Back pain

A. O. Frank

Arthritis Centre, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, UK

SIR, Mounce [1] is to be congratulated on her concise editorial on the complex subject of back pain. I am grateful for the opportunity to make some comments.

The article referred to low back pain and should have had that as its title. It made no reference to neck pain (with or without referral to the interscapular areas) or to pains arising from the thoracic spine.

Benefit payments have actually declined in the UK since 1995. Thus the number of working-age recipients of UK invalidity or incapacity benefits for back incapacities (irrespective of site in the spine) fell from 381 000 in 1995 to 308 000 in 2000 (Fig. 1



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FIG. 1. Number of working age recipients of UK social security benefits for back incapacities (000s) 1990–2000. The data were kindly provided by the Department of Work and Pensions, UK.

 
Red flags remain the bible of spinal screening, but they are not infallible. Symptomatic osteoporosis is not always generalized, is not associated with constitutional symptoms and may not be picked up on blood tests. Vitamin D deficiency is frequently seen in the presence of an elevated parathyroid hormone concentration but with normal calcium and alkaline phosphatase levels in north-west London. Metabolic bone disease is, however, the largest single diagnostic group (other than mechanical/degenerative back pain) seen in rheumatology back clinics, at least where there is a strong ethnic minority population [2]. In our large study of 667 consecutive referrals to a large rheumatology service in north-west London between 1994 and 1996, 51 of the patients (8%) had identifiable causes of low back pain. The largest subgroup of 15 patients had metabolic bone disease [2].

The term ‘sciatic pain’ was not defined by Mounce. Many prefer the use of ‘leg pain’ to describe patterns of referral into the leg [3, 4], as they would differentiate between the pains of sciatic root irritation, femoral root irritation and referred pain into the leg. In our series of 538 patients with mechanical/degenerative low back pain, 144 patients had pain referred below the knee without neurological signs and 74 had neurological signs, only 35 of which related to nerve compression confirmed with imaging [2]. Our experience did not confirm Mounce's view that the most common cause of ‘sciatica’ is nerve compression. I accept that pain from sciatic roots may arise from chemical rather than mechanical causes. Our patients with radiating leg pain were significantly more disabled (Roland score, P < 0.001) and depressed (modified Zung score, P < 0.05) than those without radiating leg pain [2].

I entirely support the view that ‘person management’ is vital in facilitating adjustment and compliance and that rheumatologists are poorly trained in helping those for whom the medical model of disease is unhelpful [5].

‘Medical interventions appear to have little effect on work resumption ... ’ needs clarification. The subject has been reviewed authoritatively by the Faculty of Occupational Medicine, who stated [6]:

There is moderate evidence that, for the patient who is having difficulty returning to normal activities at 4–12 weeks, changing the focus from purely symptomatic treatment to ‘back school’ type of rehabilitation programme can produce faster return to work, less chronic disability and less sickness absence. There is no clear evidence on the optimum content or intensity of such packages, but there is generally consistent evidence on certain basic elements—education, reassurance and advice, exercise, pain management, vocational rehabilitation in an occupational setting and rehabilitation.

The principles of rehabilitating individuals back into work have been reviewed recently and are appropriate for those with back pain [7, 8].

It is important to recognize that ‘pain management’ and ‘rehabilitation’ are converging, with the realization that pain management is facilitated by assisting the patient to focus on goals, e.g. improved leisure or returning to work. I entirely endorse Mounce's recognition of the value of cognitive behavioural therapy (CBT), but it is the incorporation of CBT with education, exercise and vocational rehabilitation that many now believe is the way ahead for those disabled by low back pain.

References

  1. Mounce K. Back pain [editorial]. Rheumatology2002;41:1–5.[Free Full Text]
  2. Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force Classification. Int J Clin Pract2000; 54:639–44.[ISI][Medline]
  3. Frank AO. Low back pain. Regular review. Br Med J1993;306:901–9.[ISI][Medline]
  4. McAuley JH, De Souza LH, Frank AO. The importance of radiating leg pain in assessing health outcomes among patients with low back pain. Spine1999;24:100–1.[Medline]
  5. Keat A, Frank AO. Undergraduate education in rheumatology. Br J Rheumatol1997;36:295.
  6. Carter JT, Birrell LN. Occupational health guidelines for the management of low back pain at work—principal recommendations. London: Faculty of Occupational Medicine,2000.
  7. British Society of Rehabilitation Medicine. Vocational rehabilitation: the way forward. Report of a Working Party of the BSRM (Chair A. O. Frank). London: British Society of Rehabilitation Medicine,2000.
  8. Frank AO, Chamberlain MA. Work and the musculoskeletal disorders [editorial]. Rheumatology2001;40:1201–5.[Free Full Text]
Accepted 22 March 2002