Low Back Pain “Shared Decision-Making”: Great Program, One Bad Assumption

February 12, 2011

Recovery from low back pain (LBP) does not always occur.  A critical decision comes when treatments are not working and it appears there may be something more seriously wrong.  We can fall prey to explanations and recommendations from those who seem to be acting in our best interests, but who also may be recommending a treatment that is as beneficial to them as to us.  The recommendation of surgery, for example, may be a very appropriate one, but the surgeon is likely less than fully knowledgable about our non-surgical treatment options.  After all, that’s not their specialty – they’re surgeons.  And we need to keep in mind that they also stand to benefit personally and substantially from performing our surgery.

Ideally, we’d like our doctor to tell us what’s best because we simply do not have the knowledge to decide for ourselves. But will they, or can they, give us their best recommendation without any economic bias?  Many leading spine experts are concerned about patients receiving a biased view of what should be done next.

Enter “Shared Decision-Making”

In recent years, some of those experts have developed a program called “shared decision-making”(SDM). With great care, educational videos have been created to inform us of our surgical and non-surgical options in treating our stubborn low back condition. Their intent is to present us with a balance between the risks and benefits of surgical and non-surgical treatment enabling us to better discuss those options with our physician or surgeon.  The concept of SDM is admirable in its intent to provide us with a more balanced, unbiased view of our treatment options. When patients are given such information to discuss with their doctors, studies have shown that they often alter their choices of whether or not to undergo surgery.  For most conditions, surgical rates dropped significantly as a result of watching these videos.

In the case of back and neck pain, most patients and physicians would agree that, if there is any way to recover otherwise, surgery is simply not the “preferred” treatment. It’s painful, risky, expensive, and recovery can be lengthy and uncertain.  Most doctors and patients would never even consider surgery until all non-surgical treatment options have been explored.

A Bad Assumption

Unfortunately, the LBP SDM programs make an important but faulty assumption in their discussion of the pros and cons of undergoing surgery. They actually offer little about the non-operative options we have, and basically assume that we’ve already attempted most and these were unsuccessful.  They especially do not take into consideration the numerous studies that report that most people with back or neck pain have a rapidly reversible condition.  To be more specific, 80-90% with acute LBP and 50% with chronic can recover fairly quickly, even if they’ve had their pain for weeks or months, perhaps years, and even if multiple different treatments have been unsuccessful.

But LBP will only rapidly reverse if it is treated in a very specific, individualized way, and that treatment varies from patient to patient. Only a specialized form of clinical evaluation can determine what that treatment needs to be for each patient.  That special form of evaluation and treatment is safe and inexpensive and the treatment is routinely performed by the patient themselves once taught what to do.  This form of care is best known as Mechanical Diagnosis & Therapy (MDT).  It’s focus is on self-care first.

Despite 30 years of available books, articles, courses and research on this topic, only a small percentage of doctors are even aware that LBP can be rapidly and intentionally reversed.  They were never taught MDT in their training.  For example, has your doctor referred you to someone trained in MDT principles for an evaluation to see if your pain might be rapidly reversible?  Instead, using their best clinical judgment, they so often prematurely conclude that you may be that occasional person in need of disc surgery.

Unnecessary Surgery?
As are most doctors and surgeons, the writers of the LBP SDM video presentation are well-intended.  But they overlook four published studies that report that as many as 50% of patients considered by their doctors to be candidates for lumbar disc surgery 
turn out to have a rapidly reversible condition if at that point in their care they are given the opportunity to undergo a proper MDT evaluation.


Despite the intent of the creators of LBP SDM to empower us to make the best decision for ourselves, if our doctors don’t tell us about this opportunity undergo this inexpensive, safe, and informative evaluation, and SDM videos also neglect this information, many of us will end-up blindly choosing to undergo unnecessary surgery.

The stated and admirable intent of the LBP SDM programs is to help patients make the best and most cost-effective decision for themselves. However, if there is published data that even hints that some individuals may be undergoing low back surgery unnecessarily, and instead might recover rapidly, safely, and inexpensively without surgery, shouldn’t this information be passed on for patients’ and their doctors’ consideration and exploration?  When it comes to honoring patient preferences, most every patient struggling with persisting LBP would prefer, if not jump at, any opportunity to recover without surgery.

This MDT form of care and its many implications are all described and discussed at length in my books “Solving The Mystery” and “Rapidly Reversible Low Back Pain”. We need far more doctors, physical therapists, and chiropractors trained in these evaluation and treatment methods. Fortunately, that training is readily available.

Dr. Ron


One Response to “Low Back Pain “Shared Decision-Making”: Great Program, One Bad Assumption”

  1. […] or more, and often incomplete. Informing pre-surgical patients of this option is the basis for “shared decision-making” (SDM) programs intended to present a balanced view of surgical and non-surgical […]

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