Talk:Low back pain

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McKenzei method[edit]

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.[1]" 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[edit]

Does not affect recovery times [1] but than again no one has claimed it does. Doc James (talk · contribs · email) 20:02, 21 February 2015 (UTC)

Sources[edit]

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.[2] 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. [3]"

  • 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

  1. ^ Dunsford A, Kumar S, Clarke S (November 2011). "Integrating evidence into practice: use of McKenzie-based treatment for mechanical back pain". Multidisciplinary Healthcare. 4: 393–402. doi:10.2147/JMDH.S24733. 
  2. ^ Smith, Allison L.; McConville, Janet C.; Kolt, Gregory S. "The effect of the Feldenkrais method on pain and anxiety in people experiencing chronic low back pain.". latrobe.edu.au. New Zealand Society of Physiotherapists. 
  3. ^ Hillier, Susan; Worley, Andrea. "The Effectiveness of the Feldenkrais Method: A Review of the Evidence". Hindawi.com. Hindawi Publishing Corporation. Retrieved 12 November 2015. 

NRT[edit]

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 [2] 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[edit]

A new systematic review and meta analysis in BMJ has suggested that NSAIDs are not more effective than placebo for spinal pain. [3] 2001:56A:75B7:9B00:441:A41B:9784:50F1 (talk) 15:20, 23 March 2017 (UTC)

I tried adding the high-quality source, but it was deleted with this revert by Doc James. The edit summary says that "the source does not say that", however, I summarized the conclusion of the abstract, which said "At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.". If the source os not saying that there are no non-narcotic medications more effective than placebo, what is it saying? Rather than delete the high-quality source, why not just correct the text added tot he article?2001:56A:75B7:9B00:441:A41B:9784:50F1 (talk) 15:29, 25 March 2017 (UTC)
The summary is "NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important."
Summarized that as "Benefits with NSAIDs; however, is often small." The ref is still there.
Low does ketamine is useful for pain and is a non opioid. That meta analysis did not look at all non opioid solutions.
And opioids for LBP are not very useful either. Doc James (talk · contribs · email) 15:39, 25 March 2017 (UTC)
Thank you for your reply and for pointing out that the source is still there, and sorry that I missed that. I am not sure if "small" and "not meaningfully better than placebo" is synonymous...I note that text regarding alternative therapies has no 'softened tone' like that, the article just states "no better than placebo". Perhaps we should apply the same standards to NSAIDs? 75.152.109.249 (talk) 22:34, 25 March 2017 (UTC)
We have other sources that say "The medication typically recommended first are NSAIDs"
The BMJ ref also says "Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction." Doc James (talk · contribs · email) 03:52, 26 March 2017 (UTC)
Fair enough; thanks for your reply.2001:56A:75B7:9B00:441:A41B:9784:50F1 (talk) 04:41, 26 March 2017 (UTC)

Spinal manipulation[edit]

Ref says "For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)"

The evidence is low quality. The strong recommendation is for non pharmacological tx rather than spinal manipulation itself. Doc James (talk · contribs · email) 18:57, 15 May 2017 (UTC)


RECOMMENDATION 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation). . Taps2386 (talk) 21:03, 15 May 2017 (UTC)'

Nonpharmacological treatment = strong recommendation to include superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). maybe the sentence should read thus. Taps2386 (talk) 21:07, 15 May 2017 (UTC)

The strong recommendation is for non pharmacological treatment and not spinal manipulation directly.
Thus IMO the wording "A 2017 review recommended spinal manipulation based on low quality evidence." is best Doc James (talk · contribs · email) 21:15, 15 May 2017 (UTC)

You are correct. Great insight.Taps2386 (talk) 21:33, 15 May 2017 (UTC)