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Open Access Highly Accessed Debate

Chronic non-specific low back pain – sub-groups or a single mechanism?

Benedict Martin Wand* and Neil Edward O'Connell

BMC Musculoskeletal Disorders 2008, 9:11  doi:10.1186/1471-2474-9-11

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Authors' response to comments

Neil O'Connell   (2008-05-06 16:21)  Centre for Research in Rehabilitation, Brunel University, UK

We have read with interest the comments made regarding our debate paper and thank the authors for their contribution to the discussion.

Addressing the points raised we would argue that while interventional techniques such as facet joint injection and discography are commonly used in an attempt to make specific diagnoses in CNSLBP, the early promise of these techniques has not been supported by high-quality evidence. For a discussion of the limitations of interventional diagnostics in CNSLBP we would refer readers to the excellent review by Carragee and Hannibal (2004).

It is possible that the low specificity and reliability of these approaches may rest with the techniques themselves. However an alternative explanation for this (and one which fits with our proposed model) is that CNSLBP is not a condition driven by specific spinal pathology.

In terms of clinical phenomena such as trigger points we feel that there is no convincing data to support the use of trigger points in making diagnoses in this condition. Trigger points may themselves be a manifestation of heightened central sensitivity in the pain matrix of the CNS rather than representing a genuine peripheral abnormality.

Whilst clinical observations are interesting they do not represent convincing levels of evidence. As most clinicians will attest, interventions that appear to demonstrate acceptable levels of efficacy in the clinic often do not perform as well in properly controlled studies. Indeed the sub-grouping argument in low back pain has arisen in part from this tension between research findings and clinical experience.

We would suggest that the difficult decision to trust robustly gathered evidence over our own personal perceptions is a prerequisite to truly understanding the difficult condition of CNSLBP and working towards more effective therapies.

Benedict Wand PhD, Neil O'Connell MSc

References

Carragee EJ, Hannibal M: Diagnostic evaluation of low back pain. Orthop Clin N Am 2004; 35: 7-17

Competing interests

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subgroups may exist!

Shahram Sadeghi   (2008-04-21 13:12)  ACECR email

Conventional interventions do not reveal the pain source in many cases.

But with the use of joint blocks and discography; the facet joint, the sacroiliac joint and internal disc disruption can be identified as pain generators in almost 80% of patients; so we can see subgroups in low back pain!

Competing interests

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MD

Mike Montbriand   (2008-02-07 15:02)  Lakeshore Medical Clinic email

In the 21st century where 85% of chronic low back pain can be diagnosed by interventional techniques, it is sad to still see articles talking about chronic non-specific back pain. Dr. N. Bogduk (1) has delineated these statistics for years and made a recent educational module for neurologists for such.

I have an interest in myofascial pain and can see 3 cases of predominantly Quadratus Lumborum spasm daily. If you sit behind a patient side-sitting and grab the back muscle mass, one will find the front edge often three times more tender than the back edge. Further examination will delineate Quadratus lumborum myofascial pain. Much of these co-exists with disc or facet disease but they do help explain the 15% Dr. Bogduk could not determine.

Talking about low back pain is like talking about a stomach-ache and lacks significant "precision".

(1) Precision Diagnosis and Treatment of Back and Neck Pain

Nikolai Bogduk, Michael Karasek

CONTINUUM Lifelong Learning in Neurology

December 2005; Volume 11(6); pp 94-136

American Academy of Neurology (Continuing Education Module)

Competing interests

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