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[Physio Discussed] Is non-specific low back pain a diagnosis? with Dr Mark Laslett and Greg Lehman

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In this episode, we dive into a lively and at times heated discussion around the clinical challenges of non-specific low back pain. This isn’t your typical clinical chat — expect strong opinions, sharp insights, and some friendly disagreement as we explore:

  • Is non-specific low back pain even a real diagnosis?
  • What impact does a diagnosis (or lack of one) have on our patients?
  • The current state of research in low back pain — and where it’s still falling short

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Dr Mark Laslett is a New Zealand Board Registered Musculoskeletal Physiotherapy Specialist (NZRPS), based in Christchurch, New Zealand. He’s a former manipulative therapy instructor for the New Zealand Manipulative Physiotherapists Association and AUT University, as well as a former international instructor for the McKenzie Institute International. Mark completed his PhD from Linköping University (Sweden) in 2005, with clinical research focused on the diagnostic accuracy of examination for patients with chronic low back pain.

Greg Lehman is a physiotherapist, chiropractor, and strength and conditioning specialist who treats musculoskeletal disorders within a biopsychosocial model. He previously served as an assistant professor at the Canadian Memorial Chiropractic College, teaching graduate-level Spine Biomechanics and Instrumentation. Greg has conducted over 20 research experiments and supervised more than 50 students. 

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Our host is @James_Armstrong_Physio from Physio Network

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UNKNOWN:

you

SPEAKER_01:

Welcome to the Physio Discussed podcast where clinical conversations meet critical thinking in musculoskeletal care. Today we're diving deep into one of the most talked about and often misunderstood topics in physiotherapy, that is non-specific low back pain. And joining us today are two internationally recognized leaders in the field. Greg Lehman, a Canadian physiotherapist, chiropractor and strength and conditioning specialist with a master's in spine biomechanics. He's known for his work in reconciling biomechanics with pain science and has taught extensively on the biopsychosocial model of care throughout his course, Reconciling Pain Science and Biomechanics. Mark Laslett is a New Zealand-based physiotherapist and researcher, best known for his pioneering work in diagnostic accuracy of spinal pain. His research on clinical prediction rules for sacroiliac joint pain and intervertebral disc-related pain has influenced practice guidelines worldwide. In today's episode, we're tackling the big questions. Is nonspecific lower back pain even a real diagnosis? What does a meaningful diagnosis actually mean to our patients? Where is the research falling short and where should it go next? What RCT should be done to move the needle in lower back pain management? And what diagnostic accuracy study would our guests design tomorrow if given the chance? Expect thoughtful disagreements, clinical pearls and ideas that challenge the status quo. Let's get into it. I'm discussed. So Mark and Greg, welcome to Physio Disgust, a podcast where we get a little bit more time to delve into some more meaty topics. Thank you so much for joining us. Mark, tell us where you're joining us from. I'm

SPEAKER_00:

in New Zealand,

SPEAKER_01:

Christchurch, New Zealand. And

SPEAKER_02:

Greg? Oh, I'm in Toronto, Canada, the 51st state.

SPEAKER_01:

Fantastic. How's the skateboarding going, Greg?

SPEAKER_02:

It's on hold. I'm back to gymnastics. Skateboarding is all injury, no fitness. It's a bad ratio.

SPEAKER_01:

Brilliant. So we've got Mark and Greg on stage. So we're going to be talking about nonspecific lower back pain and we're going to be talking around diagnostic accuracy. We're going to be going into the research, where the research might need to go and some thoughts around that. So we've got a lot to cover today. So I thought we'd kick off to begin with, with the point of is nonspecific lower back pain an actual diagnosis? And I thought that's quite a nice, juicy one to get started. Mark, should we kick start with you and your thoughts around the diagnosis to term that we often hear around this nonspecific lower back pain and your thoughts around that?

SPEAKER_00:

In a word, the answer to your question is nonspecific back pain a diagnosis? The answer is no. It is simply what the patient presents with. That is the patient's symptom. It is a symptom, not a disease. It's not a condition. It's not anything else other than what the patient complains of. It's what you begin with before you start diagnosing. So the patient comes in and says, I have back pain. That's what they say. And until such time as you make it specific, it remains non-specific. It's really that simple.

SPEAKER_01:

So you're saying the term that we're using is a presentation rather than a diagnosis?

SPEAKER_00:

No, it's what the patient says. Since there are so many things that can cause back pain, and we have they will allege that it's difficult to actually differentiate between these causes, therefore it's non-specific, and therefore they use that as a label to cover up their lack of diagnosis. That's essentially what happens. The point is that it's only non-specific so long as you keep

SPEAKER_01:

it that way. So you're saying So the clinician then would go into making that a specific diagnosis, and then the diagnosis would come along with something far more in-depth.

SPEAKER_00:

One would think so. But the important thing here is that sticking with the concept that nonspecific low back pain is in fact a diagnosis has downstream effects, which are very, very negative for both science and for treatment and for understanding the problem. And it's also, I think, problematical for patients as well. So we can discuss that later on. That's a consequence of that statement. So we must basically stop using the concept of nonspecific back pain in science. It's because it's pre-science. It's pre-understanding. It's pre-diagnosis. It's not actually a diagnosis.

SPEAKER_01:

Okay, Greg, let's go over to you. Your thoughts around that term, that diagnostic term that is often used.

SPEAKER_02:

I don't think it's something you use with a patient necessarily. I think it's just acknowledging the inherent uncertainty that we all have. want to use it. But if you use something else, you're alluding to a false sense of certainty that you don't have. Someone can have, we call it pantelofemoral pain. That's considered acceptable. And that just describes the area where someone has pain. And so when it comes to low back pain, when you use the word nonspecific low back pain, it's acknowledging that quite often we don't know where the source of nociception is. It's as simple as that. And so you might want to be aspirational and make a guess at where it's coming from. And hopefully we get better at doing that. So what do we do when we can't do that consistently? Then we have to default to something else. And that's all that nonspecific low back pain does. And it doesn't have to mean that it's inherently problematic for the patient. Because even if you're identifying a nociceptive source, that doesn't mean that you're fully encapsulating the problem that people are presenting with. So non-specific low back pain, like it's not saying that you're just doing anything willy nilly. You're also trying to find potential contributors to the pain that someone presents with. So whether or not that's a diagnosis or not, I mean, it's just acknowledging reality that you're saying, I know this person has low back pain. We're not to certain what the nociceptive driver is, but that's just a starting point. Then you go on and try to figure out what you think the variables are that you can change to maybe help this person.

SPEAKER_00:

One interruption, not interruption, but a reflection on what Greg's just said is that I think there is a very common misconception, and I've asked Greg to comment on this, but there's a misconception that diagnosis is all about the source of nociception. That's not true. It absolutely is not true. The classical concept of a diagnosis is that it is the identification of the source and cause of nociception or of the complaint. It doesn't have to be nociception. I mean, you can have a diagnosis in mental health. That's not nociception. But in terms of musculoskeletal pain, that is what we're talking about. It's not just the origin of nociception. It is what causes that origin to become nociceptive. So in other words, There are two distinct parts, if you will, of a diagnosis. There is, first of all, identifying from whence the nociception arises. And then the second part is, so what is causing that tissue structure, whatever, to actually produce nociception? And then there's a third part, right? And a third, that's the fundamental source and cause. The third part is, what are the influential factors in the experience of pain. That's quite a separate issue. So in other words, you can have, in the case of back pain, let's call it discogenic pain. That's just simply just stating that you believe the pain is coming from the intervertebral disc or associated structures around that. Then what causes that? Is it an inflammation? Is it a bacterial infection? Is it some sort of mechanical disturbance inside that disc? Or what is the reason why that disc becomes painful? And then that produces the symptom of which the patient complains, but that symptom is then modified by the patient's own cognitive, emotional, physiological response to the nociception. And so that gives you the package, as it were, of the experience of back pain. But don't confuse the experience with the diagnostic components of the diagnosis. Simplifying it down to just simple nociception is missing at least 50% of the point.

SPEAKER_02:

Yeah, I didn't. So that was my whole point. It's like when people are saying that they can ascribe the pain to a tissue, they're reverting it to just thinking that they have an idea of what tissue is creating nociception. And so we agree you can't do that. And you certainly can't tell what the cause or the source. Well, I don't know what we're talking about then.

SPEAKER_01:

Yeah, I think it's interesting because I think this is a debate that you see in and out of every physiotherapy clinic around the country, certainly in the UK that I've seen where people are having that conversation about how specific can we be when we're talking about the drivers of nociception, the causes of pain and the diagnosis that comes out of that. And I can hear from both of you that you sit very differently on two sides of the fence here in terms of whether we can be specific to diagnosing the sources of nociception and the pain. Am I right there? And I think that's okay if we disagree with that. We don't even have a way to measure a nociception.

SPEAKER_02:

So it just ends right there. We can only get an idea of the pain that someone has. Okay. And that's just self-report. And then we're assuming that it's from some tissue or that we assume that nociception is contributing to that from a tissue and then that's leading to pain. We probably won't go any further with this discussion. Maybe we should move on to the next ones of whether this is relevant and where we have to go forward here. We're just going to go around like, because to be honest, I don't even know what Mark just said there. Maybe I'm not smart enough to understand it. So I don't know what the people listening at home think. Like, it's just what's the diagnosis? Source, cause, and then how someone gets it. I mean, the diagnosis, we're sort of getting an idea of it's always just been about the tissue. It's not about the tissue. Then it opens the door to when people start talking about you have a flexion, basically low back pain as if that's a diagnosis or you have an extension based low back pain. People are arguing those are diagnoses and they'll say that is the cause and the source of the nociception. This is maybe getting beyond my pay scale of the philosophy of what diagnoses are.

SPEAKER_00:

Mark, I'll just give you one chance to have a chat. No, I'm sorry. I might move on because to me the conversation doesn't end there. The bottom line is that when I introduce a local anesthetic into a facet joint, a sacroiliac joint or a and the pain switches off and the pain comes back in due course as the anesthetic wears off. Can you actually say that you don't know where the nociception arises from? The answer is you can. The fact is that physiotherapists, chiropractors, osteopaths, people who do not have access to those particular interventions can't do that directly in a normal clinical environment. So that is part of the problem that faces non-interventional clinicians and And I've been extraordinarily fortunate that I've done research, a lot of research, with people who do that all the time. In fact, that's what they do all day. And my research has been based upon the fact that I wanted to find out if I was able to predict those anesthetic responses. And the answer is that we can with some degree of certainty. Absolute certainty is never going to happen. But it's a matter of what's the probability. It's a basis decision. And so what I'm saying is that we can predict with some reasonable confidence in the majority of cases where the nociception arises. It still does not answer the question as why that structure becomes nociceptive. That's a different question. I'm happy to leave that aspect of things there as you seem a little uncomfortable being in that space, Greg, and I understand it's fine. But that is my space. That's what I do pretty much I'm not

SPEAKER_02:

uncomfortable. I'm uncomfortable not feeling like I need to identify a tissue source. I'm cool with people doing the research. So I've been trying to find the answer to this. And you alluded to that you had the answer. This idea. So that was my question. This is why I let you know about the Chris Hand paper on the low back pain of disc, SI joint, physet joint. That's systematic review. And I know you don't like those. It was very favorable for saying that you can find potentially a diagnosis that the tests are okay sometimes. So that's great. That's a nice paper. Your work alludes to that as well. Your paper with Pearson on the disc when you get centralization. I love that stuff. I don't have a problem saying to my patient, I think that the disc could be irritated here, or it's possible that your SI joint is irritated here. I don't have any issue with that stuff. And I'm comfortable with the uncertainty. What I'd like to know what you don't see in these papers is if you have a thousand patients presenting with low back pain to a primary care provider, what's the percentage of them where you're going to be able to have a diagnosis here? And your papers and Chris' paper here, and I emailed Chris about this. No one answers that, right? So is it 30% of the time? Is it 51% of the time? Maybe you should run through for folks like the clinical tests that give you an idea of what the diagnosis is. And then the idea would be, well, how often do people have those presentations where you can make that diagnosis with a little bit of certainty? And I don't expect 100%.

SPEAKER_00:

Okay. Well, I think as far as the sacroiliac joint is concerned, it's pretty clear that about 77% of the time we get it right clinically. We can predict the injections. In the case of the facet joint, we don't have that sort of certainty at all. There's just simply no research to validate that. In terms of discogenic pain, we can get that right, I would say, 80% of the time. We have evidence there are subsets of discogenic pain, and certain subsets, we get it right around about 90% of the time. So there is, and of course, nerve root pain is another one again. I think we can get that right probably 80% or 90% of the time as well. And I think we have some evidence about that. Now, just by the way, we've just published a paper this year on radicular syndrome, and we get it right around about, it's just about 79 But

SPEAKER_02:

that's the thing, like how many people don't fall into those categories?

SPEAKER_00:

Well, it's maybe 20%. It's about 20% of the people that we actually get it wrong. But that means we get it right 80% of the time. That's

SPEAKER_02:

not too bad. Are you saying like a huge number of people, because with discogenic pain, the criteria with your Pearson paper was that it centralizes?

SPEAKER_00:

No, that's one subset.

SPEAKER_02:

What was the other finding? That was the only one in your Pearson paper. And in the hand paper, that's also the criteria. I

SPEAKER_00:

know, because that's the only data that exists. accuracy in that subset. In other words, if those people centralize, there's a 90% chance they have discogenic pain. That's not bad. Now, there are still at least half of the people with discogenic pain, as proven by provocation discography, whose symptoms do not centralize.

SPEAKER_02:

Yeah, so if 50% of the people centralize and you got 90% of them right, that's only 40% of the population. So what about all the other people? That's what I'm wondering about here. What do we do with those folks?

SPEAKER_00:

The point is, when you have high specificity of 90%. That means that you get it right 90% of the time. So in other words, if a person centralizes, there's a 90% chance of that person having discogenic pain. There are still 50% of discogenic pains for whom we have no proven or validated method of identifying. Okay. That's not a problem. In the clinic, you wouldn't know then.

SPEAKER_02:

You don't know that they're discogenic in the clinic.

SPEAKER_00:

No, there's a difference between having no data. and having some certainty or having some preliminary certainty. I can tell you with some confidence, without having published the data, I have to say, I mean, we don't have the data on this. The research has never been done, right? But I can tell you that in those people whose symptoms are in the midline, centralized midline pain, who do not centralize, those patients almost certainly have anterior column pain. Whether or not that's due to discogenic pain of non-mechanical behavior, whether it's due to motor changes or high-intensity zones, that is a matter for further investigation. It hasn't been done properly yet. There's just no data, but the chances are we can do that. It's just all uncertain. We can't know. It's just not right. I

SPEAKER_02:

didn't say we can't know. I said when you're in the clinic, you can't know. Someone might be able to know. Even with your numbers, even if I accept your numbers, that 50% is the amount that you think are centralizing and you get it right 90% of the time, there's still like 60% left over. And then you're saying that 60% are anterior column pain because of some other tests that we don't do in the clinic. So that sounds pretty nonspecific, but you're just

SPEAKER_00:

testing.

SPEAKER_02:

Well, you're just hoping that is. You're just assuming that if someone has some other advanced testing, that'll get cleared up. I don't doubt that the tissue's involved. I'm just saying, how do you know? And we can't all do our... like you did. So how does the average clinician put this into practice? This is what I don't understand here.

SPEAKER_00:

Well, I'm going to probably solve that problem fairly quickly because, no, no, I am because in actual fact, I'm actually in the final stages of publishing a book called The Art and Science of Diagnosis in Musculoskeletal Pain. So that's actually going to be coming out within the next several months. And basically, that's exactly that question that I'm intending to answer. How does the clinician on the basis of what you can find with a non-invasive, non-interventional diagnostic protocol, how can you actually make a diagnosis? And I hope to be able to answer that. And I'll be interested in your comments once it ultimately comes out. And it will be this year that will happen. But again, that's still not proof, if you want to put it like that. Absolutely not. I'm not claiming that it is. But it is, it sort of marshals a lot of the data and the proof into a fairly coherent little package, I hope.

SPEAKER_02:

Great. I love hearing your clinical experience here. I think there's huge value in that stuff. But we were just sort of talking about numbers and that stuff.

SPEAKER_00:

Well, half the book is actually case studies. Fantastic.

SPEAKER_01:

Time to probably just move us on to the next question, both of you, because I think we could easily carry on this and I'm fascinated just listening, but I've got to remember that I'm hosting this and need to move us on properly. But essentially, I think we can really nicely move on to the importance of this and the diagnosis for patients and what does it mean to them? And Mark, you alluded to this sort of right at the beginning a little bit in terms of sort of starting us off with, I suppose we're talking about the importance of a diagnosis for the patient and what it means to them.

SPEAKER_00:

There are two levels here. One is in terms of the importance to the patient is that, I mean, I ask my patients, almost every patient, I wouldn't say I'm that consistent, but I would say 95% of the time I ask the patient, so what do you want from me? I mean, I ask them that question. My practice is on referral. In other words, patients are referred to me, I'm a specialist, the people are referred to me by medical doctors and by physiotherapists They send patients to me for diagnosis. So I mean, that's part of what I do. So I know what the clinician wants from me, but I always ask the patient, what does the patient want from me? So that is a, if you like, a direct question of the patient about what their expectations are. And I would say 30 to 40% of the time, that would be a rough guess. Patients directly ask me, I want to know what's causing this pain. Now, that's not always their only answer, but it is a very, very common answer. And it's certainly not the dominant one, but it is certainly in there. So the patient often wants a diagnosis. Now, that doesn't mean to say they need a diagnosis. Greg is quite correct in what he was saying before, that it doesn't matter a lot of the time. And that is true. But the point is that people want some sort of explanation as to why they're in this pain and why the pain won't go away. That's fair enough. But There is a second level of how is it important to the patient and that if you have, for example, let's say discogenic pain and you have, it centralizes all those directional preference, then that particular subset of mechanical discogenic pain is eminently treatable and there is a lot of good evidence to support that. There is also evidence that the people whose symptoms do not centralize do poorly. So knowing whether it's mechanical or non-mechanical And it's the same, for example, with facetogenic and sacroiliac joint pain. It's been my experience that people who have confirmed, I'm talking about radiologically, interventionally confirmed facetogenic and sacroiliac joint pain, the success of non-interventional treatments is very poor. Manipulation, mobilization, exercises, cognitive behavioral therapy has limited value in these cases. So it matters. whether or not a person has one of those sorts of conditions or something that we can actually treat. And the diagnosis should be a guide to whether you can or you cannot expect to get a good result from your intervention. So it matters to the patient on that level. Okay. Greg, your

SPEAKER_01:

thoughts on that? What was the question again? So we're looking at what does diagnosis for patients with lower back pain mean? So what does it mean for the patient, this diagnosis?

SPEAKER_02:

I like what Mark said with that. I like when you ask, well, what do you want from me when you ask your patients that. I ask that too. So what do they expect? I think what's important with the diagnosis or our explanation for pain, or if I can steal like from the Peter O'Sullivan group and Samantha Bunsley, it's like It's really important that patients, like they make sense of their pain problem. And then I would go a step beyond that with whatever explanation that you have for pain, you tailor your treatment to that. So when someone like me says, well, I'm not sure that we can be tissue specific, or I'm not sure if an anatomical diagnosis is guiding your treatment, that doesn't mean that you just do something that's willy nilly in general. You can still tailor an intervention, just like within the knee and the foot. And you would do it by asking other questions, you would say, Is this person an avoidance coper? Are they an endurance coper? And Mark probably sees people like this all the time, which the whole idea of like, of the directional preferences, for some reason, people just keep doing the same thing over and over and aggravating themselves. So we would say, well, does this person need to back off and change how they're sitting? And maybe they don't flex their spine as much, or maybe they flex their spine more. There's ways to tailor this. And then we would go beyond, and I don't think Mark would disagree here, we go beyond just And we use the simple idea, okay, well, some tissue is sensitive. What are all the factors in your life that are driving this sensitivity? And then now we're acknowledging we're not sure what tissue it is. And we're sort of suggesting, okay, well, what are all the things that are causing this pain to persist? And this is where we talk about anxiety and stress, the coping strategies, the beliefs they had. Are they resuming the activities in their life that they love? If they're not, what are their barriers? So I want to stress that you can have this sort of non-specific approach or acknowledging the uncertainty, and yet you can still have an incredibly tailored and patient-specific treatment program. And it still involves mechanical interventions. And then at the same time, I'm always worried about when is something really specific that really will decrease my options for care. If I work with a 15-year-old and she's she has low back pain with lots of extension and she's a gymnast and maybe she has relative energy deficiency and she's not sleeping well, then you can be damn right that I'm worried about a stress fracture, you know, because that would decrease some of her treatment options. So that's what I would suggest about what's important there.

SPEAKER_01:

Can I just ask here, because obviously we talked about what this means for treatment. So we said, what does a diagnosis mean? And we've come out with a lot about what it means for our intervention, for our understanding understanding for our treatment and i'm going to throw a bit of a bomb in here i feel but what about the idea of the patient walking away with something a diagnosis and we've i know we talked about this at the beginning i don't go back to that but how important for the patient is it to walk away with a diagnosis a specific diagnosis or not greg you want to kick us off

SPEAKER_02:

to be honest i would much rather be able to say oh obviously it's your facet you know that would be great i i realize that that sounds great for people and then you have or i'd love i wish i I used to be a chiropractor, but I never really ascribed to that. I wish I could say, well, obviously it's L3 is not moving on L4. Put it back in place. I get that, that people like that certainty. But I still think for the patients, you can really understand them. And if you listen to them and you see all of the factors that influence their pain and how their pain influenced their life, and you have a plan that resonates with them, and you even acknowledge that you can't be tissue And you work with that uncertainty, but that you can still show that there are things that we can do that can help you. Then your patients will get on board there, acknowledging that there's probably going to be a subset who want to hear that there's one specific tissue thing and you might lose them. But I think with a huge number of people, as you show you care and you have a really good understanding of all the factors that are going on in their life, it clicks with them. And they're cool with this explanation.

SPEAKER_01:

And Mark, we'll Obviously, without going too much back into the tissue-specific side of things, your thoughts about that patient leaving with a diagnosis and thoughts on what Greg's just said. There's a small

SPEAKER_00:

proportion of patients for whom that's actually really important. I would not say that's the majority at all. A lot of patients who just have a huge degree of trust, so long as they feel as though they're with somebody who has experience and understanding and that they're given specific instructions and a rational and reasonable way forward, that's plenty for them. But for some people and the engineers, the patients who are engineers or people who are mechanistic in their own mindset, they want to know why and how and what's doing it and all the rest of it. In a way, you can be completely wrong but give them a rational explanation and they'll be happy with that. But being happy with the explanation doesn't mean that the pain goes away. That's the completely different thing. So I have patients for whom I have no answers in terms of how to solve their problem. But I can do is I say to them, look, I think your brain's coming from this particular structure. We don't know why it is hurting or we suspect it's because of this. There is no treatment for which we have inadequate results. You know, you're going to have to live with this, but you're not going to die. It's not going to cripple you. You're going to have to live with some pain. And people often walk away with that saying, that's all I needed. And they're happy Peter O'Sullivan has tapped into this very, very nicely, I believe, in that he has developed a system whereby people are shown that moving and functioning is not going to crash them, you know, and that they can actually get on with their lives and they can be more confident in their bodies and what have you. This is really important stuff. It doesn't get rid of the pain, all right, but it can be enormously valuable in terms of managing that patient. Greg, you want to add anything to that?

SPEAKER_01:

No, no, I'm all on board. The next bit, I think, brings back and encapsulates what we talked about an awful lot around the research and what's needed, where the gaps are. For From each of you, if in an ideal world, what research would you like to see? And it links in with another question we've got in terms of the ideal RCT, really. Where would you want to see the research really focus now? Greg, do you want to kick us off for that? I'm still a fan

SPEAKER_02:

of trying to find a diagnosis. I think that stuff should still go on, but it would be nice to go take the next step, which is saying, does this matter for the treatment, right? This is where we should be testing specific treatments. I want pragmatic trials. I want to know when tissue matters and when I have less options to help somebody. That's always my holy grail. It's easier to talk about like tendinopathy or something like that, right? Like if someone has a tendinopathy and the tendons sore, do you have to do heavy loading for that tendon? Or could you get away with other types of exercise? The same thing with low back pain. If we get better with a diagnostic or if we take what we already have and then start putting those people into tailored interventions based on the diagnosis, and that would be really nice to see. I want to be told

SPEAKER_00:

what to do sometimes. I 100%

SPEAKER_02:

agree with that, Craig. I know that. why I set it for you. I was setting you up.

SPEAKER_00:

Thank you so much. I think that I'm probably well known in my, with regards to my, not opposition, but my, I had it up to here with RCTs on nonspecific low back pain. I think that in 1999, Moritz van Tilde, he's a Dutch epidemiologist, he wrote a book on accumulating all the current evidence on the RCTs. I think at that time and this is now 25 years ago, he pointed to about 135 RCTs on low back pain. And his overarching statement in that book was the difference between treatments or no treatment, placebo treatments and active treatments is so small as to be insignificant. In other words, it doesn't matter what you do to back pain. On average, the results are about the same regardless of whether the person is in severe pain, mild pain, chronic pain, acute pain, whether you smile at them, whether you pray for them, whether you manipulate them, whether you give them acupuncture, whether you give them pills or no pills, it doesn't matter what you do, you are going to get some success and you're not going to really see a lot of difference between treatments. That was known in 1999. There are now nearly 500 RCTs and nothing has changed in 25 years. So we do not need another RCT on nonspecific low back pain. We know the answer. We already know the answer in advance. We have to stop doing RCTs on that. And what Greg has said is absolutely on the money. We need RCTs on subsets. Now, you mentioned whether it's a diagnosis. Yes, correct. But it doesn't have to be a pathoanatomic diagnosis. We need to subset people and say, okay, We have a more homogeneous group of people. What is the best treatment for that more homogeneous group? Even you take facet joint, for example, there are subsets of that. There are inflammatory ones and there are mechanical ones, right? We know that from people's response to corticosteroid injection, for example. So here's the thing is that we need to find out what are the factors that will lead to a better result with a different treatment all right and so it begins with diagnosis and i think that's pretty much what you said is it not begins with diagnosis and the better we get at that obviously the better our rcts will be all right but we did we had to stop doing non-specific back pain rcts absolutely

SPEAKER_01:

okay perfect feel stumped about that really to be fair i think you've agreed for a start and i'm not sure uh where else we go i mean because one of the questions we had was about what rct would podcasters recommend next so mark we're obviously saying none no i'm not on non-specific back pain. Yeah, not on non-specific low back pain. So if we were to have any RCTs, Mark, what would you go with?

SPEAKER_00:

Well, there are certain subsets that we can identify relatively easily. For example, I think if we were to take people whose symptoms were repeatedly and reversibly directional preference passions and then say, okay, let's do an RCT where we compare direction-specific treatment versus non-direction-specific treatment. Now, Audrey Long did do that back nearly 20 years ago, and she showed a significant difference. But that needs to be replicated. It needs to be challenged. It needs to be validated or rejected. We know that there are good results if you do that. But we need to actually test that more thoroughly. And that's a subset of people. We know that they have discogenic pain, and they're a subset of discogenic pains. And we know that we can treat those people, but we need to challenge that more. Then we need to take a whole bunch of people who we know are highly likely to respond positively to an intra-articular injection of local anesthetic into the sacroiliac joint. Physiotherapists, chiropractors, and osteopaths all believe that they have a treatment for sacroiliac joint pain, and it's often mobilization or manipulation or exercise. The question is, is it true that these treatments are beneficial for that subgroup? Now, there was an attempt at that, and it was done by Fritz and Delito and Flynn and those guys from Pennsylvania, where they looked at a manipulation, and it was published in 2014 on which patients respond to this particular manipulation. If you have a look at the manipulation, the manipulation is a classic manipulation of sacroiliac joint. Now they were, I believe that they avoided the discussion about what that manipulation was alleged to do. They were clearly looking for a sacroiliac joint problem because you look at all the tests they did, all of the provocation tests, they did all of the palpation tests and none of those were a predictor of the response to their so-called sacroiliac joint manipulation. None of them were predictive. But they never mentioned that. They just went on and said, here are the predictors of that manipulation outcome. Now, I felt as though they failed to mention the fact that they were looking for a sacroiliac joint subgroup and didn't find it. They didn't say that, but that's what actually happened. Now, we need more of that sort of research. We need to find out the subsets of people we know, for example, have sacroiliac joint pain. Are there treatments for these patients that actually work? Now, that to me is an RCT absolutely but you've got to first of all identify those patients most likely to respond to the injection and we can do that with an accuracy of around 80% alright now that's a good RCT alright we don't know how to predict people with facet joint pain with any certainty so maybe we need to have people who have proven facet joint pain and then let's see if mobilisation manipulation exercise cognitive behavioural therapy acupuncture and all these things that we physiotherapists do, are those any good for that subset? We don't know the answer to that. There is not a single RCT on people who have proven for sacroelectroin pain. Not a single RCT ever been done. There's not a single RCT on a set of patients who have proven sacroelectroin pain. Not a single one. Now, that sounds like a good idea. It's a gap.

SPEAKER_01:

Greg, anything you'd

SPEAKER_02:

add to that in terms of your ideal RCT? create a comprehensive program. And then in the other group, it would be tailored interventions to the diagnoses that they were given, right? It would be tough because then you'd have to, you might have to do preliminary work first, like Mark mentioned of, well, what's the ideal way to treat the disc? What's the ideal way to treat the facet? Let's say that's done preliminary. Then you would have this group where it's tailored to the diagnosis. And the one One group wouldn't have got any of that diagnosis and the other one group would have done CIT or something like that, some generalized comprehensive program. So that would be an interesting study for me.

SPEAKER_00:

And CFT is one example, but another example. It could be anything else. I mean, yeah, I know you've done a lot of work with Stuart McGill. Oh, no, not

SPEAKER_02:

really. No, that was a long time ago. That was another life.

SPEAKER_00:

You've looked at that. I think you've looked at that fairly closely. And I think that that would be a program that would be non-pognitive behavioral, but more mechanistic. And so that would be a more generalized program compared to a specific program, for example. That'd

SPEAKER_02:

be another way to test it. I think his work tries to be specific, but it's kind of more like the Shirley Sarman approach where the diagnosis are related to finding the specific trigger, which is often a movement trigger and aggravating. And then you create your specific program around the movements. I don't think they would do your type of testing, but they would still say they're being very specific. So that'd be interesting. That would be like two specific programs going after one another, like comparing one another. Is there a better way to try to think that you're specific?

SPEAKER_00:

Well, Shirley Simon, of course, is well known for her complete resistance to the concept of a pathoanatomic diagnosis. As far as she's concerned, that is not necessary, and physiotherapists don't do that. And she's quite clear.

SPEAKER_02:

But she thinks she's pretty specific. So her specificity is in terms of movement.

SPEAKER_00:

Yeah, but specific to a particular movement.

SPEAKER_02:

Yeah, and I feel like McGill is sort of like that as well. It's hard to say, because you don't really see a lot of RCTs with his ideas. But he'll bust out anatomical stuff when you hear him talk, but it's based on movements and things like that. So that'd be really cool to see too.

SPEAKER_01:

That's probably a fantastic place to finish, I think, to be honest. We've told the world what we need. Which one of you is taking it on? Who's got$10 million? Yeah, exactly. Exactly. Not me, I wouldn't be here. We need more diagnostic accuracy research too. Yeah, so where would you go with that then, Mark, in terms of what would a diagnostic accuracy study look like in a per if we could put it together?

SPEAKER_00:

The biggest problem that we have with diagnostic accuracy research is you have to have some access to the criterion standard of diagnosis that's usually interventional. It can also involve high-tech imaging as well. And I was fortunate enough to have access to that, and I still do have access to it, by the way. And my research has all been based upon comparing clinical examination to criterion standards. But it's not enough for me to have done a few studies, all right? The results that we have achieved need to be challenged. I have no issue with that. In fact, I have been attempting for the last 20 years to have people do that and it has never been done. For example, I work on facet joint there, clinical prediction rules for the facet joint blocks that has been published in 2006 it was. And I have been trying to get somebody else to do that independently of me on different patient subsets and it's never been done. In 2004, We challenged Ravel's model for facet joint blocks and for identifying facet joint pain. And we, both myself and a fellow called Laxamaya Manchakanti from Kentucky, He and I both have published papers showing that Ravel's criteria are not replicatable in other studies. We published our results in 2006, and I've been trying to get other people to do exactly the same thing, and nobody has ever done it. So at the present time, you have to say the only research that enables us to demonstrate we can predict the outcome of facetia in blocks is the study that we published 20 years ago. And it needs to be challenged. It needs to be replicated. It needs to be validated or rejected. It needs to be improved upon. That's research that is begging right now. And the same roughly goes, we had a little bit of validation of the Sacarelli joint stuff. Peter van der Werff in the Netherlands has partly validated our approach. We got exactly the same results, by the way, within very small differences, uncannily similar results. But the point is, it's still not the full picture. So we need replicating, validating, challenging research on what we started. And I can't do this. I'm 75 years old. years of age. I'm not going to do another study on this. It's up to you guys. We need

SPEAKER_02:

to create a fund in your name. You don't have to be dead for Memorial, just like to remember your work. We can start the GoFundMe now. You can still be around and see the fruits of it.

SPEAKER_01:

And Greg, finishing us off, in terms of diagnosing accuracy studies, anything you'd add to what Mark just said there?

SPEAKER_02:

I would love to see those. I think that's a great place to start. Absolutely. The replication stuff and then just fine-tune

SPEAKER_00:

them. And reliability studies. I mean, they're easy to do. We can do this in a clinic. Most of the tests that we use in the clinical practice have never been subjected to reliability studies. Most journals don't even want to publish these things. Why? We need to have reliable tests to then, once we have reliable tests, then we can subject them to validity studies. There's a sequence here. We did that on the sacroiliac joint, for example, right? It has been partially done on repeated movements and the centralization idea. That's been partially done as well. But we need more research and physiology Psychotherapists are the only people who are going to do this. Well, chiropractors and osteopaths, they can do it too. Whether they will or not, that's another story. But reliability studies need to be done and they need to be published. We need to start off with what's reliable, the intra-examiner reliability, repeatable reliability, intra-examiner reliability as well. And then we can do the validity studies as well. So that's lots of stuff on diagnostics. Brilliant.

SPEAKER_01:

Mark, Greg, we'll leave it there. We've had a good chat. It's been really interesting. We started off with a really good discussion, I think, and we've come up with some gold. Then

SPEAKER_02:

we went downhill. What are you saying?

SPEAKER_01:

Not at all. Not at all. As a host, I actually interject and put some more questions to you both. But I really appreciate it. I'm sure the listeners do your time for me this evening and your replicable time zones. So thank you so much, both of you. I'm sure we'll no doubt hear lots more from you in the near future whether that be in research studies or general bits and pieces on social media and things like that

SPEAKER_02:

you're hearing me when i get to write the forward to mark's book

SPEAKER_01:

before yeah there you are there you are mark

SPEAKER_00:

you heard

SPEAKER_01:

it

SPEAKER_00:

here greg's doing the forward for your book apparently oh okay there are three more papers that we are currently in the process of publishing oh good congrats the one's on directional preference another is on the prevalence of clinical findings and physiotherapy type clinics and there's one other as well so yeah

SPEAKER_01:

Brilliant. We'll keep our eye out for that and also your book as well, Mark, coming out this year, which would be great.

SPEAKER_00:

It's looking good.

SPEAKER_01:

I'm really hoping I'll get it published by about July. Nice. Excellent. Looking forward to it. Mark, Greg, thank you so much. We'll see you soon.