Re: Evidence-informed management of chronic low back pain

[Guest guest]

Patients with chronic low back pain (CLBP)

are finding it increasingly difficult to make sense of the growing

list of treatment. The current approach to the management of CLBP

and interventions, that make meaningful improvements in symptoms and

functional capacity confusing and virtually unobtainable.

Explanation Wanted Explanation Given Explanation Examined

It appears to me the way to eventually pull back the veil on

the mysteries of the back (core back etc?) and see what is going on

is to adopt the attitude of seeking explanations and when

explanations are give, thoughtfully examine those explanations.

Old Arab saying. Life is made up of many mysteries. There is no

greater mystery then that of the woman that lies behind the veil.

And that mystery is never is so exquisitely revealed when the veil

is lifted willingly.

There are many here that willingly and for free promote their work

or others work relative to improving the strength and conditioning

of the back. This gives this group a great opportunity to gain

knowledge. To take full advantage of those that would share their

technology and promote their sharing to learn more we need to

realize there are three types of people on this group that examine

the information.

First type is the person that does not really care about the

subject. Caring is evidenced by research. This person has not

developed an intellectual level that allows them to competently

evaluate, appreciated or revere explanations.

2nd type is that person that cares about the subject. Their

research evidences their caring. When explanations are given they

have established an intellectual level and interest that makes them

one who appreciates explanations and then with reverence they

competently examine the explanation and ask thoughtfull questions.

3rd type is that person that is in direct competition with an

explanation. We have to be on guard against this person. One would

hope that their interest and sincerity in the subject would lead to

better questioning of the explanation to make it better to

understand, but the opposite can happen. Their knowledge is more

used to question the explanation in a manner that makes it confusing

and seeks to denigrate it then help to make it clearer.

It is okay to use knowledge to expose weaknesses in an explanation,

but it should be stated that the one questioning the information has

a problem with and then their explanation.

People truly interested in subject appreciate examining explanations

that are given and that they can arrive at conclusions on. The

ultimate result of their examination and conclusions being the

development of beneficial applied technology.

The best Explanations are those that are the most transparent. When

you examine them you can fully see and understand them.

There is a lot of research relative to the back, which should as

said be applauded. However, he also stated no matter how

awesome it is to say 5000 words in tongues that no one understands

it is more awesome to say just 5 words that when said the unknowing

come away knowing and saying Amen.

We should promote those here that would openly share their

technology with the group and seek to have them explain themselves

in the hope that we can come away knowing and saying Amen I learned

something.

Scherger Chiropractor

Washington State USA

> One of our collegaues on Somasimple recently submitted the below

post. Members may find it to be of some interest:

>

> The Spine Journal has just published an enormous, free access,

special issue of reviews of the current evidence for CLBP treatments.

>

> http://www.sciencedirect.com/science/journal/15299430

>

> The Spine Journal

> Volume 8, Issue 1, Pages 1-278 (January-February 2008)

>

> Intro (extract):

> Patients with chronic low back pain (CLBP) are finding it

> increasingly difficult to make sense of the growing list of

treatment

> approaches promoted as solutions to this widespread problem. Their

> confusion is compounded by the financial and emotional cost of

> previous failed attempts. This frustration is felt not only by

> patients, but by all interested stakeholders, including clinicians

> trying to offer accurate advice and provide the most effective

> treatment to their patients, and third-party payers responsible for

> providing access to reasonable and necessary care. All share a

common

> goal and wish to use limited healthcare resources to support those

> interventions most likely to result in clinically meaningful

> improvements in symptoms and functional capacity. The current

> approach to the management of CLBP makes this goal virtually

> unobtainable.

>

> When a new treatment approach is being considered in fields as

> cardiology, infectious diseases, acute trauma, or neurology, there

is

> a general expectation that adequate research will support its

> effectiveness, safety, and cost effectiveness before it is endorsed

> as a viable treatment option. With CLBP, however, treatment options

> appear virtually endless and increasing every year, have strong and

> vocal advocates, and often limited scientific evidence. Treatments

> that have never been subjected to methodologically sound randomized

> controlled trials are routinely promoted as cures to unsuspecting

> patients. Conversely, approaches that have demonstrated only

minimal

> benefit in clinical trials continue to be recommended by proponents

> who allege that such studies were flawed and do not accurately

> represent current clinical practice....

>

> Here is a small excerpt from the concluding summary-

> Quote:

> This special focus issue contains review articles written by

> clinicians and researchers who summarized the evidence on 25

classes

> of commonly used interventions for CLBP. The wealth of information

> provided by these articles cannot be understated and every article

> must be read in its entirety to appreciate the particular strengths

> and weaknesses of the arguments used by the authors for each

> treatment approach. It is also necessary for the reader to look at

> the entire special focus issue to obtain an overview of the

different

> treatment options and place them in perspective. Although it was

> initially hoped that global recommendations regarding the use of

> specific interventions for CLBP could be made based on the

> information presented in each article, this goal has proven to

> elusive at this moment. When viewed as a whole, the articles in

this

> special focus issue pose more questions than they answer. Taken

> together, these reviews demonstrate the serious deficiencies in the

> available research for many of the treatment approaches that are

> commonly used for CLBP because of either unavailable, insufficient,

> or conflicting research results. These articles do not present

> convincing evidence that it is currently possible to select one

> treatment approach over another for patients with CLBP and give

very

> little guidance on when any specific treatment approach is

indicated.

>

> When viewed optimistically, the articles in this special focus

issue

> do suggest that a reasonable approach to CLBP would include

education

> strategies, exercise, simple analgesics, a brief course of manual

> therapy in the form of spinal manipulation, mobilization, or

massage,

> and possibly acupuncture. In patients with longstanding or severe

> symptoms and psychological comorbidities, there is some evidence

that

> a comprehensive multidisciplinary approach with cognitive

behavioral

> treatment, fear-avoidance training, or functional restoration is at

> least as beneficial as surgery. This interpretation of the best

> available evidence is not materially different than the

> recommendations from the Practice Guidelines on Acute Low Back Pain

> in Adults that were published by the Agency for Health Care Policy

> and Research in 1994 [2]. Although potentially heartening to the

many

> clinicians who have adopted aspects of this approach, it is

somewhat

> disappointing to note that 14 years after dozens of highly promoted

> new interventions, thousand of studies, millions of lost work days,

> and billions of dollars spent on its care, so little has changed in

> the evidence available to guide stakeholders and support treatments

> for CLBP.

> As noted in the review of the economic burden of LBP in this

special

> focus issue, the magnitude of this problem is likely increasing in

> the United States and the question that needs to be answered is

> whether any treatment should be offered and widely used before

there

> being sufficient research evidence to establish its efficacy,

safety,

> and cost effectiveness. It is a generally accepted principle in

most

> fields of health care that a treatment should not be offered to the

> public until there is sufficient evidence supporting its safety and

> effectiveness and a consensus by clinicians of different

backgrounds

> as to its most appropriate indications and contraindications. It

> should be evident to most readers that this is not the norm when

> dealing with CLBP and additional research is required to achieve

this

> long-term goal. In the interim, patients, clinicians, third-party

> payers, and policy makers have a responsibility to become

thoroughly

> familiar with, critically appraise, compare, and openly discuss the

> best available evidence presented in this special focus issue. In

> this supermarket of over 200 available treatment options for CLBP,

we

> are still in the era of caveat emptor (buyer beware)....

>

> =================