Rheumatology Advance Access originally published online on December 3, 2007
Rheumatology 2008 47(2):231; doi:10.1093/rheumatology/kem305
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Comment on: Do baseline characteristics predict response to treatment for low back pain? Secondary analysis of the UK BEAM dataset
Department of Rheumatology, Morriston Hospital, Swansea SA6 6NL, UK
Correspondence to: B. J. Sweetman. E-mail: Brain.Sweetman{at}swansea-tr.wales.nhs.uk
SIR, It is pleasing to see the further special analysis of the UK BEAM low back pain study [1]. However, it is sad to see that they found no predictors of response to treatment. I would therefore like to draw attention to a very similar canonical analysis of variance relating to an earlier study [2] that had better luck.
This study [2] was again of a controlled trial of physical treatments for low back pain, but lumbar traction was used rather than manipulations. Physical signs recorded at the outset served to identify subgroups, which was an accomplishment in its own right. Furthermore, one subset in particular seemed particularly likely to respond to the traction regimen.
The feature that helped identify the subgroup is referred to as ‘contralaterality’. The patient says that the back pain is on one side of the back, but this relates to pain at the dorsolumbar junction, as can be shown by palpation for tenderness, or even better by the curious leg twist test. The pain is referred downwards so that the patient describes this as their low back pain.
However, they also have problems lower down at the lumbosacral level that may be on the opposite side, and so the signs of tenderness and painful tests show up on this opposite side. Hence the patient seems to be getting the sides mixed up. The mechanisms and elucidation of this phenomenon are explained in detail elsewhere in the summary monograph [2].
However, it turns out that this is probably a special case subset of a more general pattern. The important element is the coincidence of involvement at two distinct levels, i.e. dorsolumbar and lumbosacral junctions, but only on one side at each level; though when on the opposite sides—top and bottom—giving a more enigmatic appearance as described above. It turns out that this picture overlaps and enlarges on what would seem to be the same entity scored on a five-part rule identified by Childs et al. [3] as responding to manipulation and referred to in the recent article in the journal regarding the UK BEAM study [1].
The ‘contralateral’ aspect along with other baseline examination features help explain a number of other back pain mysteries, including the identity of the facet joint syndrome, and the differing relationships of heavy work with different types of back pain. Overall, prognostic criteria were also identified, but in this case were like the findings of Underwood et al. [1], in that they were only useful at a ‘probabilistic’ level for groups, and not reliable enough for guiding patients at the individual level.
In summary, it seems that there may indeed be ways to ‘select patients for different treatments’ as espoused as an ideal by Underwood and colleagues.
Disclosure statement: The author has declared no conflicts of interest.
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- Underwood MR, Morton V, Farrin A. Do baseline characteristics predict response to treatment for low back pain? Secondary analysis of the UK BEAM dataset. Rheumatology (2007) 46:1297–302.
[Abstract/Free Full Text] - Sweetman BJ. Low Back Pain, Some real answers (2005) Castle Hill Barns, Harley, UK: tfm Publishing Ltd.
- Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med (2004) 141:920–8.
[Abstract/Free Full Text]
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