A New Era in Managing Low Back and Neck Pain

December 1, 2010

In his book entitled “Innovator’s Prescription”, Clayton Christensen describes three eras of medicine: intuitive, empirical, and precision.

The intuitive era is characterized by highly trained, usually expensive, professionals who solve medical problems through intuitive experimentation.  They use and re-use treatments that just seem to work for them.

As medicine evolves, an empirical era emerges where data are amassed that show there are certain treatments that seem to work better when treating patients on average.  This era is often referred to as “evidence-based” using randomized clinical trials that determine what works best for the average patient suffering from a non-specific symptom.

In the precision era, each individual’s disease or disorder can be diagnosed with such precision that a predictably effective, standardized treatment can be identified that addresses the cause of that individual’s problem rather than just the symptom.

Christensen points out that the care of infections moved through all three of these eras. Once diagnosed intuitively as immorality or weakness of faith, and then empirically as a result of unsanitary conditions in a city, as technology progressed, microscopes and staining techniques enabled the identification of microorganisms, some harmless and some deadly.  Identifying the specific organism causing an infection provided clues about the aggressiveness and spread of the disease, a patient’s prognosis, and, over time, enabled the development of consistently effective therapies. Infections used to account for the majority of health care costs but that has declined to about 5% per year of what it was in 1940. They now comprise just a tiny part of the U.S. health care budget.

The treatment of non-specific low back is following this same path.  Care remains in the intuitive phase for those clinicians who choose their treatment based on their best theory as to what causes most low back pain, and then often prescribe their favorite treatment.  Thousands of randomized clinical trials over the past 25 years have defined our current evidence-based/empirical era that has, not surprisingly, failed to identify an effective treatment for the “average patient” with non-specific low back pain.  After all, are any care-seeking patients “average”?

When an anatomic diagnosis is confidently made of a herniated disc causing sciatica and a neural deficit, even that diagnosis lacks sufficient precision to guide predictably effective treatment or determine early whether or not recovery can occur without surgery.

Ironically and unfortunately, most academic spine clinicians, researchers, and policymakers are deeply committed to empirical care with little or no understanding or vision for the importance of moving toward precision medicine.  They incorrectly think that RCTs of a non-specific symptom will somehow identify a predictably effective treatment for most patients.

So how do we move toward a precision diagnosis for low back or neck pain?
When we take our car to a mechanic seeking help with a problem, he doesn’t start by taking pictures of the car or its engine.  He begins by asking details about how the car is misbehaving and then takes it for a test-drive to personally evaluate its behavior so he can determine what treatment it needs.

It is similarly valuable and informative to “test-drive” a painful low back or neck while monitoring for familiar patterns of symptom response.  Numerous studies show that this form of dynamic assessment, part of an approach to spine care known as Mechanical Diagnosis & Therapy, provides far more precise information about the pain source than does most physicians’ clinical examination and way more than is provided by spinal imaging. This assessment can also uniquely identify predictably effective treatment for the great majority with low back and neck pain.

Unfortunately, the extensive evidence that validates this MDT form of assessment continues to be ignored by most spine experts who remain deeply entrenched in the empirical phase of spine care.  Despite 25 years of minimal progress in identifying effective treatments for non-specific low back pain, most experts remain fixated on finding ways to improve studies that still focus on subjects with a non-specific symptom.

The MDT assessment research has strongly established that the underlying cause of most low back and neck pain can be corrected quite quickly and easily without having to make an anatomic diagnosis. Making a precise dynamic mechanical diagnosis is far more informative and cost-effective than making a mere anatomic diagnosis. I’ll write about this more in future blogs.

The MDT assessment and its extensive research support is ushering in a new decade of spine care focused on establishing a far more precise diagnosis.  This is good news for everyone, especially patients and employers.  Identifying a precise mechanical diagnosis early will not only bring about rapid and inexpensive recoveries, there will be much less need for expensive spinal imaging, prolonged non-surgical care, injections, medications, and surgery.

For more information on this and many other topics, go to www.selfcarefirst.com.

Dr. Ron

Ronald Donelson, MD, MS

SelfCare First, LLC
See the new patient education book: “Solving The Mystery: The Key to Rapid Recoveries for Back and Neck Pain” at http://www.selfcarefirst.com


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