Letter to the editor: other interventions in approach to lumbar disorders.

Dear Editor:

With great interest we read the recent article by Burns et al[4] titled “A Treatment-Based Classification Approach to Examination and Intervention of Lumbar Disorders.” We would like to commend the authors’ efforts in providing a treatment-based classification approach to low back pain (LBP) in athletes that involves 3 steps. Additionally, this study suggests matching interventions for athletes according to their stage of LBP, which is very informative and robust. However, we think in this article, some therapeutic interventions in approach to athletes with LBP were missed.

As it was mentioned in the article, there is an extensive list of differential diagnosis for LBP[8]; however, most of the causes are infrequently seen in practice.[8] It is reported that about 85% of patients with LBP seen in a primary care have no identifiable cause, and so it is termed nonspecific LBP.[7] It seems some treatments, such as acetaminophen, nonsteroidal anti-inflammatory drugs, relative rest, coldness, heating, and massage therapy, can also be used to decrease the intensity of pain in patients with nonspecific LBP, while these treatments were missed in the article by Burns et al. In addition, although the effectiveness of alternative medicine for the treatment of chronic nonspecific LBP is not without dispute,[13] it currently plays an indispensible role in management of patients with chronic LBP. Acupuncture as a therapeutic intervention is widely used in treatment of patients with nonspecific LBP.[13] The superiority of acupuncture to sham acupuncture for pain relief of patients with LBP has not been established in previous studies.[15] However, in well-designed randomized controlled studies with a low risk of bias, the effectiveness of this traditional intervention for symptom relief of LBP has been shown.[3,10-12] Furthermore, clinical guidelines of societies such as the North American Spine Society,[1] the American College of Physicians,[5] and the National Institute for Health and Clinical Excellence[14] have also recommended acupuncture as a possible treatment option for patients with LBP. On this base, it seems reasonable to consider acupuncture as an effective therapeutic intervention in approach to patients with LBP.[2]

We agree with the authors that no treatment should be started for patients with LBP before performing a complete diagnostic evaluation and ruling out the major and sometimes life-threatening diagnoses that are called “red flags.” However, considering acupuncture in approach to patients with chronic LBP, which contain the majority of cases of LBP, seems to be useful. The points commonly used for acupuncture of patients with LBP have been listed before,[2] although most of the time, supplemental points will also be selected by the physician according to the medical history and pain location of the patients. In use of acupuncture, there is also a list of contraindications, such as bleeding and clotting disorders and warfarin use, that should be considered by the physicians.[6]

We can suggest that acupuncture might be more effective in a subgroup of LBP patients. In this regard, a review of the literature reveals the following points: Most of published studies that reported the effectiveness of acupuncture in treatment of LBP were carried out on patients with nonspecific LBP in which patients do not have a radicular pain resulting from nerve root compression.[9] In some of these studies radiculopathy has been stated as the exclusion criterion for the participants.[3,15] In addition, insertion of needles into trigger and painful points has been reported as a part of acupuncture treatment for patients with chronic LBP.[9] Therefore, we believe that in Table 4 of the article by Burns et al,[4] acupuncture could be added as a therapeutic intervention in patients in stage I. As it is mentioned above, the preferred criteria for doing this intervention on the patients are patients with persistent (> 6 weeks) nonspecific LBP (no radiculopathy pain) who have positive findings of tender or trigger points in their muscles.

Sincerely,