What If People Were Dying From LBP?

May 4, 2015

Of course, low back pain (LBP) isn’t a diagnosis.  It’s a symptom, and a very non-specific (NS) symptom at that.  Unfortunately, the lumbar spine, with all its complexity, has a very limited vocabulary with which to express itself when some part of it is in trouble.  So LBP can be the result of many different pathologies for which there obviously is no single effective treatment.  Yet we keep conducting research trying to find the best treatment for the 85% or more with this NS symptom.

Let’s for a moment consider fever, which long ago was another NS symptom, but a very serious one.  For centuries, millions with a fever ended up dying, many during pandemics, many others as more isolated cases.  Many treatments were desperately tried hoping to save lives.  The breakthrough came when the microscope was invented that revealed microbes causing what became known as infection.  Culturing techniques and other diagnostic innovations eventually led to the accidental discovery of penicillin and other very effective antibiotics based on their specificity for each microbe.

If the scientists and physicians of that day had simply searched for the best treatment for NS fever, people would have continued dying. Instead, it was a breakthrough in diagnostics that led to saving millions of lives from infections.

What if people were dying from NS-LBP?  How long would we persist in searching for the best treatment for NS-LBP? Wouldn’t we be far more focused on learning something about its cause?

While many LBP treatments likely have value for some types of LBP, they are certainly not one-size-fits-all-treatments as they are commonly delivered and portrayed. Would abdominal or chest pain treatment be dictated primarily by the clinician the patient selects for care? Does every LBP patient simply look like a nail for the hammer(s) each clinician is trained to use?

Instead, as with fever, shouldn’t LBP researchers be focused on learning more about the cause of LBP? Unfortunately our best imaging technology has failed to help us find structural causes.  Knowing that, the Cochrane Back Review Group wrote in 1998: “There is urgent need for good ideas about how to identify homogeneous subgroups. The efficacy of interventions in the subgroups should be studied in randomized controlled trials.”(1)  Their “urgent need” was seventeen years ago!

Five years later, they wrote again: “systematic reviews on the efficacy of preventive and therapeutic interventions can never provide an adequate basis for clinical guidelines.  We clearly need additional systematic reviews of etiological, diagnostic, and prognostic studies.  Only then can the guidelines hope to offer an evidence-based answer to the “Holy Grail”-type questions, such as “which interventions are most effective for which patients?”(2)

Consider further two surveys (1998 and 2013) of international LBP researchers.(3, 4) Both reported that the #1 research priority was: “Can different varieties or subgroups of LBP be identified and, if they can, what criteria can be used to differentiate among them?” One listed twenty and the other twenty-five top research priorities.  The focus of most RCTs and LBP guidelines, i.e.“finding the best treatment for NS-LBP”, was of such low value to the responders that it didn’t appear on either list.

Little clinical research and no LBP clinical guidelines to date offer any insight into which interventions are most effective for which patients.  They contribute little or nothing to the quality of our decision-making when treating an individual with LBP. When will we get the message and shift our research focus?

Identifying and validating subgroups needs to become our top research focus.  But that requires more than RCTs. A new research paradigm(5) is needed that begins with reliability studies to demonstrate that both subgroup members and non-members can be reliably identified. A reliably identified subgroup then feeds subgroup-specific observational cohorts to identify potentially effective treatments.  Only then can the time, effort, and expense of conducting an RCT be justified in hopes of validating that subgroup by identifying a standardized, predictably effective treatment.

Ironically, guidelines have yet to acknowledge the considerable research over the past twenty-five years that has successfully identified and validated some LBP subgroups, most based on clusters of clinical findings. One with considerable support is the “derangement” subgroup in whom “pain centralization” and a “directional preference” are reliably elicited during a standardized baseline mechanical examination. Subgroup-specific observational cohorts, RCTs, and systematic reviews have validated this mechanical diagnosis. But these studies are routinely overlooked by most clinicians, researchers, and every guideline-to-date, constrained by their tunnel vision on finding the best treatment for NS-LBP.

What a great concept: matching treatments to individual patient characteristics!! Sorta like selecting an antibiotic for a specific microbe instead of treating a fever with blood letting.

Of course, for every validated LBP subgroup, the percentage considered to have NS-LBP decreases…..and that’s a good thing.  So why do funders keep funding RCTs focused on NS-LBP?  It was Einstein who defined insanity as “doing the same thing over and over again and expecting different results.”

In summary, it’s deeply troubling that 1-our lack of progress in solving LBP, 2-the large numbers who are disabled by low back conditions, and 3-the increasing amount we spend each year for ineffective care, are insufficient motivation to bring change in either the conventional LBP research paradigm or the focus of clinical guidelines.

How quickly would we change our research focus if people were dying from LBP?

References
1. Bouter L, van Tulder M, Koes B. Methodologic issues in low back pain research in primary care. Spine. 1998;23(18):2014-20.
2. Bouter L, Pennick V, Bombardier C. Cochrane back review group. Spine. 2003;28(12):1215-8.
3. Borkan J, Koes B, Reis S, Cherkin D. A report from the second international forum for primary care research on low back pain:  reexamining priorities. Spine. 1998;23(18):1992-6.
4. Costa L, Koes B, Pransky P, Borkan J, Maher C, Smeets R. Primary care research priorities in low back pain: an update. Spine. 2013;38:148–56.
5. Spratt K. Statistical relevance. In: D.F. Fardon ea, Editors, editor. Orthopaedic Knowledge Update: Spine 2. 2nd ed. Rosemont, Illinois: The American Academy of Orthopaedic Surgeons; 2002. p. 497-505.

Please share your thoughts with me and ask whatever questions come to mind.

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