Talk:Low back pain

Manual therapy and acupuncture for LBP

This article could be improved by adequately represent the effectiveness of manual therapies and acupuncture. The evidence is of clear benefit for SM and c-LBP and mixed for acute. There also needs to be a discussion why osteopathic physicians, chiropractors and physical therapists manipulate the spine. That is is to help reduce pain, improve mobility to mechanical dysfunctions of the spinal segments. These mechanical dysfunctions are in the WHO and are most reliable with painful palpation of a spinal segments as this review suggest [1]. The JAMA has also recommended chiropractic care for LBP [2]. So, it seems like we may be minimizing the appropriateness of chiropractic management of low back pain. Massage has also been shown to be of short term benefit in this new review [3]. There is also good evidence of acupuncture for low back pain, maybe even moreso than medication, "The current evidence is encouraging in that acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP" [4] in this new review. The lede is rather ambiguous with spinal manipulation when the research is much more succinct, there is no mention of acupuncture whatsoever despite the evidence which suggests comparable effectiveness. Hoping we can have a good discussion and help make this article better by offering a complementary POV. Regards, DVMt (talk) 03:49, 16 May 2014 (UTC)

Re PMID 15454722, this 2004 review is very out-of-date; re the article in JAMA by Goodman et al., "JAMA" is not the one doing any recommending, and the authors of the article are not in any way recommending chiro; re PMID 24043951 I think you're overstating the findings (although the review is useful), same with PMID 23269281 which absolutely does not state that the evidence for acupuncture "good" as you're characterizing it. The sources you have offered and your interpretations of them send up red warning flags, I think we will need to review suggested edits to the article very carefully for source quality and accurate representation of the findings. Recommend we use RFCs and drop notifications at WT:MED for any significant suggested changes. Zad68 15:11, 16 May 2014 (UTC)

That's a rather interesting characterization. It would be red flags if I entered this into the article instead of discussing it. The representation of the findings are accurate, and this domain is my wheelhouse. "The current evidence is encouraging in that acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP. " http://www.ncbi.nlm.nih.gov/pubmed/23269281. When the AMA makes a recommendation for something 'non medicinal' like manipulation or acu, and there's a RS, well, it's worth consideration for inclusion in the article. Is the systematic review 'poor' evidence? I was using the term colloquially, but nonetheless, my point remains. DVMt (talk) 15:37, 16 May 2014 (UTC)

Agree with Zad68; I am concerned about the insistence that PMID 23269281 is being characterized as "good" evidence for acupuncture. The article states several limitations about the evidence, which should suggest that the evidence is not "good" - and suggests further suggestions by this editor needs to be careful scrutinized. Characterizing a one line mention in a short JAMA patient handout as a "recommendation" by the entire American Medical Association is beyond bizarre. Yobol (talk) 18:43, 16 May 2014 (UTC)

Did you not read my comment above? I said the paper itself was good. If JAMA recommends a trial of care for LBP, isn't that worthy of a mention considering the AMA once called chiropractic an unscientific cult? How about we discuss the paper itself which is why I posted here on talk instead of casting aspersions. DVMt (talk) 19:00, 16 May 2014 (UTC)

No, you said there is "good evidence" for low back pain, citing PMID 23269281. That would seem to be an incorrect reading of PMID 23269281. If you want to talk about a source, suggest a specific wording change citing the specific source. Short patient handouts are generally inferior to other sources such as systematic reviews so I see no reason why we should include that. Any insinuation that this is an endorsement or recommendation by the AMA is pure hogwash. Yobol (talk) 19:12, 16 May 2014 (UTC)

Look at the conclusions of the source, Yobol, and quote it back to me to prove that you've read it. If I made a claim that said "JAMA has recommended chiropractic care for LBP" you would ask me for a source. Then I provided you one. Is it a reliable source? Prove to me, using a reliable source, that JAMA did not endorse chiropractic therapy for LBP"many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed." Are you suggesting that the AMA's own medical journal is not a mainstream, reliable source? DVMt (talk) 19:21, 16 May 2014 (UTC)

I am suggesting that everything published in JAMA is not necessarily endorsed by the AMA, as you implied. I am also suggesting patient handouts are of lower quality than review articles, specifically systematic reviews, which there are plenty of in the medical literature. I have found that the main reasons editors try to use a lower quality source is to push a specific POV. Either present a specific statement by the AMA endorsing chiropractic, or let's drop the subject because it is going nowhere fast. Using a JAMA patient handout to backdoor a mention of the AMA will not work. Yobol (talk) 19:30, 16 May 2014 (UTC)

So, things that gets published in the journal of the AMA isn't endorsed by the AMA. That's speculative. Do you have a source for this? I never once said that the AMA endorsed chiropractic, I simply stated that the JAMA recommends chiropractic therapy (along with acu) for LBP. You seem to getting rather defensive. LBP, is after, all, a specialization of chiropractic as demonstrated by the World Spine Care [5] initiate. Looks like MDs and collaborating with DCs there too. Interesting. DVMt (talk) 19:37, 16 May 2014 (UTC)

The article cited does not "recommend" chiro in the first place. What it actually says is, "Some people benefit from chiropractic therapy or acupuncture." This is an observation about what some people with LBP have done, it is not a recommendation that people with LBP go get chiro, and certainly not ahead of exercise, physical therapy or medication. To see what an actual recommendation looks like, see for example this article on dietary salt, which has a definitive recommendation "Eat salt in moderation." The chiro reference in the LBP article is not most accurately characterized as a "recommendation." Zad68 20:01, 16 May 2014 (UTC)

(e/c)Of course, it's not "speculative", that's a fact. Besides being well known that publishers (AMA) do not necessarily endorse every statement written that they publish (JAMA), there is this statement, written in every single journal of JAMA, which reads, "All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do not reflect the policy of the American Medical Association, the Editorial Board, or the institution with which the author is affiliated, unless this is clearly specified." You did state the AMA endorsed chiropractic, when you said "When the AMA makes a recommendation for something 'non medicinal' like manipulation or acu, and there's a RS, well, it's worth consideration for inclusion in the article" in this edit. As it appears you do not even know what you yourself are writing, I'm taking leave of this discussion as a waste of my time. Cheers. Yobol (talk) 20:05, 16 May 2014 (UTC)

You're conflating things, Zad. Also, most chiro's are multi-modal so your insinuation that exercise or pt (whatever that means nowadays since they're jumping on the manipulation and acupuncture bandwagon) aren't part of chiropractic management is incorrect. Also, the quote is "ome people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed"'. The JAMA article is clear on this point, it suggests some people benefit. If you're getting hung up on a word, by all means, 'suggests' is the actual quote, but Yobol's assertion that the the JAMA isn't necessarily endorsed by the AMA is grasping at straws. How do you suggest we deal with this? It is factual, JAMA is a reliable source. DVMt (talk) 20:14, 16 May 2014 (UTC)

I have asked for wider input from the editors at WT:MED here. Zad68 20:31, 16 May 2014 (UTC)

Sounds good. DVMt (talk) 20:35, 16 May 2014 (UTC)

JAMA publishes all kinds of things. Practically none of what they publish is an official position of the AMA. A good analogy would be the conversations or casual publications of the pope and the pope's infallible ex cathedra statements - one is much more weighty than the other. Journal publications are like conversations unless they are position papers. Blue Rasberry (talk) 20:38, 16 May 2014 (UTC)

Speaking as an interested reader, not a medical practitioner, I think that:

1) - this discussion has become highly focused on the extent to which an article in the JAMA represents an AMA "position", so much so that

2) - the initial concern raised by editor DVMt is getting lost.

For example, here are two sentences from the beginning of the Alternative medicine section of the article: "It is not clear if chiropractic care or spinal manipulation therapy (SMT) improves outcomes in those with low back pain more or less than other treatments. Some reviews find that SMT results in equal or better improvements in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up; other reviews find it to be no more effective in reducing pain than either inert interventions, sham manipulation, or other treatments, and conclude that adding SMT to other treatments does improve outcomes."

What the second sentence seems to say to me is "Some reviews find that SMT results in equal or better improvements in pain and function ...; other reviews ... conclude that adding SMT to other treatments does improve outcomes." In other words, "some reviews" are neutral or positive and "other reviews" are positive. I don't know if this is what it was meant to say. I fear the meaning is buried in too many words. Wanderer57 (talk) 22:26, 16 May 2014 (UTC)

Thanks Wanderer57. We could be more concise with respect to acute LBP, chronic LBP and maintenance SMT for LBP. We have editors here who 'don't believe' in manipulative therapy instead of understanding manipulative therapy. Also the article doesn't really address that 'alt med' such as manipulation is combined with exercise (mainstream) which seems to yield better outcomes. DVMt (talk) 22:58, 16 May 2014 (UTC)

Leading cause of disability?

Low back is currently the leading cause of disability globally. -- Buchbinder R, Blyth FM, March LM, Brooks P, Woolf AD, Hoy DG. (2013). "Placing the global burden of low back pain in context". Best Pract Res Clin Rheumatol. 27 (5): 575–589. doi:10.1016/j.berh.2013.10.007. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

A new edit citing Buchbinder says that according to the 2012 Global Burden of Disease study that LBP is now the #1 cause of disability. However, the WHO's site here: http://www.who.int/features/factfiles/global_burden/facts/en/index7.html which is tagged as updated 2013 says that "Hearing loss, vision problems and mental disorders are the most common causes of disability". I am not sure how to reconcile the two. Zad68 15:28, 16 May 2014 (UTC)

That would be because Buchbinder is probably using a different metric than the WHO (reading the Buchbinder article, they are using "years living with disability" as the metric for cause of disability, which would probably not be the one WHO is using. Since they are purportedly using WHO data, and the WHO disputes their interpretation, I would remove mention of it from this article. Yobol (talk) 19:32, 16 May 2014 (UTC)

We don't 'remove' mention of systematic review, we present both sides. DVMt (talk) 19:39, 16 May 2014 (UTC)

Agree w/Yobol, based on this I am removing the recent addition from the article and bringing it here for discussion, to see if there's consensus for including it, and if so, how. There's no rush on this. Zad68 20:04, 16 May 2014 (UTC)

Why wouldn't you include it? And feel free to discuss, but it's rather odd that you selectively take out a reliable source rather than including the WHO source until we find something better. DVMt (talk) 20:18, 16 May 2014 (UTC)

It is definitely a top cause of disability globally. Let me look at the GBD report. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:57, 17 May 2014 (UTC)

• Okay we have [6] which gives "116 704" for the DALYs for LBP. Ischemic heart disease comes in at "129 820" so I agree strange. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:04, 17 May 2014 (UTC)

That review however is from 2012 and the Buchbinder is from 2013. This site suggests it did compare it again heart disease and other conditions [7] We might have to dig deeper. DVMt (talk) 16:01, 17 May 2014 (UTC)

Yes am also trying to figure out the definition they are using. Was 6th for overall disease burden based on DALYs in 2010

Ah they are using years lived with disability (YLDs). It was also highest in 1990. Because it doesn't kill you and it develops fairly early thus many people have LBP much of their life. Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:11, 18 May 2014 (UTC)

Agreed. It is a recurrent issue and a big drain on health system. Speaking of having LBP for much of their life, this recent review discusses the topic [8] and might be useful to the article. DVMt (talk) 15:54, 18 May 2014 (UTC)

User:Zad68, User:Jmh649, have you found any more research that states whether or not LBP is the leading cause of global disability? Regards, DVMt (talk) 16:33, 4 June 2014 (UTC)

McKenzei method

This was added to the lead "There is growing recognition of the role of physiotherapy McKenzie method in treating lower back pain and evidence appears to support the directional preference exercises in lower back pain, particulalry with the first attack." Already discussed in the body of the article. Removed as IMO undue weight for the lead. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:01, 1 October 2014 (UTC)

Paracetamol

Does not affect recovery times [9] but than again no one has claimed it does. Doc James (talk · contribs · email) 20:02, 21 February 2015 (UTC)

Sources

This content

"The Feldenkrais Method is an educational system that may be useful in teaching individuals with back pain to move more efficiently and easily. In scientific trials, the method has been found effective in reducing the affective dimension of lower back pain. A systematic review of existing research into the method's efficacy concluded that clinicians may promote use of the method to enhance patients' physical performance and efficient self-use, but that further research is needed. "

• The first source is primary and not pubmed indexed and from 2001.

• The second source is not about back pain?

Doc James (talk · contribs · email) 15:09, 14 November 2015 (UTC)

References

NRT

The ref concludes "NRT appears to be a safe and effective intervention for nonspecific LBP. This conclusion is limited to three trials conducted by a small number of experienced clinicians."

The the results are tentative.

Tentative? Dr. Urrutia (the first author of the Cochrane review) sent this explanatory letter to Dr. Kovacs. Dr. Urrutia said that this review and its three RCTs provided valuable scientific evidence, proving that NRT is effective, safe and cost-effective to treat lumbago. The same author acknowledged that wording of conclusions could lead to misinterpretation but editors of Back Review Group were keen on stating that NRT good results must be restricted to Spain (All editors were from english speaking countries and The Netherlands).

This ref calls it alt med [10] Doc James (talk · contribs · email) 04:40, 1 December 2015 (UTC)

This ref describes NRT as something incompatible with alternative and complementary medicine. — Preceding unsigned comment added by 80.30.141.138 (talk) 21:46, 3 December 2015 (UTC)

Incompatible how? Doc James (talk · contribs · email) 05:07, 4 December 2015 (UTC)

Technique developed by medical specialists and researchers, based on scientific evidence, reviewed by Cochrane, implemented and audited by Spanish National Health System. — Preceding unsigned comment added by 81.38.49.12 (talk) 08:25, 4 December 2015 (UTC)

Does nothing to mean it is not alt med Doc James (talk · contribs · email) 16:47, 4 December 2015 (UTC)

Just three? Can we really justify including it at all here? -- BullRangifer (talk) 05:02, 1 December 2015 (UTC)

There has been a few not very well done trials since. But yah not sure if it is notable. I am okay with one sentence. Doc James (talk · contribs · email) 05:08, 1 December 2015 (UTC)

User:BullRangifer the IP in question is also trying to add primary sources here Neuroreflexotherapy Doc James (talk · contribs · email) 07:14, 3 December 2015 (UTC)

I guess their are two main disagreements

• Is NRT alt med
• Is the evidence preliminary or tentative?

I would say yes to both based on the evidence above Doc James (talk · contribs · email) 16:49, 4 December 2015 (UTC)

I'm assuming you mean that it is tentative, but in that case I agree, it is both alternative medicine and has very little support. CFCF 💌 📧 18:22, 12 December 2015 (UTC)

Alt med? Tentative evidence?
Let us see:
- Three trials, two of them high quality, and a Cochrane systematic review.
- Four clinical guidelines (COST B13-EU, NCCPC-UK, ACOEM-US, American Pain Society-US) reviewed NRT primary sources.
- Results allways better than placebo/sham and standard care and technique recommended for chronic LBP if available.
- Technology permitted only to medical practice after appropriate postgraduate training.
- Taught in the OMC (Spanish Official Medical College) via AEMEN (Spanish Asocciation of NRT Medical Specialists).
- Partially Implemented and audited in Spanish National Health Services
- Since 2004, 25000 to 30000 spanish patients treated over a decade.
Preliminary? possibly.
Tentative and alternative? well, then the motor vehicle is also an alternative transportation based on tentative evidence.Nortingi (talk) 17:09, 18 December 2015 (UTC)

The UK guideline states " However, the results are limited to trials conducted in one country by small number of specially trained practitioners" Doc James (talk · contribs · email) 17:59, 18 December 2015 (UTC)

Then, according to the same guideline, I suggest a coherent change. "1+ evidence level" instead of "tentative evidence". We may also use A level or strong evidence (EU guideline), fair evidence (APS guideline) or C level (AECOM guideline). We agree?Nortingi (talk) 21:44, 18 December 2015 (UTC)

"Tentative", "limited", or maybe "weak" would all be fine here I think (remember this is for a general audience). Alexbrn (talk) 21:48, 18 December 2015 (UTC)

For general audience but also subject to verification, isn't it? I think "Tentative" and "weak" evidence are not verifiable. "Limited" could be used because effectiveness is limited to trhee trials and more RCTs are required for other locations but "fair evidence" is undestood by general audience and verifiable citing the APS guideline.Nortingi (talk) 22:56, 18 December 2015 (UTC)

We should definitely use common language. Doc James (talk · contribs · email) 01:02, 19 December 2015 (UTC)

Given our sources overall, I think "fair" would be overselling it. Alexbrn (talk) 07:22, 19 December 2015 (UTC)

"Fair evidence" is common language and also verifiable. According to Wikipedia content policy,"tentative evidence" is not verifiable regarding NRT. In addition, "fair" is a commonly accepted level of evidence unlike "tentative". On the other hand with all due respect, it is an editor's opinion whether "fair evidence" is "overselling" or not and it should be left aside. As far as I know, we are talking about content and verifiability, and trying to reach a consensus. Nortingi (talk) 09:54, 19 December 2015 (UTC)

Yeah but plucking out EBM vocab and using it in a lay context can be subtly misleading. We are obliged to summarize the totality of our sourcing accurately for the general reader: we verify against meaning, not by doing a string comparison. I see no problem with the way Doc has done this - the information that "the results are limited to trials conducted in one country by small number of specially trained practitioners" in particular colours any report of efficacy we might want to make. Alexbrn (talk) 09:42, 19 December 2015 (UTC)

(Add) in fact reading the Cochrane review, I wonder if we still aren't overselling this as the reviewers have their eyebrows raised over the "surprising claims" made for this treatment. I think we should be including the Cochrane caveats that while very limited (and now old) research appeared to show benefit, the lack of confirming research makes it impossible to generalize about the effectiveness of this therapy. Often, a strong geographic preference for a particular treatment is a "tell" of quackery since what works, spreads. Has this therapy been picked up by the skeptic community yet? Alexbrn (talk) 10:06, 19 December 2015 (UTC)

NSAIDs no better than placebo

A new systematic review and meta analysis in BMJ has suggested that NSAIDs are not more effective than placebo for spinal pain. [11] 2001:56A:75B7:9B00:441:A41B:9784:50F1 (talk) 15:20, 23 March 2017 (UTC)