Editorial

Why is the recent research regarding non-specific pain so non-specific?

Low back pain is a complex condition, often recurring or chronic, which has proved difficult to characterise. To explore an alternative approach to assessing low back pain, an expert panel adapted the ‘Miracle Question’ from Solution-Focused Brief Therapy. This asks about a forward scenario of waking without the problems that the client had presented with. The question was adapted to: What would you do if you did not have back pain?

To explore the use of the Adapted Miracle Question (AMQ) within an interview study of patients with low back pain.

The AMQ was used in an interview study of 34 participants recruited from the UK Back Skills Training (BeST) trial, assessing the effectiveness of a cognitive behavioural approach intervention for the management of low back pain. Responses to the AMQ were analysed thematically and then case by case.

Interviewees talked about details of their activities and ability to function that would be different, and about change to their quality of life. Some talked about work. Five interviewees said that it would make no difference to them. When considered overall, the responses could be categorised as: no change; some change in activity/function; a return to their pre-back pain state; and life would be transformed.

The AMQ was straightforward to ask and prompted a breadth of responses which may be useful in tailoring treatment. This question warrants further evaluation in the clinical setting.

Low back pain is a common, disabling condition with high personal and economic costs. Despite clinical guidelines, there have not been tangible reductions in the population prevalence of back pain or its serious long-term consequences. One reason for this might be that the ‘one-size fits all approach’ advocated by many guidelines fails to target treatments at patients who might benefit the most, thus diluting their potential benefits. Identifying subgroups of patients for whom different treatments are superior has been referred to as the ‘Holy Grail’ of low back pain research.

Maximising the potential for targeted interventions is predicated on better understanding of the prognostic factors that are causally related to clinical outcome and identifying which are a) most predictive of outcome and b) most likely to be modifiable. Systematic identification of key obstacles to recovery in primary care back pain patients from high quality epidemiological studies can inform the development of early, targeted interventions. Only then can closer matching of treatments to patient characteristics be a clinical reality.

This paper critically reviews progress in subgrouping for targeted treatment for patients with low back pain, identifies the key arguments for and against subgrouping and highlights the attributes of robust approaches in this field.

Do the self-reported aggravating activities of people with chronic non-specific low back pain move the spine in a consistent direction?

Cross-sectional observational study.

240 people with chronic non-specific low back pain.

The self-reported aggravating activities from the Patient Specific Functional Scale were classified as flexion, extension or unilateral according to the direction of lumbar spine movement. Participants were described as demonstrating a directional pattern if all three self-reported aggravating activities moved the spine in the same direction.

Of the 148 participants with three classifiable aggravating activities, 47 (32%) demonstrated a directional pattern with 46 (98%) demonstrating a flexion pattern and 1 (2%) an extension pattern. The observed incidence of a directional pattern in the three self-reported aggravating activities of the 148 participants (32%) was no different from what would have been expected by chance. There were no clinical or demographic differences between those who demonstrated a directional pattern and those who did not.

There is no evidence for the existence of a consistent direction of spinal movement during the self-reported aggravating activities of people with chronic non-specific low back pain.