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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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 412 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 elementseducation, 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.
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