Back Pain Studies: Are we missing the point?

[Physiobase]

After reading this forum and numerous research articles day in day out now for years I have come to a simple deduction about longterm outcome measures in the treatment of Low Back Pain (and maybe other pains as well).

If we look at all the research it is clear to say that back pain is a normal condition. It appears at some time or another in most of us during working age. The jobs has little to do with it as it happens in workers, tribal communities and non-workers alike with little to no relationship to the "work" being performed. Psychosocial factors, moral, homelife etc does however show much more statistic relevance.

Alophysio recently noted when commenting on a knife wound that you could take a pain killer and, when that wore off, take another. Eventually the body heals underneath and you don't need to take the pain killer anymore. The point is the pain killer did not cure the problem. The body did. What the pain killer did was resolve you symptoms quickly and effectively letting you get on with it.

So what of longterm outcomes? The body for the most part heals itself. So won't most groups placebo or not be the same the longer we follw them up? The answer for the most part is YES.

Physiotherapy is good at making a difference now! when the problem is there! to ease the suffering and return the person to as a normal a life as possible as quickly as possible. Why then are we not looking at research into which gives more relief more quickly and leaving it as that. Returning a person to work quickly is more important than leaving them for 12 months to "self heal" from within. Now this is the nice thing as there is a direct cost implication for the economy. Of course we never make savings in the health care dollar because as one person comes off the list another one is always there to take their place. So we will never reduce the demand for healthcare, we will just increase the throughput. And because the populations is growing this is exactly what we need to do to manage the ever increasing waiting lists.

I beg all physios to question the relevence of any collegues research project for low back pain that bothers to look at anything post about 6 months. 1 and 2 year follow ups are a waste of time as the nature of low back pain is that it is recurring. What we do is increase the time between episodes and reduce the time the person suffers during the episode.

Any and all comments welcome 8o

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[polaroz]

I do agree partially with your statement. Though, I believe that pain release treatment is inevitable part in the whole healing process.

Therapists may seen some sorts of pain feeling is not bad things and one should not touch it unless it ought to, but as patients, they wouldn't know all the mechanism that works behind the theories, what they know is just the pain sometimes and somehow is just unbearable.

Indeed, there are always very different views b/w a therapist and a patient.

[Physiobase]

Indeed, often advice might be the treatment of choice. This is not always well received though, especially by the fee paying client

[alophysio]

Interesting...

In defense of my statement about the knife wound, it was about electrotherapy not solving problems...

I agree that low back pain is common and nearly everyone will experience it at some stage of their life no matter who, what, where, when or why.

I would argue that the body doesn't necessarily heal itself particularly well after an injury. People often develop habits and patterns and coping strategies that are quite mal-adaptive - that is the strategies are bad for them despite trying to assist themselves in their pain. That is often why you will see patients with chronic pain 2 years after the initial injury. Everyone has written them off as malingerers but a simple change to movement patterns, motor control, sequencing of muscle activity etc will change the loading on their perpetually inflammed structures and healing begins.

I agree that we help to increase the time between episodes and decrease the time of suffering.

About follow-up studies - I think you mean that people are going to hurt their backs anyway so why produce evidence to support an argument that physio won't prevent future occurrences, right?

If that is so, I agree. There are so many things that go on with an individual, especially one who is feeling better, that it is impossible to so that because they had a relapse, the effect of physio is not long-lasting enough.

For instance, i had a patient who had terrible back pain and saw me 3 times with complete resolution of their pain. She came back in 3 weeks later complaining of back pain. However, this time it was completely different. Initially she had sciatica with radiating pain down the left leg. This time, she had pain in the upper L/S from being hit during sport. Completely unrelated areas of pain in the L/S. No recurrence of the initial pain. But still back pain...

The reason why I am so deadset against electrotherapy is because to me it is only a band-aid. There is not enough support for it. I appreciate its other uses such as time-filling, soothing and time to speak with the patient when using U/S and of course the strong placebo effect it has. I also do use it as a "band-aid" for pain so I can get in and do something that is painful first then make them feel a little better for a short time (and warn them!).

A collegue is doing his PhD on ?pain beliefs and some of his initial data suggests that those who believe you should always bend at the knees to lift/pick something up tend to have the most pain/disability (I hope I got that correct!). Which says to me that people who are in pain tend to be the ones who try to correct their posture when lifting. But even lifting "experts" cannot prevent their L/S from flexing during a deep squat to lift a 10kg weight (reference currently eludes me).

I would love to see more studies showing a good outcome for manual therapy and specific, appropriate exercise vs rest, general exercise and electrotherapy...

[Physiobase]

About follow-up studies - I think you mean that people are going to hurt their backs anyway so why produce evidence to support an argument that physio won't prevent future occurrences, right?

No, I am simply saying that in longterm followups of placebo and treatments groups both will exhibit similar results for low back pain, say at 12 months, 18 months or 2 years. Luckily this is as the majority will be pretty much pain free. This is as the majority of LBP is non-specific and therefore those that will still be suffering in a placebo group will be to small to exhibit any statistical significance.

We should focus our attention on the short term recovery and put a measure/cost against that to show how effective we can be. To continue to look at longterm measures will siply continue to weaken our position on why physio should be the first port of call for a client with LBP.

[alophysio]

Yes I agree wholeheartedly.

I am glad you clarified that.

I want to see studies that basically show that you are so much better off seeing a physio than seeing your doctor or resting in bed.

Or that specific, patient specific exercises concentrating on segmental motion and stability is better than general exercises given out on a sheet of paper by the doctor.

Or that manual therapy produces far quicker results than electrotherapy.

Or that seeing the physio within 1-2 weeks of the onset of pain results in better outcomes than waiting 4-6 weeks.

Any others?

[sdkashif]

Here are some useful resources for review of the studies on backs pain. I would like to have comment on these too.

Acute low back pain-Interdisciplinary clinical guidelines

Clinical Pathways for Work related Injury Back Pain

A structured and rigorous methodology developed for
the formulation of evidence-based clinical practice guidelines (EBCPGs),then was used to develop EBCPGs for selected rehabilitation interventionsfor the management of low back, neck, knee, and shoulder pain.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARE

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF CHRONIC
NON-SPECIFIC LOW BACK PAIN

Does it matter which Exercise?

Non-specific low back pain in primary care in the Spanish National Health Service: a prospective study on clinical outcomes and determinants ofmanagement

Low Back Pain- Musculoskeletal Disorders

Are chronic low back pain outcomes improved with co-management of concurrent depression?

Nonspecific Lower-back Pain

Improving services for people with back pain

Iliac crest pain syndrome in low back pain

Back Pain: The Facts

Treatment of Chronic Pain

A Systematic Approach To Adult Hip Pain

[neving]

wow.
that BOTHERS me no end!
You "want to see studies that show that ...so much better off seeing a physiotherapist than...seeing a doctor", or that "...patient specific exercises are better than general exercises..." or that "manual therapy produces quicker results than electrotherapy..."
Research doesn't work that way, and we must make SURE that we DO NOT fall into this trap of producing results in agreement with our "wishful thinking", if we want to be taken seriouisly by the scientific community, specially the medical community. The first rule of research is to KEEP AN OPEN MIND, and to accept the results, even if they are different than we expected or hoped for.
neving

[Physiobase]

not at all. We should research what the actual question should be. e.g. Does physio give someone a faster and more productive recover and return to normal activities of daily life and work in a faster time frame to another technique or therapy or doing nothing. Who cares if everyone is about the same 12 months or 2 years later. By then they have lost their job, their spouse, their enthusiasm for life.......

Yes we should research what we prove "empirically" to be correct and we should positively affirm the fact, for if we prove it to be false then that would be extremly powerful. AFter all that is what an RCT should be used for.

[friendlypain]

Research has LOST ITS WAY!!!!!!!!!!

I agree with Neving. Big business has come into the picture and is funding research projects to promote their products and services. If you look at any research paper today you can tear it to shreds because of the bias in the interpretation of data. Yes this includes the health care professions!!!!!! I hate to say it but we are as corrupt as the "peanuts lower cholesterol" (which was funded by planters nuts) study as we try to prove the new, innovative (puke), extremely complicated and expensive techniques that we have to learn to earn our CEUs actually work.

PS. If you don’t think health care is big business you are very very naive. What better way to make people to part with their money than to provide them with hope.

As for the nature of the healing process... If you take a piece of paper, rip and bring the edges closer together and then glue or tape the edges, you have a wrinkled piece of paper. This piece of paper will now behave differently. As with any injury, unless full range of movement is achieved almost immediately, the wrinkled paper effect will occur. This can be reversed with therapy and near full range can be achieved. So what we do will always impact our patient's health.

The body is absolutely DUMB when it comes to healing. It seems like the body is always responding to severe trauma and is unable to cope with minor trauma in a toned down way. Remember the body was design with CONSTANT MOTION in mind. The design and function of the hip flexors is a liability to the lumbar spine for those of us who sit as much as we stand (notice that I did not say move). Those two functions create HUGE stresses on the lumbar spine. If you doubt this view I encourage you to wall climb. The trick of climbing is CONSTANT MOTION. Never hang as the muscles in the forearm will be fatigued and cant be used for several minutes as it recovers from the stress (ie. lack of blood flow) of isometric contraction (which will lead to an impressive fall).

I am going to stop now before I go into a winded rant about biomechanics.

Adamo

[Physiobase]

This piece of paper will now behave differently. As with any injury, unless full range of movement is achieved almost immediately, the wrinkled paper effect will occur. This can be reversed with therapy and near full range can be achieved. So what we do will always impact our patient's health.

I agree with your sentiment but do not see how it agrees with a previous post. I am in fact opposed to RCT's (random controlled trials) in general as I do not think that they fit the model of heatlhcare.

However the reality of the world is dollars and sense. To sit and argue is to let others who jump on board gain market edge and healthcare dollars, from government, insurance company, grant money etc. Whilst we need not agree with it perhaps we can do some RCT's that even when biased, support our cause. Why not even make it blatnantly biased but correct in methodology. Then we have a strong right to say "See RCT's are not a valid nor reliable measure in the healthcare market"... you see what we just proved. Proving the ridiculous to be true could well be the best way to get people to listen and change course.

[neving]

1. define research, including the purpose of it.
2. define "random controlled trial"
3. define "double blind"
4. now explain to me how a "blatantly biased" study can
be "correct in it's methodology".
5. explain why propper research (random controlled trials?)
do not "fit the model of health care"

even in a world of "dollars and cents", no - especially in a world of dollars and cents - would it not be vital to get to the truth and find methods proven to work, thus in the long run saving us $$$$$$$$$$$$$$$$$$$$$$ on wasted time and effort!
neving

[Physiobase]

From Wikipedia:

double-blind
The Double blind method is an important part of the scientific method, used to prevent research outcomes from being influenced by the placebo effect or observer bias. Blinded research is an important tool in many fields of research, from medicine, to psychology and the social sciences, to forensics.


Single-blind trials
Blinding is a basic tool to prevent conscious and unconscious bias in research. For example, in open taste tests comparing different product brands, consumers usually choose their regular brand. However, in blind taste tests, where the brand identities are concealed, consumers may favor a different brand.

In a single-blind experiment, the individual subjects do not know whether they are so-called "test" subjects or members of an "experimental control" group. Single-blind experimental design is used where the experimenters either must know the full facts (for example, when comparing sham to real surgery) or where the experimenter will not introduce further bias. However, there is a risk that subjects are influenced by interaction with the researchers - known as the experimenter effect. Single-blind trials are especially risky in psychology and social science research, where the experimenter has an expectation of what the outcome should be, and may consciously or unconsciously influence the behavior of the subject.


Double-blind trials
Double-blind describes an especially stringent way of conducting an experiment, usually on human subjects, in an attempt to eliminate subjective bias on the part of both experimental subjects and the experimenters. In most cases, double-blind experiments are held to achieve a higher standard of scientific rigour.

In a double-blind experiment, neither the individuals nor the researchers know who belongs to the control group and the experimental group. Only after all the data are recorded (and in some cases, analyzed) do the researchers learn which individuals are which. Performing an experiment in double-blind fashion is a way to lessen the influence of the prejudices and unintentional physical cues on the results (the placebo effect, observer bias, and experimenter effect). Random assignment of the subject to the experimental or control group is a critical part of double-blind research design. The key that identifies the subjects and which group they belonged to is kept by a third party and not given to the researchers until the study is over.

Double-blind methods can be applied to any experimental situation where there is the possibility that the results will be affected by conscious or unconscious bias on the part of the experimenter.


Medical Applications
Double-blinding is relatively easy to achieve in drug studies, by formulating the investigational drug and the control (either a placebo or an established drug) to have identical appearance (color, taste, etc.). Patients are randomly assigned to the control or experimental group and given random numbers by a study coordinator, who also encodes the drugs with matching random numbers. Neither the patients nor the researchers monitoring the outcome know which patient is receiving which treatment, until the study is over and the random code is broken.

Effective blinding can be difficult to achieve where the treatment is notably effective, or where the treatment is very distinctive in taste or has unusual side-effects that allow the researcher and/or the subject to guess which group they were assigned to. It is also difficult to use the double blind method to compare surgical and non-surgical interventions (although sham surgery, involving a simple incision, might be ethically permitted). A good clinical protocol will forsee these potential problems to ensure blinding is as effective as possible.

Triple-blind trials are double-blind trials in which the statistician interpreting the results also does not know which intervention has been given. Sometimes triple-blind is used to mean that multiple investigators are all blinded to the protocol (such as the clinician giving the treatment and a radiologist or pathologist who interprets the results.)

Evidence-based medicine practitioners prefer blinded randomised controlled trials (RCTs), where that is a possible experimental design. These are high on the hierarchy of evidence; only a meta analysis of several well designed RCTs is considered more reliable.

[Physiobase]

Oh... and RCT's rely heavily on a homogeonous treatment and control population. As the body is a living organism, no two groups are homogenous. As the diagnosis of the actual problem in most cases is also either individually specific or in fact somewhat cryptogenic (unknown) then how can any group be homogenous. Homogenous by age, culture, location is a rare thing only perhaps Darwin observed.

[neving]

so, once again, how can a "blatantly biased" study be "correct in it's methodology", and why does this type of research not fit the "model of health care"?
neving

[Physiobase]

OK, take a group of 100 people suffering non-specific low back pain. The need only be a representation of the normal population that present for non-specific low back pain. It was your comment that said studies were blatantly biased, I am not sure that this is an issue if the methodology is correct. Support for a product,treatment is great. The problem to often lies in the operationalisation of the question and therefore interpretation of the data, not in the actual concept of the study.

Give 50 advice that it is nothing serious and that they will be OK with rest and if pain persists to take a NSAID. e.g. GP guidelines.

Give the other random 50 a 3 week course of Pilates studio classes with a private physio instructor specialising in non-specific low back pain. Classes run individually 2-3 times a week for the 9-10 sessions.

Prior to the study record important things like, stress, mood, pain, function, ability to go to work, general sense of well being, feeling of understanding their problem and future ability to self-manage etc etc.

Then remeasure them following the treatment period. I am sure that this short time frame and "biased" approach to questions and outcomes that you will find that the treatment group does better than the non-treatment group. If of course only a few questions appear strgongly significant, then repeat the study with more bias again to that line of questioning. Don't however remeasure at 12 month, 18 months etc as they are much more likely to show similar results at that time. There is nothing wrong in this methodology.

I would not say things are biased just because they support what you believe to be true and is why in fact you are using a RCT to show it to be true.

In my book this type of research is extremely relevent. If is about a quick, effective access to treatment that has some self-management component that could be long lasting.

[neving]

my last comment to this subject:
in your post 483 your words were"...blatantly biased but correct in methodology..."
my point is that correct methodology means a trial is as UN-BIASED as possible, what you are proposing is not possible.
sorry, but you've lost all credibility for me.
neving

[Physiobase]

Sorry if you have missed the point of this posting neving but you have taken it rather off course.

My words are simply a reiteration of other's comments on supposed "biasing of results. Perhaps I should simply clarify and state:- We need to do research that will hopefully support whether OR not we are the best treatment option when compared to another treatment option, rather than just against placebo control groups. Sure we can have a control group as well but healthcare is about where the dollar goes and therefore we must compare to other therapies and management strategies.

I reviewed over 3,500 studies in researching and co-authoring the 2000 UK Guidelines in the treatment of Occupationally related low back pain. During the 18month review we looked at all sorts of trials and, with Prof's. Kim Burton and Gordon Waddell's expert lead, we produced the guide for the Royal College of GP's in this country.

Unfortunately despite our best efforts we were unable to include Physio as a useful first port of call in the treatment of this condition. (Even though at the time two small studies has shown Physio to be better than placebo, which was in turn shown to be better even than GP management). Now these scandanavian studies were exactly what we needed more of to gain more of a foot in the door as primary practitioners. Comparing to a control group/placebo group alone did nothing for our cause, nor did longterm followup studies that showed most groups end up the same.

I am a physio/clinician who also has a prior degree in pure mathematics and am very interested in the power of research. I remain very annoyed with the blatant wasting of grant money on studies that do not further our profession in the eyes of the greater public. hence the reason for this post.

You appear to be a follower of the western biomedical model. Perhaps you feel able to provide an example of worth to support it. I would be only to happy to comment on any useful double blind RCT you care to produce.

[Physiobase]

If you look at any research paper today you can tear it to shreds because of the bias in the interpretation of data.

Not really "bias" just invalid conclusions. This is typical of the RCT.

It seems like the body is always responding to severe trauma and is unable to cope with minor trauma in a toned down way.

I like you suggestion here. We do cope rather well with major trauma unless of course it is to the low back! (as an example). I imagine though that infact we all undergo minor trauma on a daily basis without exhibiting pain as a result means that we do cope ok with minor trauma as well. The stronger factors from the research appears to the the more psychosocial factors (yellow and red flags) which the body doesn't seem to cope with so well. Hence the influence they have on the physical system.

If you doubt this view I encourage you to wall climb.

I wall climb frequently and yes, constant movement is key. But more key is the use of the legs in preventing forearm "blow-out". I have not read to much on the monks in Nepal who meditate for hours on end, day after day, but I don't think the incidence of low back pain is that great in their sitting population. And they have rather porky tummies some of them

[friendlypain]

Hahahaha..... Those monks have figured out the riddle of the ,uscle. Keep them lax and you can assume any position you want for however long you want. Long live the skeleton!

I like this whole thread although at one point I was wondering if things are becoming personal. Pain is way too subjective to study in a clear cut way. What we need to do is prove physiologically that the condition has improved. Biochemistry would take a more positive role in this case.

Adamo

[alophysio]

Hi.

I am back after having baby #3 (well, my wife did)...

I would like to add some comments to neving's initial complaint...

wow.
that BOTHERS me no end!
You "want to see studies that show that ...so much better off seeing a physiotherapist than...seeing a doctor", or that "...patient specific exercises are better than general exercises..." or that "manual therapy produces quicker results than electrotherapy..."
Research doesn't work that way, and we must make SURE that we DO NOT fall into this trap of producing results in agreement with our "wishful thinking", if we want to be taken seriouisly by the scientific community, specially the medical community. The first rule of research is to KEEP AN OPEN MIND, and to accept the results, even if they are different than we expected or hoped for.
neving

Firstly, I think you would find that people who research (and I am not a researcher) ask a question about something they already have a hypothesis for: e.g. I think specific exercises are better than general exercises because of the importance of segmental control. I don't think people do research because they have no idea one way or the other - at least not often in physiotherapy.

Secondly, you don't get published if your research ain't conclusive - or least not often. From what I read, it is often "It works" or "it doesn't work". The results of the study usually have to contribute to the discussion on the topic.

Thirdly, bias is when you DO put your own beliefs ahead of the results of the research. If i do the study on specific vs general exercise and i find that general exercise is better, then i have choices- re-do it, publish it or not publish it. Only if i manipulate the results to twist it to my way of thinking am i biased. Some might argue not publishing the study is also biased - perhaps.

Lastly, from the people (doctors and physios) i speak to about their research, they have a very firm idea on what they believe and what they hope the research will show. They map out the PhD to establish credibility for their methodology, measurement styles, etc, etc. They know what they need to estabilsh the foundation for the results (whatever they are) of their research.

So to conclude,

I want to see studies that basically show that you are so much better off seeing a physio than seeing your doctor or resting in bed.

Or that specific, patient specific exercises concentrating on segmental motion and stability is better than general exercises given out on a sheet of paper by the doctor.

Or that manual therapy produces far quicker results than electrotherapy.

Or that seeing the physio within 1-2 weeks of the onset of pain results in better outcomes than waiting 4-6 weeks.

Any others?

[neurospast]

It seems to me that we all know what helps, for some time at least..... Why? Maybe because in reality we have not looked for the cause at all but we have as is usual within the medical world been treating symtoms. As far as I know there is little or no consensus on the cause of low back pain and therefor we are treating it by symptom treatment, alike a mecanic who says if you tell him that if you turn to the left the car behaves in such and such a way and he replies tha in tha case you better always turn to the right. Personally I feel we make the mistake to simplify things in order to understand and to be able to measure ; research demands to symplify, to have the least variables and we have to agree: WE AS A PROFESSIONAL GROUP ARE HOOKED ON RESEARCH. So maybe we just do not understand backpain and cannot admit it. As far as I can see: why not introduce the interaction of mind and body or is it that we in that case overstep a line, e.g. the psychology line and we could end up in court for malpractice while in reality we are as things stand malpractising?
Cheers

[sdkashif]

Dear colleagues, Hi!

It is really great to see the comments of all of you on Back Pain. Be friendly and positive while discussing more views and comments. Here is also a bit of information to share with all of you. Have a look over that.

Evidence-based Management of Acute Musculoskeletal Pain

Management of work related acute low back pain

Low-Back Pain Frequency, Management and Prevention from
an HTA perspective

National practice guidelines for physical therapy in patients with low back pain

Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain

Acute Low Back Problems in Adults

Using Published Evidence to Guide the Examination of the Sacroiliac Joint Region

New Zealand Acute Low Back Pain Guide

Manual medicine guidelines for musculoskeletal injuries

The management of persistent pain in older persons

Management of fibromyalgia syndrome

Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines.

Vertebral subluxation in chiropractic practice

Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations.

North American Spine Society Phase III: clinical guidelines for multidisciplinary spine care specialists. Spinal stenosis version 1.0.

Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis.

Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain.

Assessment and management of pain.

Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic non-malignant pain syndrome patients.

Acute low back pain.


VHA/DoD clinical practice guideline for the management of medically unexplained symptoms: chronic pain and fatigue.

Overview of implementation of outcome assessment case management in the clinical practice.

Guideline for hospitalization for low back pain.

Low back - lumbar & thoracic (acute & chronic).

Pain

The McKenzie method for the management of acute non-specific low back pain: design of a randomised controlled trial