Prognosis in people with back pain

We thank Dr Gunn for his interest in our paper. We acknowledge that non-specific low back pain may have a variety of causes however current diagnostic techniques, including physical examination, are unable to reliably identify the source of pain in the majority of individual patients (1). As well, while it may yet be possible to identify treatment effect modifiers (characteristics that identify subgroups of patients who might respond better to a particular treatment), evidence for their existence is not yet convincing (2). We would be interested in any robust research showing that the classification system proposed by Dr Gunn is a treatment effect modifier. In the meantime, guidelines typically recommend triage of patients with low back pain into one of three categories: nonspecific low back pain (the vast majority), back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause (3). We wonder if Dr Gunn's relationship to the iStop pain clinic (http://www.istop.org/index.html), that uses and teaches this approach, might be considered a conflict of interest that he should have declared.

References 1. Rubinstein SM, Van Tulder MW. A best-evidence review of diagnostic procedures for neck and low-back pain. Best Prac Res Clin Rheumatol 2008;22(3):471-82.

2. Kamper SJ, Maher CG, Hancock MJ, Koes BW, Croft PR, Hay E. Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best Prac Res Clin Rheumatol 2010;24:181-191.

3. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and treatment of low back pain: A joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-91.

Conflict of Interest:

None declared