Student interpretation of LBP literature : “nothing works, more research needed”

When teaching or discussing LBP, the conversations invariably wind up with students voicing frustration that, 1. A diagnosis is impossible and 2. Very few treatments have any effect. I’ll comment on each of these individually with what I see as the main reason this happens. It is not that PT is ineffective or that PTs cant make a diagnosis with LBP, but the literature fails to study treatments appropriately and I am not sure the majority of our profession knows what a diagnosis is and is not.

A diagnosis is, as defined by the Oxford dictionary, “the identification of the nature of an illness or other problem by examination of the symptoms.” In PT and in all of medicine we typically deal with the most likely diagnosis. No diagnosis that I am aware of is complete, certain, and without other possibilities. Even something like a medial meniscus tear. Seems simple but it goes along with effusion, hypomobility, and pain. I would guess that based on the anatomy that a typical medial meniscus tear is associated with capsulitis and a ligament sprain. So with LBP we can and do arrive at the most likely diagnosis, which is associated with other diagnoses. A disc protrusion can be associated with stenosis, muscle spasm, joint hypomobility, and lower extremity weakness. That is pretty specific. The use of NSLBP seems to ignore this nuance and, in my opinion, turns a PT lazy, accepting that we cant make a diagnosis, so why bother.

When we consider treatment, nearly all treatments have an immediate effect. Massage, manipulation, reassurance, mobilization, heat, and exercise, all have been shown to have immediate effects. No more research needed. Nearly all treatment effects are enhanced when multiple treatments are given at the same time. Even something like kinesiotaping, can add to the efficacy of treatment, even when, as a stand alone treatment, it is ineffective.

So when we give up and use a diagnosis like NSLBP we are putting all LBP into one big pot and trying to add one treatment at a time to make a change. This is not acceptable. Would you treat an acute ankle sprain the same way as a talar stress fracture? I hope not. Why do we accept this with LBP? Would you treat an ankle sprain with one treatment? Again, I hope not, so why do we think through some magic this would make sense with LBP?

Lets get rid of NSLBP and start to use MOST PROBABLY DIAGNOSIS or CLASSIFICATION so we can select an appropriate treatment for the patient in front of us considering our skills, the evidence, and the person’s preferences. Research and clinical experience combine to enhance critical thinking to deliver the best possible care for the person who needs our expertise. Lets start thinking a bit more, be a bit more precise, use diagnosis as intended, and treat using a variety of interventions, even if the literature on LBP fails to guide us in that direction.

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