To the Editor: In Bogduk’s review of the management of low back pain,1 he cited several international guidelines but did not address the effect of returning the patient to work. Disappointingly, return to work was mentioned only as an outcome of multidisciplinary therapy, with no mention at all of a planned and purposeful return to work in the suggested approach. This is surprising, given the literature available2,3 and the significant adverse effects of being out of work.4

Further, the algorithm in Box 3 (general practice management of chronic low back pain) appears to have a never-ending loop: I am cautious of the adverse effects that the reductionist model can have,5 and it appears possible in this algorithm to be forever stuck in the investigative loop. An additional pathway from this loop to intensive therapy would allow progression in some cases.

The inclusion of a return to work in management of low back pain has been extensively analysed in the Australian setting and shown to significantly reduce disability.6 This advice should be included in any clinical update on management of low back pain.

To the Editor: Bogduk’s article on management of chronic low back pain1 was disappointingly retrogressive as a guide for general practitioners. Compartmentalising back pain management as monotherapy, multidisciplinary therapy or “reductionism”, and favouring the last, reinforces the medical model which has singularly failed to stem the epidemic of low back pain disability affecting the developed world.

The biopsychosocial model of chronic spinal pain is now widely accepted and rationally emphasises the multi- or interdisciplinary model of management.2,3 Bogduk’s preference for the reductionist approach may be reasonable in a specialised centre and as a basis for research, but must justify its practical relevance in the face of the following:

• Available data on the reductionism approach are meagre, conflicting and mainly derived from pain-clinic populations likely to differ from patients presenting to GPs.

• Diagnostic joint and disc injection procedures and radiofrequency treatment performed to the required standard are available in only a very few centres.

• Radiofrequency lesioning of the nerve supply to symptomatic joints has been shown to provide pain relief limited to 9–18 months.4 Repeat lesioning may be less effective and is impracticable in the long term.

At best, these treatments could be considered palliative.

Of course, patients can only benefit from accurate diagnosis and reduction of pain from identified peripheral generators. Unfortunately, for most people with chronic back pain, it is not that simple. Usually there are multiple pathologies and pain generators, multisegmental dysfunction, disrupted motor control and interacting peripheral and central neural sensitisation mechanisms. And that is just the “bio” of the biopsychosocial model. There is then the interplay with the individual’s psychological and social environment.

It is often a challenge to communicate the diagnosis effectively in the face of conflicting input from other health providers, the media and patient preconceptions. Just “plonking” “the diagnosis” before a patient and dangling a seductive “techno fix” that does not deliver in the long term is precisely what renders patients with chronic pain increasingly bewildered, dysfunctional and desperate to try one passive treatment after another.

The biopsychosocial model provides a basis for management in both general and specialist practice. Appropriate interventions to reduce pain-generator input are embedded in a cognitive behavioural management matrix that imbues patients with accurate, relevant knowledge of their conditions and commonsense self-management techniques to maintain appropriate activity levels, goal setting and psychological positivity.

For a time-challenged GP, collaboration with an activation- and exercise-oriented physiotherapist can be effective. The GP’s role is to provide the “white coat authority” so vital in recruiting patient confidence.

In reply: There is a difference between wishful thinking and evidence. Elder advocates a focus on return to work. Elsewhere, I have described how this should be pursued.1 However, the evidence supports success only in the context of acute and subacute pain. I was commissioned to write on low back pain. In that context, evidence is lacking. Even Waddell, whom Elder cites,2 conspicuously avoided the issue of chronic low back pain; his evidence pertains only to acute low back pain.

Salmon and Hilyard promote the biopsychosocial model. Indeed, this model is now widely accepted. Even our own studies have shown how successful it can be to recognise and treat patients’ fears and mistaken beliefs.3 However, the evidence of success is limited to acute and subacute low back pain. The predictions of the biopsychosocial model have not been fulfilled in the context of chronic low back pain. Although better than no therapy, behavioural therapy is not more effective than other therapies, and does not “reduce pain generator input”, as Salmon and Hilyard contend. Insurers, who pay for this treatment, do not share their enthusiasm for it.4

Salmon and Hilyard also repeat the commonly held view that patients have multiple pain generators. There is no actual evidence for this assertion, while the available evidence indicates the opposite. When investigated comprehensively, fewer than 10% of patients have more than one simultaneous pain generator.5

Further, Salmon and Hilyard consider that complete relief of pain for 9–18 months amounts to palliative therapy. Yet the opposite is true. Not relieving pain by behavioural therapy is palliative. They also deprecate radiofrequency neurotomy with the accusation that it “may be less effective” when repeated, but fail to cite the literature showing that this is not the case.

They are correct in stating that reductionist procedures performed to the required standard are available in only a few centres. However, this does not invalidate these procedures; it reflects only a political and ideological problem in healthcare delivery. They also fail to reveal that in many places where these procedures are available, they are not performed according to best-practice standards. It is not the procedures, but misguided and unscrupulous practitioners, who render patients bewildered and dysfunctional.