In Reply

As we expected, most comments are critical of the classification of back pain as either “specific” or “nonspecific” stated in the National Disease Management Guideline for Low Back Pain. It should be noted that as the opposite of the term “specific” we prefer the term “nonspecific” back pain, as “unspecific” is inappropriate from a purely linguistic point of view.

Regarding the very understandable observations made by Dr. Bambach, it should be noted that “nonspecific” by no means denotes “low back pain with no somatic basis” and does not lead to “diagnostic and therapeutic nihilism.”

The umbrella term “nonspecific back pain” does not rule out investigation of the functional disturbances generally found in such cases, just as it does not indicate an appropriate treatment. However, instrumental diagnosis that goes beyond physical examination and invasive therapy should be avoided unless there is evidence of a patho-anatomical correlate. For example, MRI examinations with descriptive findings on initial contact with back pain patients, sometimes performed as screening, lead to irrelevant diagnoses and the beginning of invasive therapy.

Restraint when diagnosing will certainly not delay the recognition of “chronification,” but rather will tend to avoid it. For example, inopportune attribution of pain to irrelevant imaging findings is caused by demonstrating findings to the patient. There is no basis in either the literature (3, 4) or our experience for attributing back complaints with certainty to questionable disease entities such as “discogenic low back pain” on the basis of differentiated diagnostic procedures, e.g. discography, as promoted by the cited Bogduk research group (1, 2). eTable 1 and eTable 4 of our article contain summaries of physical findings with no clear patho-anatomical significance and of specific types of back pain requiring further diagnostic evaluation; for reasons of space we were obliged to display these online. The sine qua non of successful handling of common functional disturbances seen in nonspecific back pain are a meticulously taken pain history and competent manual diagnostic or other physical examination.

The algorithm for acute back pain management contains a summary of psychosocial risk factors for chronification (“yellow flags”); it is recommended that, if pain persists despite 6 weeks of treatment in conformity with the guidelines, patients should undergo prompt interdisciplinary assessment, i.e. including assessment by a psychotherapist. Depending on the findings of this assessment, targeted treatment ranging up to an interdisciplinary multimodal pain treatment program may be begun. The coanalgesics mentioned, such as antidepressants or anticonvulsants, may also be used, but these must under no circumstances be used as primary pharmacological treatment.

One further, frequently discussed point is the evidence-based recommendation not to implement reduced activity and bed rest for nonspecific back pain. The context of this recommendation is the experience that fear and anxiety lead many patients to follow to the letter the well-intended advice to reduce activity and avoid exercise, thinking that resuming activities will cause further damage. In other words, the behavior appropriate to red flags is often extrapolated to nonspecific back pain. This leads to pain-avoidant behavior, a significant factor in chronification. This does not mean that relief of strain, heat, and limitation of activities must not be recommended in the short term—i.e. a few hours to a few days—if there is severe pain and major tension, as Dr. Feldmann reminds us; however, if these measures are taken, the patient must be informed that the functional disturbance is reversible and that prolonged immobilization has adverse consequences. With this individual, patient-oriented procedure, the experience of the primary treating physician certainly also plays a role in evaluating functional disturbance and the patient’s personality.

The same applies to the predominant muscular causes of back pain (accounting for approximately 80% of cases) discussed by Dr. Roth, which we described in detail in our article when discussing functional disturbances. Back pain caused by muscle complaints resulting from trauma is specific, as there is a clear cause on the basis of clinical history, clinical findings, and patho-anatomy, and specific treatment is indicated.

Dr. Schneider provides a good summary; in addition, we would like to state that such a complex, frequently recurring common complaint as back pain requires both prompt and lasting assessment and treatment in line with patients’ problems and needs, from initial treatment onwards. Less is often more in this regard.