Six articles on PainSci cite Saragiotto 2017: 1. The Complete Guide to Low Back Pain 2. The Complete Guide to Chronic Tension Headaches 3. The Complete Guide to Neck Pain & Cricks 4. The Chiropractic Controversies 5. Does Spinal Manipulation Work? 6. Cognitive Behavioural Therapy for Chronic Pain
PainSci commentary on Saragiotto 2017: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.
These authors conclude that the idea that some back pain patients respond better to some treatments is probably still mostly hype.
Most low back pain has no known cause and is therefore considered “non-specific,” and there’s a wide range of response to treatment in these patients. A common assumption is that they actually have specific causes for their pain, even though we can’t identify them — but there is a hope that we can identify the patients who respond to specific treatments. This is the hope or hype about “subgrouping”: you don’t necessary have to understand how their pain works to identify types of patients that will respond better to treatment. There is a large, enthusiastic movement in back pain research to achieve this.
In this paper, in which the authors thoroughly “have deliberately chosen to argue 2 extreme positions,” both for and against the investigation of subgroups. Key points in favour:
- One size fits all does not work well; non-specific back pain is clearly not all the same beast.
- Research methods are improving, and there are some good examples of subgroup analysis
- Subgrouping does not need to be complex or difficult, and there are success stories in other areas of medicine (e.g. subgroups of stroke victims).
- Subgrouping patients with nonspecific LBP fits well into the “personalized medicine” movement.
- Both patients and clinicians prefer the subgroup approach.
And key points against:
- Subgroup analyses are mostly very low quality still, and “authors commonly overstate their claims of subgroup effect.”
- Identifying stronger treatment effects for certain patients without a clear biological reason for why it works is not very persuasive, and by definition “there is no identified biological source of nonspecic LBP.”
- If some subgroups respond well to treatment, there should also be groups that respond poorly, and this evidence is missing.
- Clinicians cannot actually perceive the treatment effects that their enthusiasm for subgrouping is largely based on.
- “Subgroup analyses are associated with a high risk of false-positive and false-negative results” and may mislead us.
They conclude: “the current research initiatives and achievements in this field are far from optimal and not yet ready to be implemented in clinical practice.”
~ Paul Ingraham
original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.
Clinicians and clinical researchers share a common goal of achieving better outcomes for patients with low back pain (LBP). For that, randomized controlled trials and systematic reviews are the most reliable study designs to determine the effects of interventions. Subgroup analyses in these research designs have been used to examine treatment-effect modification across subgroups defined by patient characteristics. In this Viewpoint, the authors present supporting and opposing arguments for the subgrouping approach in nonspecific LBP, considering the progress made so far in the LBP field and the relevant literature in adjacent fields. J Orthop Sports Phys Ther 2017;47(2):44-48. doi:10.2519/jospt.2017.0602.
- “Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials,” Machado et al, Rheumatology (Oxford), 2009.
- “A systematic review reveals that the credibility of subgroup claims in low back pain trials was low,” Saragiotto et al, J Clin Epidemiol, 2016.
- “Chronic low back pain is highly individualised: patterns of classification across three unidimensional subgrouping analyses,” Rabey et al, Scand J Pain, 2019.
This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:
- Cannabidiol (CBD) products for pain: ineffective, expensive, and with potential harms. Moore 2023 J Pain.
- Inciting events associated with lumbar disc herniation. Suri 2010 Spine J.
- Prediction of an extruded fragment in lumbar disc patients from clinical presentations. Pople 1994 Spine (Phila Pa 1976).
- Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study. Konstantinou 2015 BMC Musculoskelet Disord.
- Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial. Kuyken 2022 Evid Based Ment Health.