine 2003;28(2):177-9.
3. Spinal surgery and severe vitamin D deficiency. Plehwe W, Carey
RPL. MJA 2002;176(9):438-439.
4. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D
in patients with persistent, non-specific musculoskeletal pain. Mayo Clin
Proc 2003;78:1463-1470.
5. Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc
2003;78:1457-1459.
Competing interests:
None declared
Competing interests: No competing interests
Cathy Speed’s concise overview of “low back pain” cannot possibly do
justice to every aspect, but inclusion of more practical guidelines for
the case of low back pain with sciatica would have been useful. Having
established that true sciatica is present, and given the unavailability of
multidisciplinary teams in everyday practice, what is the optimum course
of action for the general practitioner?
I propose that in the presence of a motor weakness, an MR or CT scan
is performed within two weeks. Is that achievable? In the presence of
sciatica and/or a dermatomal area of dysaesthesiae, the patient is advised
to avoid strenuous activity, and be seen by a physiotherapist within four
weeks for isometric stabilizing exercises. Do I hear laughter from my GP
colleagues? “Back education” can be covered with a leaflet such as that
from www.patient.co.uk - and reinforced by the physiotherapist. Surely
this, at least, is achievable?
My concern is whether patients will believe that their doctor can
help at all, and whether they will return to the surgery should their pain
persist and neurological deficit enter the scene. Sound information on all
aspects is not easy to impart in a seven minute consultation. But perhaps
a special mention of the 25 - 50 yr old man or woman with true sciatica
should be made, as the case most likely to have a disc prolapse that would
benefit from a professional “keeping an eye” on it.
Competing interests:
None declared
Competing interests: No competing interests
I was surprised to see Cathy Speed stating that 1% of back pain
presenting in primary care is due to a neoplasm. In 20 years in general
practice I must have seen hundreds of cases of back pain, much less than
one in a hundred caused by a tumour. Was this a misprint?
Competing interests:
None declared
Competing interests: No competing interests
Re: 1% of back pain caused by neoplasm?
Editor,
I read with interest Dr Robert Smith’s comment
questioning the percentage of patients presenting in
primary care with ‘back’ pain due to a neoplasm in his
response to Dr Speed’s (1) statement that 1% of
people presenting with back pain in primary care have
a neoplasm. Before I retired as Clinical Director of the
Multidisciplinary Spinal Pain Unit at Townsville General
Hospital, Queensland, my colleagues and I ran a
prospective investigation on 1775 patients (2) who
presented with spinal pain syndromes and who
underwent a routine clinical history, physical
examination, appropriate imaging and laboratory tests
to determine the percentage of patients presenting with
various conditions. We found malignancies in 0.6% of
the patients (bone (1); neural (2); Pancoast (1);
prostatic (5); pancreatic (1); myeloma (2)). I no longer
have the breakdown of figures for just low back pain.
However, it would appear that Dr Speed’s comment
that 1% of people presenting with ‘back’ pain in primary
care have a neoplasm, may be somewhat high.
(1) Speed C. ABC of Rheumatology. Low Back Pain.
BMJ 2004; 328: 1119-1121. (8 May.)
(2) Giles LGF, Muller R, Winter GJ. Patient satisfaction,
characteristics, radiology, and complications
associated with attending a specialized
Government-funded Multidisciplinary Spinal Pain Unit. J
Manipulative Physiol Ther 2003; 26: 293-299.
Competing interests:
None declared
Competing interests: No competing interests