World Congress on Low Back and Pelvic Pain

November 7, 2013

RD & Dr.Sood

Dr. Ron and Dr. Sarveshwar Sood of India

In my last blog posting, I was heading to Dubai to give a presentation at the World Congress on Low Back and Pelvic Pain.  This conference is considered by many to be “the place” to hear the latest and greatest research from the world’s top spine and pelvic researchers. Attendees include clinicians (doctors, physical therapists, and chiropractors mostly) and researchers – both clinical and basic science. The Congress is held every three years in a different, and always attractive, city.  More than 1,000 attended this four-day conference from 58 countries. The conference venue was outstanding and Dubai a fascinating city.

I’m sure most considered the presentations to be excellent research, yet so many were in fact only lectures about myofascial and musculature anatomy and physiology of the spine and pelvis, but no clinical data. The rationale for these presentations?… these structures are essential to spine movement and stability, ergo, they must in some way be deficient in painful individuals and therefore in need of strengthening or stretching.  So many presenters offered no explanation for how pain is generated related to these structures and their deficiencies, nor did they present any data as to the beneficial impact when people perform exercises that theoretically address these alleged deficiencies. In other words, so what?  Interesting anatomy and physiology, but where’s the clinical relevance?

One positive and significant program feature for me was the final half-day that focused on the topic of subgrouping: why is it important, how to validate subgroups, and examples of subgrouping efforts.

The final talk of that final day by Hanne Albert, PT, PhD from Denmark, was especially well-received.  She is an excellent presenter who reviewed her research in identifying and validating a new, but very small, subgroup within the chronic low back pain population whose pain appears to be due to an infection within a disc that was previously herniated and now has Modic 1 changes in the adjacent vertebrae.  Her RCT reports that this small subgroup does quite well with antibiotic treatment vs. being treated with a placebo medication.

What is remarkable is that identifying and preliminarily validating this subgroup is being hailed as a major breakthrough by the spine care world, despite only one RCT.  Further, even if this is all true, it is still only about 1% of the LBP population.

Meanwhile, my presentation, described in some detail in my last posting, preceded Dr. Albert’s.  It focused on two cases of radiculopathy and how both became completely pain-free in just 30 min. and were able to avoid scheduled surgery.  They both then fully recovered within days, and remained pain-free when last checked two years later.  All this happened because of their mechanical (MDT) assessment followed by performing some simple, safe exercises without risk or side-effects.

But then I additionally presented a great deal of published evidence that these rapid recoveries are actually very common, occurring in 70-89% of acutes, 50% of chronics and radiculopathies, most axial neck and low back pain, as well as a good percentage of stenotics and spondys.

Of course, most researchers have never, or have rarely, seen a patient evaluated or treated, so they have no appreciation for the rapid and rather dramatic rate and ease of eliminating these patients’ severe pain, sensory loss, and tension signs, while simultaneously restoring normal movement and reducing the size of their disc herniations – all within their 30-minute first session!

Just one question was addressed to me during the subsequent discussion. I was asked how the status of a painful disc’s hydrostatic mechanism influences whether the pain can be centralized or not. I responded with the results of our study published in 1997 that compared the findings of the MDT evaluation in patients who promptly underwent discography that identified the status of the anulus and hydrostatic mechanism in centralizers, peripheralizers and those who had no change in pain with their MDT assessment.

Not surprisingly, conference participants without any MDT training were described by one as “spellbound” because, on one hand, these two patients’ presentations were very familiar to them, yet they had no idea that such severe disc pathology could be turned around so quickly and easily.  One U.S. physiatrist also noted that I was the only speaker to present so much data in my literature overview.

Nevertheless, my sense was that Dr. Albert’s presentation caused the greater buzz, by far.  So why was that?

On one hand, even if we assume that her Modic infection subgroup is validated, that still only represents a very small portion of non-specific chronic LBP patients.  Furthermore, treatment consists of 100 days of oral antibiotics that routinely creates GI side-effects, an occasional temporary blackening of teeth, and some treatment failures of course.  Pain relief doesn’t begin until weeks into the treatment and then often does not resolve completely.  Nevertheless, even this small validated subgroup is worthwhile identifying for those with this infection who otherwise would continue in pain.

On the other hand, the “reducible derangements” (dir. pref. and centralization) that I described account for 70-89% of acutes, 50% of chronics and sciaticas.  The treatment is simple, safe, routinely brings complete pain relief, usually in minutes, hours or a few days, and commonly leads to long-term freedom from pain for patients who perform very simple exercises on a regular basis and guard their posture a bit.

So how much ‘buzz” did my presentation create?  Only a handful came up to me at the gala dinner that night to comment.  So my sense is that it did not cause as much stir as Dr. Albert’s work. Was that because those dramatic recoveries I showed were viewed by some as too-good-to-be-true? Or perhaps these highly prevalent rapid recoveries were just too disruptive to clinicians’ rigid perception of back pain’s pattern of slow recovery.

Regardless, the evidence indicates that every patient with neck or low back pain should undergo an MDT assessment and every clinician should be obliged to provide such an assessment for their painful spine patients. The strong possibility of such rapid, simple, and safe recoveries should be made available to all.

As always, I welcome feedback and questions. Please be sure to click on “Like” if this was useful and enlightening, or “Leave a Comment” by clicking on “Comment” below. Have a wonderful week everyone.

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