Correspondence (letter to the editor): Multiple Causes

The present review article requires critical discussion (1). Regarding the analysis of the literature, the article does not give rise to any complaints.

A central problem of such meta-analyses is the fact that the evidence is assessed on the basis of only a selected number of “high methodological quality” studies. If these are lacking, then the argument that is often heard is that evidence is lacking. However, methodologically good studies are difficult in view of the multitude of causes of back pain. In many studies, an exact definition of the symptoms is lacking, as is a clear focus on specific disease entities, a precise description of the orthosis, and, in particular, a clear indication. There is, for example, a crucial difference as to whether a lordosing or delordosing lumbar orthosis is prescribed for zygapophyseal joint syndrome (facet syndrome). Often, chronic, non-specific back pain (often with psychological comorbidities) and specific causes are investigated together in the same study.

The present article by Zarghooni and colleagues also tends to give too much weight to the Anglo-American literature. German-language articles, which do exist, are rarely given any consideration—and that is the case for this review article.

Another point of criticism is the fact that the same review article deals with multiple symptoms. Furthermore, I noticed that the authors' assessments are in some cases impossible to follow. With regard to chronic cervicobrachial syndrome, the authors say that a comparator study showed significant reductions in pain symptoms after six weeks versus a control group, but not as a long term success. The authors reach the conclusion that orthoses are therefore not indicated in such syndromes. Since it is common knowledge that radicular cervicobrachial syndromes can actually substantially exacerbate for a limited, short period of time, however, this conclusion is doubtful in view of the fact that orthoses were effective.

In conclusion, one could have wished for a more critical discourse.

Orthotic treatment has been empirically tried and tested as a therapeutic modality for decades, and the number of prescriptions—which the authors mentioned in their article—underline this fact.

Empirical knowledge gained through experience continues to have its place, and the absence of high methodological quality studies signifies merely that more research is needed. The conclusion that really should not be drawn from this review article is that orthoses are generally ineffective.