Low Back Pain, Some Real Answers

The publication unfortunately suffers from being too technical and thus uninteresting to say the least. The absence of a preface does admirably hide the fact of the real purpose of this book from the readers quite effectively. Some nuggets of information do find their way through the acknowledgements but it is no secret that most of the readers flip their way past this section too cursorily to notice. The readers are reminded that that a scientific approach cannot deliver hard and fast answers to such a contemporary questions in such a wide and wild field and thus much depends on the choice of problems to study.

Much has been made of the obscure facts, one of which is the leg twist test. The fascination for these manoeuvres may lie with student researchers in the business but hardly of any practical or scientific significance. Apt indications and relevance are not lost though for stressing the importance of diagnosing higher level pathology masquerading as low back symptoms and in my view, very important in correct diagnosis and relevant management. The manuscript, unfortunately, is sketchy and jumps from relevant to irrelevant and back and ends up confusing the readers. The essence is lost in this style of story-telling.

Explanations for explaining the painful sides and side-bending tests to pinpoint diagnoses are discussed in great detail but again lost in the quagmire of too much text and not enough science. By the authors own admission, “these findings can hardly be considered of any use to the Western economies or back pain patients en masse.” Déjà vu.

Various clustering techniques have been outlined in great detail, perhaps greater than ever required in the current context of back pain symptomatology and current clinical practice. A classification grid to score symptoms and signs may perhaps, by a very long shot, be remotely useful in a research setting to gauge outcomes but hardly is predictive of diagnosis or the treatments required therefrom. There is an attempt to force a new order using “some” valid classifications which randomly and co-incidentally were reproduced in a subsequent set of patients. This subsequent set remains largely undescribed.

Attempts to explain facet joint symptomatology and various patterns are described brilliantly and are of direct clinical significance. More importantly this section educates the authors on what facet joint syndrome is NOT. A clear pointer is provided in differentiating a facet joint syndrome from a rotation back pain syndrome and is followed up with two quite convincing case studies. Disc patterns and pelvi-spondylotic and sacro-iliitis patterns make interesting reading and the pattern with No signs is described succinctly, a common occurrence in clinical practice.

Significant strides have been made in grading severity of back pain and the phenomenon of intentionally exaggeration of symptom severity vis-à-vis duration for ulterior motives is well researched. This not too unfamiliar scenario is usually played out in contested benefits claims and personal injury court cases. The pain-scale approach is valid and a useful pointer to differentiating the genuine from the malingerer where high scores contrast with presence of very little signs on examination. Unfortunately as the author points out the disenchantment with this technique has given birth to more tangible techniques such as eliciting history of analgesia consumption or disability engendered by the pain.

Various terminologies like impairment, disability and handicaps are explained but not in details. Treatment of “timing” and “treatment” are cursory to say the least. Older and out-of-date studies though historically interesting (Cochrane monograph 1971) fail to establish meaningful correlations with current presentations. In one clean sweep, the proponents of “back schools” have been given a bad name though by the authors own admission that “in most cases it is very difficult to stop people getting up when they feel better”. Beware, warns the text, of articles that suggest supervised incremental return to activity. I disagree.

There are genuine attempts to explain “other” conditions to explain low back pain like fibrositis, ME (myeloencephalopathy) and CFS (chronic fatigue syndrome) but with many prestigious publications questioning the very existence of ME/CFS the significance is not great. Whiplash injuries have received a more detailed treatment and makes useful reading. The arguments for diagnosing RSD for the back have been put forth convincingly though it remains a matter of great difficulty in diagnosing and once diagnosed having to treat that demon.

This book, in summary, makes for dry and uninteresting reading. Of interest perhaps to the researcher, this in unlikely to benefit the common practitioner of the art looking for clear and concise take home messages.

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