Editor—Several concerns arise from the 10-minute consultation on chronic back pain by Samanta et al.1 The case presented is that of a man with a two year history of chronic back pain. The advice given is in line with the suggested management of a person with acute back pain, not one with an exacerbation of a chronic condition.2
The assessment of “yellow flags” is essential,2 but not, as the authors suggest, to identify factors that cloud assessment and treatment, but to identify those factors suggestive of a poor outcome if they are not managed appropriately.3 In this regard they illuminate and inform the management of the patient.
The patient's reactions to pain must not be seen as extraneous noise but indicators of the type of treatment required. The suggestion that one must assess for depression or unhappiness at work is rather simplistic. People with back pain only occasionally require treatment for clinical depression, although low mood, fear of a recurrence of pain and difficulty managing work are common findings.3,4
The advice to let pain be one's guide has been refuted repeatedly in guidelines for the management of chronic back pain.2 The patient must be encouraged to engage in increasing activity, and appropriate symptom management is essential to promote this. People with chronic low back pain should be referred to an active rehabilitation programme that increases physical activity and promotes early resumption of activity including return to work. The programme should incorporate the management of yellow flags including fear of (re)injury, flare-up management, low mood, and workplace issues. Simple educational approaches, with or without written information alone, are not effective in managing patients with chronic pain problems.5
Competing interests: None declared.
References
- 1.Samanta J, Kendall J, Samanta A. 10-minute consultation: Chronic low back pain. BMJ 2003;326: 535. (8 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. London: RCG, 1998.
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- 5.Waddell G. Burton AK. Occupational health guidelines for the management of low back pain at work—evidence review. London: Faculty of Occupational Medicine, 2000. [DOI] [PubMed]