Rheumatology Advance Access originally published online on August 9, 2006
Rheumatology 2006 45(11):1451-1452; doi:10.1093/rheumatology/kel274
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Physiotherapy management of non-specific back and neck pain
Department of Rheumatology, Morriston Hospital, Swansea, SA6 6NL, UK
Correspondence to: B. J. Sweetman, Department of Rheumatology, Morriston Hospital, Swansea SA6 6NL, UK. E-mail: lisa.howie{at}swansea-tr.wales.nhs.uk
SIR, How is one to manage the common presentation of back pain? Reported searches of the Cochrane evidence base make me think that many have forgotten that it was in fact Archie Cochrane himself who was chairman to the first white paper on low back pain [1], and also forgotten that it had been concluded that there was insufficient evidence upon which to base guidelines on back pain management.
However, it is not that there has been a lack of studies, but that the results have proved difficult to interpret or else no useful conclusions could be drawn. So it was always going to be difficult for anyone, let alone physiotherapists [2], to manage this type of morbidity.
It all seems to come down to the old and vexed question as to whether non-specific back pain is a single entity or covers a multitude of sins. Can it be subdivided into several different sorts of specific back pain? Moffett and McLean in their review in this journal [2] preface their deliberations thus: ‘Many researchers have tried to classify back and neck pain and many different methods have been proposed’. The implication is that none of the systems work in the sense that they do not predict response to particular forms of treatment. What would the ideal be? Perhaps a few simple questions and tests would lead to a particular diagnosis for which a particular and effective treatment could be given.
But there are so many possible questions and tests that no one study could include them all. But we tried [3]. In essence we reduced a list of about 400 such items to a shortlist of 11, of which two were particularly crucial for splitting up the so-called ‘non-specifics’. These helped distinguish the long sought after ‘facet joint syndrome’ (the contrabend test) and low back pain sprain also incorporating involvement at the dorso-lumbar junction (the leg twist test). The tests are easily and quickly performed and have been described elsewhere and have recently been reviewed [4]. Cluster analysis helped identify the clinical importance of the contrabend test. The meaning of the ‘stuck’ leg twist test had remained obscure for about a century. Without such information incorporated at the beginning of the study it is not then possible to go on and check for the response to treatment of meaningful subsets of patients. It is the failure to emphasize this element of study design that seems to explain the lack of progress in this field of research.
No doubt there are other tests that will further help embellish diagnostic ‘structure’ in a repeatable manner. But if all those therapeutic trials could only have included some of the magic tests, then we might have had many more answers.
The author has declared no conflicts of interest.
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- Department of Health and Social Security. (1979) (Cochrane A) Report of the Working Group on Back Pain(HMSO, London).
- Moffett J and McLean S. (2006) The role of physiotherapy in the management of non-specific back pain and neck pain. Rheumatology 45:371–8.
[Abstract/Free Full Text] - Sweetman BJ, Heinrich I, Anderson JAD. (1993) A randomised controlled trial of exercises, short-wave diathermy and traction for low back pain, with evidence of diagnosis-related response to treatment. J Orthop Rheumatol 6:159–66.
- Sweetman BJ. (2005) Low Back Pain, some real answers(TFM Publishing, Harley, UK).
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