Open Access Highly Accessed Study protocol

Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation

Esther T Maas*, Johan NS Juch, J George Groeneweg, Raymond WJG Ostelo, Bart W Koes, Arianne P Verhagen, Merel van Raamt, Frank Wille, Frank JPM Huygen and Maurits W van Tulder

BMC Musculoskeletal Disorders 2012, 13:260  doi:10.1186/1471-2474-13-260

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Additional acknowledgement

Esther Maas   (2013-04-03 12:18)  VU University Amsterdam email

The authors would like to add an acknowledgement to the article: funding for this open source publication was received from The Netherlands Organisation for Scientific Research (NWO). We thank NWO for this funding.

Competing interests

None declared


Trial plans

Brian Sweetman   (2013-01-24 17:15)  NHS email

The plans of Maas et al (1) to evaluate back pain treatments have two important features not usually included in such studies. One is to check for cost effectiveness. The second is to study subgroups. But individual treatments need to be inspected for each subgroup.
All these aspects were designed into a randomized controlled trial of three types of treatment and a linked classification study (2,3). There was no benefit shown when the results for the total of unseparated patients were inspected. But when subgroups were inspected, one type responded particularly well to traction. This type may well correspond to what Maas et al will select by sacroiliac block, though our definition had wider and easier clinical selection criteria.
The patients were also asked about the effects of previous treatment for the better, worse or no effect (2,4). Though this particular information was retrospective and the effects clearly not curative in the sense that these patients were all attending for further intervention, the answers might just be of some help in selecting specific treatments for particular conditions.
Thus from our database totaled standardised deviates for facet joint pain suggested help with injections as is part of the Maas definition, but also somewhat surprisingly there was a little bit of help with manipulation. There was no obvious effect with traction or firm bed. Symmetrical pain potentially due to degenerative disc disease without radiculopathy was possibly helped with traction; there was no effect with tender spot injection, and it was worse with manipulation, exercises and a hot bath. The Maas sacroiliac group may be the same as our strain group, which was helped by traction as also shown in the prospective RCT mentioned above.They were alsohelped by injection and possibly short wave diathermy. They tended to be somewhat worse with manipulation, firm bed and hot bath
If it is not too late to amend the study protocols, we would recommend including sufficient initial clinical classification observations. They would also need outcome measures for each type of treatment given by the therapists as part of their pckage so as to allow subsequent analysis.

Sweetman BJ, Sweetman SJ. NHS

Swansea, UK.


1. Maas ET, Juch JN, Groeneweg JG, Ostelo RW, Koes BW, Verhagen AP, Raamt M, Wille F, Huygen FJ, Tulder MW. Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation.
BMC Musculoskeletal Disorders 2012, 13:260
Provisional Abstract 28 December 2012.

2. Sweetman BJ. Numerical classification of common low back pain. MD Thesis, London University, 1985.

3. Sweetman BJ. Low Back Pain, some real answers. 2005. tfm Publishing, Harley SY5 6LX.

4. Sweetman BJ, Sweetman SJ. Common low back pain databases: in preparation; 2012.

Competing interests



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