Editor—We have misgivings about the conclusions drawn by Guzmán et al on multidisciplinary rehabilitation for chronic low back pain.1 Low back pain problems are as heterogeneous as the wider category of chronic pain, and in disregarding systematic reviews and meta-analyses of multidisciplinary rehabilitation in chronic pain Guzmán et al have missed a large body of relevant evidence, including trials of cost effectiveness.2,3
Standard quality criteria used for randomised controlled trials cannot be applied in an unmodified form to psychological treatments, which constitute important components of multidisciplinary rehabilitation. The impossibility of blinding patients and therapists need not lower standards. Several trials reviewed employed recognised methods for establishing treatment equivalence: patient rating of treatment credibility or expectations; manualised treatments; blind rating by experts of treatment excerpts; and close supervision of therapists. It is disappointing to see the Cochrane Back Review Group continuing to apply inappropriate criteria and thereby misjudging methodological quality of trials.
Variability in outcome arises from heterogeneity among patients, differences in treatment, and their interaction, not only from length of treatment. Content of treatment is far more important than the total time of the programme. Physical treatment alone, as Guzmán et al say, is a weak way to change behaviour, particularly in relation to work and use of health care. Patients who have become fearful of further pain and damage, and who are disabled as much by their fears and misapprehensions as by the pain itself,4 need psychologically based treatment, which is still in short supply.
The emphasis on return to work as the primary outcome is inappropriate when the population includes homemakers, as did several of the trials reviewed. Disability or function is a broader issue and includes the important, but neglected issue, of change in use of healthcare resources. An undue focus on return to work to define effectiveness leads to restricting access to treatment for non-workers, particularly among older patients.
Guzmán et al acknowledge that their conclusions may not apply in primary care, but patients are better defined by their level of disability than by the setting in which they are seen, and their treatment defined not by hours but by its adequacy to restore as near as possible normal function, whether in secondary prevention of recently injured workers or chronically disabled non-workers.5 This review offers clinicians little help in selecting the right level of treatment for patients with low back pain.
References
- 1.Guzmán J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001;322:1511–1516. doi: 10.1136/bmj.322.7301.1511. (23 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Morley SJ, Eccleston C, Williams ACdeC. Systematic review and meta-analysis of randomised controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13. doi: 10.1016/s0304-3959(98)00255-3. [DOI] [PubMed] [Google Scholar]
- 3.Goossens ME, Rutten-Van Molken MP, Kole-Snijders AM, Vlaeyen JW, Van Breukelen G, Leidl R. Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial. Health Econ. 1998;7:39–51. doi: 10.1002/(sici)1099-1050(199802)7:1<39::aid-hec323>3.0.co;2-s. [DOI] [PubMed] [Google Scholar]
- 4.Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317–332. doi: 10.1016/S0304-3959(99)00242-0. [DOI] [PubMed] [Google Scholar]
- 5.Marhold C, Linton SJ, Melin L. A cognitive-behavioral return-to-work program: effects on pain patients with a history of long-term versus short-term sick leave. Pain. 2001;91:155–163. doi: 10.1016/s0304-3959(00)00431-0. [DOI] [PubMed] [Google Scholar]