Management of chronic low back pain

To the Editor: Bogduk’s article on management of chronic low back pain1 was disappointingly retrogressive as a guide for general practitioners. Compartmentalising back pain management as monotherapy, multidisciplinary therapy or “reductionism”, and favouring the last, reinforces the medical model which has singularly failed to stem the epidemic of low back pain disability affecting the developed world.

The biopsychosocial model of chronic spinal pain is now widely accepted and rationally emphasises the multi- or interdisciplinary model of management.2,3 Bogduk’s preference for the reductionist approach may be reasonable in a specialised centre and as a basis for research, but must justify its practical relevance in the face of the following:

• Available data on the reductionism approach are meagre, conflicting and mainly derived from pain-clinic populations likely to differ from patients presenting to GPs.

• Diagnostic joint and disc injection procedures and radiofrequency treatment performed to the required standard are available in only a very few centres.

• Radiofrequency lesioning of the nerve supply to symptomatic joints has been shown to provide pain relief limited to 9–18 months.4 Repeat lesioning may be less effective and is impracticable in the long term.

At best, these treatments could be considered palliative.

Of course, patients can only benefit from accurate diagnosis and reduction of pain from identified peripheral generators. Unfortunately, for most people with chronic back pain, it is not that simple. Usually there are multiple pathologies and pain generators, multisegmental dysfunction, disrupted motor control and interacting peripheral and central neural sensitisation mechanisms. And that is just the “bio” of the biopsychosocial model. There is then the interplay with the individual’s psychological and social environment.

It is often a challenge to communicate the diagnosis effectively in the face of conflicting input from other health providers, the media and patient preconceptions. Just “plonking” “the diagnosis” before a patient and dangling a seductive “techno fix” that does not deliver in the long term is precisely what renders patients with chronic pain increasingly bewildered, dysfunctional and desperate to try one passive treatment after another.

The biopsychosocial model provides a basis for management in both general and specialist practice. Appropriate interventions to reduce pain-generator input are embedded in a cognitive behavioural management matrix that imbues patients with accurate, relevant knowledge of their conditions and commonsense self-management techniques to maintain appropriate activity levels, goal setting and psychological positivity.

For a time-challenged GP, collaboration with an activation- and exercise-oriented physiotherapist can be effective. The GP’s role is to provide the “white coat authority” so vital in recruiting patient confidence.