Management of chronic low back pain

In reply: There is a difference between wishful thinking and evidence. Elder advocates a focus on return to work. Elsewhere, I have described how this should be pursued.1 However, the evidence supports success only in the context of acute and subacute pain. I was commissioned to write on low back pain. In that context, evidence is lacking. Even Waddell, whom Elder cites,2 conspicuously avoided the issue of chronic low back pain; his evidence pertains only to acute low back pain.

Salmon and Hilyard promote the biopsychosocial model. Indeed, this model is now widely accepted. Even our own studies have shown how successful it can be to recognise and treat patients’ fears and mistaken beliefs.3 However, the evidence of success is limited to acute and subacute low back pain. The predictions of the biopsychosocial model have not been fulfilled in the context of chronic low back pain. Although better than no therapy, behavioural therapy is not more effective than other therapies, and does not “reduce pain generator input”, as Salmon and Hilyard contend. Insurers, who pay for this treatment, do not share their enthusiasm for it.4

Salmon and Hilyard also repeat the commonly held view that patients have multiple pain generators. There is no actual evidence for this assertion, while the available evidence indicates the opposite. When investigated comprehensively, fewer than 10% of patients have more than one simultaneous pain generator.5

Further, Salmon and Hilyard consider that complete relief of pain for 9–18 months amounts to palliative therapy. Yet the opposite is true. Not relieving pain by behavioural therapy is palliative. They also deprecate radiofrequency neurotomy with the accusation that it “may be less effective” when repeated, but fail to cite the literature showing that this is not the case.

They are correct in stating that reductionist procedures performed to the required standard are available in only a few centres. However, this does not invalidate these procedures; it reflects only a political and ideological problem in healthcare delivery. They also fail to reveal that in many places where these procedures are available, they are not performed according to best-practice standards. It is not the procedures, but misguided and unscrupulous practitioners, who render patients bewildered and dysfunctional.