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Articles: Peter A. Rives and Alan B. Douglass Evaluation and Treatment of Low Back Pain in Family Practice J Am Board Fam Pract 2004; 17: S23-31S [Abstract] [Full text] [PDF]

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Reply to: Repeating failed policies will not improve outcomes, Jason D. Jones DC (11 January 2005)

Peter Rives MD, Alan Douglass MD   (27 January 2005)

Repeating failed policies will not improve outcomes

Jason D. Jones   (11 January 2005)

Reply to: Repeating failed policies will not improve outcomes, Jason D. Jones DC (11 January 2005) 27 January 2005
Peter Rives MD , Alan Douglass MD Send response to journal: Re: Reply to: Repeating failed policies will not improve outcomes, Jason D. Jones DC (11 January 2005) prives{at}adelphia.net Peter Rives MD, et al.	Our article was designed as an evidence-based review of the diagnosis and management of low back pain in the primary care medical setting, with emphasis on treatments supported by level A and B evidence. In response to the main points in Dr. Jones’ letter: 1. We believe a robust body of medical evidence supports the prompt resolution of most episodes of acute low back pain. While the exact percentage of patients whose symptoms resolve within a given period of time will continue to be debated, we do not feel that the recent literature quoted by Dr. Jones substantially changes our assertion. 2. As we point out in our article, physical modalities play an important role in the treatment of low back pain. However, we are unaware of any high-quality evidence supporting Dr. Jones’ assertion that “effective and timely treatment is essential to preventing chronicity,” nor that recurrent episodes of low back pain necessarily lead to permanent neurological changes. 3. Dr. Jones is correct in pointing out that a precise anatomical pain generator is not always found in patients with low back pain. We do not, implicitly or otherwise, advocate an aggressive search in every patient. However, in our view, ignoring the possible presence of a treatable lesion in deference to functional assessment is not in the best interest of patients. 4. In our opinion the literature strongly supports the view that psychosocial variables play a significant role in the persistence of low back symptoms. These issues were explored in depth within our article. In summary, although we acknowledge Dr. Jones’ points of view, we stand by the approach to diagnosis and treatment of low back pain outlined in our article. Peter Rives MD Alan Douglass MD
Repeating failed policies will not improve outcomes 11 January 2005
Jason D. Jones, Chiropractor none Send response to journal: Re: Repeating failed policies will not improve outcomes jjones{at}spinacare.com Jason D. Jones	The recently published second edition of Gordon Waddell's "The Back Pain Revolution" starts out "Back pain was a 20th-century medical disaster and the legacy reverberates into the new millennium." The article by Rives and Douglass advocates the same failing model. (1) Three unfortunately common errors pervert their understanding of the problem and thus prevent a useful conclusion. The errors are: misunderstanding the natural history of low back pain, looking for a diseased tissue instead of analyzing the system and giving only a superficial look at psychosocial issues. The author states that up to 90% of low back pain patients will recover within 12 weeks. The reference to this was an NIH grant guide that did not give a source for this data. We know that approximately 90% of low back pain patients will not continue to consult a medical practice after 3 months, but this does not mean that they are recovered. (2). In fact, a recent review of 36 studies reveals that at one year between 42%-75% of low back patients continue to have pain. (3) Two more recently published studies showed 52% of low back pain patients and 53% of sciatic patients still had pain and back-related disability at 5 and 4 year follow-ups, respectively.(4,5). While the authors did note that the recurrence rates are high, they did not note the most relevant aspect of this. All episodes are not created equal. Evidence suggests that chronic low-back pain causes neurologic remodeling leading to centrally mediated pain. (6) With each recurrent episode, the intensity, disability, duration and peripheralization of symptoms tend to increase and eventually not resolve.(7,8). Time is of the essence. A recent study showed that waiting even six weeks for treatment prevented improvement in psychosocial variables with symptomatic improvement. The oversight of these factors falsely casts a shadow of triviality over episodes of low-back pain, leading one to the false conclusion that timely treatment is not important. Rives and Douglass state that "An exact diagnosis and anatomic pain generator may not always be evident." That is certainly true, but this implicit assumption that we should search for an anatomic pain generator is misguided. Not to feign omnipotence, but I am unaware of a case where this has been fruitful - aside from pathology or a clear cut HNP with a predominance of anatomic leg symptoms. Bogduk has shown that painful tissues can be found in most cases, but what have we gotten from this? (9) Our affection in previous years for the disc - an undoubtedly painful tissue in many cases - was a complete and utter failure. The Quebec Task Force said "the inability to find diagnostic subgroups is the fundamental source of error in low-back pain management." Emphasis should be on functional classifications which can find relevant - if not yet perfect and complete low-back pain sub-groups. As just one example, a McKenzie assessment can provide an excellent predictor of outcomes. (10-20) Most PT's and many DC's know this. However, the generals (MD's) are not talking to their soldiers (PT's and DC's). Any guidelines or review that hope to positively effect outcomes must address this. Further, we see when the pain is effectively treated, the psychosocial issues tend to resolve as well. (21). These psychosocial variables are not simply a result of LIG (Lawyer Induced Greed) as the authors implied with their reference to a 31% reduction in claims when pain and suffering settlements were eliminated. Litigation is not a great predictive factor. (22) A more reasonable - or at least as reasonable - hypothesis for the 31% reduction in claims is that their treatment was ineffective, so without a monetary settlement they had no incentive to stay in the system! Non-organic signs do not indicate psychogenic pain. (22) Evidence is mounting that central hypersensitivity may account for the presence of Waddell's signs. (23). As we have seen, the natural history of low back pain is not a rosy as our authors have led us to believe. Effective and timely treatment is essential to preventing chronicity. To treat effectively, we must have a meaningful diagnosis. Currently the best tools we have are functional analyses. It would be profitable to our patients to have increased interdisciplinary communication so that the gatekeepers are truly aware of the treatment options available. And while psychosocial issues such as co- morbid depression do indicate a more complicated case, they do not indicate greed, malingering or psychosis. References: 1) Rives PA, Douglass AB. Evaluation and Treatment of Low Back Pain in Family Practice. J Am Board Fam Pract: 17:S23-S31 (2004). 2) Croft PR, Macfarlane GJ et al. Outcome of Low-Back Pain in General Practice: A Prospective Study. Br Med J: 316:1356-59. 3) Hestbaek L et al. (2003) Low Back pain: What is the Long-Term Course? A Review of Studies of General Patient Populations, Europ Spine J 12(2):149-165. 4) Enthoven P, et al. Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis. Spine 2004 Nov 1;29(21):2458-65. 5) Tubach F, et al. Natural history and prognostic indicators of sciatica. J Clin Epidemiol. 2004 Feb;57(2):174-179. 6) Oliver HG, et al. Preoperative back pain is associated with diverse manifestations of central neuroplasticity. Pain. Volume 97, Issue 3, June 2002, pp. 189-194. 7) Donelson R, et al. The low back pain experience: a natural history survey. North American McKenzie Conference. Orlando, FL, 2000. 8) Waxman R, et al. A prospective follow-up study of low back pain in the community. Spine 2000;25:2085-2090. 9) Bogduk N, et al. (1996) Precision diagnosis in spinal pain. In: Campbell, J. (Ed.) Pain 1996 - An updated review (pp. 313-323). Seattle: IASP Press. 10) Spitzer WO, et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management. Spine 1995;20:1S-73S. 11) Delitto A, et al. Evidence for an extension-mobilization category in acute low-back syndrome: a prescriptive validation pilot study. Physical Therapy 1993;73:216-28. 12) Donelson R, et al. A prospective study of centralization of lumbar and referred pain: A predictor of sympomatic discs and anular competence. Spine 1997;22:1115-1122. 13) Donelson R, et al. The centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine 1990;15:211-213. 14) Long A, et al. Does it matter which exercise? A multi-centered RCT of low back pain subgroups. Spine 2004 Dec 1;29(23):2593-2602. 15) Long A, et al. The centralization phenomenon: its usefullness as a predictor of outcome in conservative treatment of chronic low back pain. Spine 1995;20:2513-2521. 16) Sufka A, et al. Centralization of low back pain and perceived functional outcome. J Orthop Sports Phys Ther 1998;27:205-212. 17) Werneke M, et al. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26:758-65. 18) Werneke M, et al. A descriptive study of the centralization phenomenon. A prospective analysis. Spine 1999;24:676-683. 19) Karas R, et al. The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain. Physical Therapy 1997;77:354-360. 20) Kopp JR, et al. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposis, a preliminary report. Clinical Orthopedics 1986;202:211-218. 21) Wallis, BJ, et al. Resolution of psychological distress of whiplash patients following treatmen by radiofrequency neurotomy: A randomized double-blind, placebo controlled study. Pain, 73:15-22. 22) Waddell, G. The Back Pain Revolution. Churchill-Livingstone. New York. 2nd Edition. 2004. pp. 200-2001. 23) Centeno CJ, et al. Waddell's Signs Revisited? Spine 29;32:1392.