Abstract
BackgroundLow back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches.DiscussionMany clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient.An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention.SummaryThe disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed.
Highlights
Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research
This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials
We propose instead that current treatment may be ineffective because it has been misdirected
Summary
Sub-grouping is only one of a number of possible explanations for the manifestations of CNSLBP What clinicians and researchers mean by a sub-group is not always clear. Lumbar stabilisation training programmes, which interpret these problems as causative and address them from a biomechanical perspective [172] and other active [173] and passive [174] interventions aimed at changing the mechanical behaviour of the lower back demonstrate limited clinical effectiveness. The mechanisms presented in the model should be acknowledged as speculative but represent an attempt to interpret the alterations in brain function that have been demonstrated in CNSLBP in light of the clinical manifestations of the condition. CNSLBP patients have back pain yet no conservative or surgical pain relieving measures directed at the back appear effective They display a number of biomechanical abnormalities, treatment directed at normalising lumbar biomechanics has little effect and there is no relationship between changes in outcome and changes in spinal mechanics. Given the growing body of evidence indicating similar neural mechanisms in CNSLBP, the development of clinical strategies targeted at normalising neurological processing represents a challenging new direction for musculoskeletal clinicians and researchers involved in the management of CNSLBP
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