Low Back Pain: A Symptom-Based Approach to Diagnosis and Treatment.

Low Back Pain: A Symptom-Based Approach to Diagnosis and Treatment Rucker KS, Cole AJ, Weinstein SM, eds. Woburn, MA 01801, Butterworth-Heinemann, 2001, paperback, 406 pp, illus, ISBN: 0-7506-9485-8, $35.

The editors of this book, 3 allopathic physicians specializing in rehabilitative medicine, have gathered contributions from 23 authors: 18 physicians, 2 doctors of philosophy, 2 physical therapists, and 1 nurse. Although they do not specify the intended audience, the editors comment that the purpose of their book is to enhance the clinician's understanding of the practical management of patients with low back pain.

The first section of the book deals with the examination of patients with low back pain. Different authors provide their opinions on evaluation of the lumbar spine in adolescents, adults, and the geriatric population. This may cause some confusion for the reader because each author has a different opinion on the evaluation of the lumbar spine. The chapter on the evaluation of the adult spine demonstrates a comprehensive approach that is educational, clinically useful, and interesting, and it comes from the point of view of 3 physicians who specialize in physical medicine and rehabilitation.

A chapter devoted to the biomechanical assessment of low back pain categorizes patients into 1 of 3 reported stages of pathophysiology: dysfunction, instability, or restabilization. The chapter emphasizes the facet joints and disk and pays little or no attention to other musculoskeletal tissues such as bones, muscles, and ligaments. The three stages of healing--inflammation, repair, and remodeling--were not a part of the discussion on the 3 phases of pathophysiology. Unfortunately, this chapter does not provide sufficient detail and clarity to give entry-level physical therapists the tools they need to perform a comprehensive biomechanical assessment. For example, some aspects of a complete biomechanical examination are left out, such as rotational movements, quadrant testing, passive range of motion testing separate from the special tests, resisted testing of spinal musculature, and a complete description of segmental mobility testing. The assessment technique presented is primarily from the McKenzie school of thought.

Several clinically relevant topics receive comprehensive, in-depth coverage from the authors. The chapter on radiology of the lumbar spine includes topics ranging from plain radiographs to discography and includes analysis of metabolic, infectious, and malignant disorders. The presentation on electrodiagnosis of lumbosacral radiculopathy, covering both electromyography and nerve conduction studies, includes an insightful differentiation of dermatomes, sclerotomes, and myotomes. Six case studies are included to help the reader understand the clinical rationale and usefulness of electrodiagnostics. The chapter on pharmacology contains a review of 11 different categories of medications and 22 drug-related tables that make it easier for the reader to absorb all of the information.

A comprehensive and clinically useful chapter on injection therapy contains a clear description of the following injection procedures: epidurals, selective nerve root injection, facet joint injection, sacroiliac joint, discography, and radiofrequency neurotomies. A chapter on lumbar surgery covers different approaches to surgery in detail and includes the topics of chemonucleolysis, percutaneous nucleotomy, arthroscopic microdiskectomy, spinal endoscopy, and fusion. The authors provide a valuable discussion on indications and complications and their own conclusions regarding the efficacy of each surgical approach. Even though the chapter is titled "Modern Advances in Lumbar Surgery," there is no review of intradiscal electrothermal anuloplasty. Finally, the presentation on occupational medicine is also very good because it gives a physician's viewpoint on the management of clients who are receiving workers' compensation for low back pain. Five clinical case studies and an algorithm provide interesting insight into the clinical decision-making process.

The book presents a good overview of the principles of medical management using a multidisciplinary approach to the assessment and treatment of chronic low back pain. The authors' discussion varied from the cellular and tissue level of the injury to the consequences of the injury for the individual's psyche. The topic of physical therapy for low back pain appears to be written as a general overview for physicians. Most of the currently accepted schools of thought in physical therapy are briefly presented. A majority of the treatment recommendations are for a McKenzie-oriented approach or the use of pelvic traction. Very little attention is paid to manual therapy techniques (soft tissues and joints) or examples of various therapeutic exercises. This general overview is not specific enough for it to be useful as a practical learning tool for physical therapists.

The editors did meet their stated purpose of enhancing the reader's practical understanding of the management of patients with complaints of low back pain. This book appears to be geared toward an audience of physicians and is not a book that is to be recommended for physical therapists who wish to learn treatment techniques or specific treatment protocols. This book is, however, a very good reference for both the entry-level and the experienced physical therapist who works with clients reporting low back pain. The information from a medical perspective is especially interesting and useful for the areas of radiology, electrodiagnosis, pharmacology, injection options, surgery, and the management of clients injured on the job. The best part of this book is the insight that all of the authors give the reader by presenting opposing viewpoints and controversies, referencing current literature, and discussing clinical decisions that are warranted but that are not yet supported by research.

John C Gray, DPT, OCS Sharp Rees-Stealy Medical Center San Diego, Calif

Dr Gray is a faculty member of the Ola Grimsby Institute and the lead clinical specialist in orthopedic manual physical therapy at Sharp Rees-Stealy Medical Center.