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.

I am continually reminded of the ineffectiveness of most clinical spine research and virtually all guidelines that collectively block any improvement in either the quality or cost of spine care.  The latest documentation is this month’s lead article in the BackLetter (“U.S. Spine Care System in a State of Continuing Decline”, Vol. 28, No. 10, October 2013).  Its focus is on the “state of crisis” in spine care within the U.S.

A new study is cited (Mafi et al: Worsening trends in the management and treatment of back pain/JAMA Intern Med/2013) that presents data that this system is actually accelerating the development of chronic pain, work disability, narcotic addiction, use of injections and surgery, and guideline-discordant care in general.  Sky-rocketing costs tied to increased utilization of unproven invasive procedures and devices have generated little if any evidence of any improvement in patient outcomes. The growing use of MRIs generates more and more mis-diagnoses and more opioid prescriptions lead to more addiction. That’s our predicament after more than 1,000 randomized clinical trials and hundreds of millions spent on research and guideline creation over the past 25 years.

What is particularly disturbing about this article is the analysis by experts as to why we are in this situation, and their ideas about solutions. They understandably, but mistakenly, put all their confidence in the recommendations of clinical guidelines.  Their explanation for this crisis is primarily clinicians’ non-compliance with guidelines and recommend that doctors provide far less treatment for both acute and chronic low back pain (LBP) and let the favorable natural history (NH) run its course to recovery for most.  That would make some sense, IF the natural history was truly as favorable as they believe.  I repeat…..if.

Many studies challenge that view of NH (i.e. Donelson et al: Is it time to rethink the typical course of low back pain? PM&R Journal. 2012;p394–401). There are very credible population-based studies that continue to be ignored by those who we would expect to be very familiar with the breadth of this literature. But those same experts seem irreversibly entrenched in the belief that a high percentage of LBP recovers on its own within 90 days.  The data supporting that belief are simply flawed and those population studies, though highly credible, remain unacknowledged.

Meanwhile, this article correctly points out that the exam room reality is that it takes far less time, with the same reimbursement, to order an MRI, write a narcotic prescription, or refer to a specialist than to explain to a patient in pain the optimism supposedly tied to NH and the rationale for not prescribing those interventions. So guideline-concordant care is just not going to happen, unless guidelines change (see below). Further, the lack of validity for any treatment gives clinicians license to prescribe whatever treatment he or she wishes. After all, if the NH is that favorable, even an ineffective, unproven treatment can appear successful to both the clinician and the patient if the patient recovers by NH.  The classic line: don’t believe your treatment was effective just because the patient got better.  Of course, the generous reimbursement for those treatments further incentivizes guideline-discordant care.

But there is an even more fundamental blind spot in these experts’ point-of-view. Throughout this entire BackLetter article, the symptom of “low back pain” is treated as “the diagnosis”. The article’s focus, just like the vast majority of RCTs and literally all guidelines, is entirely on how to treat this non-specific (NS) symptom.  That modus operandi drives the near-universal acceptance of the notion of one-size-fits-all care, or treating every patient with LBP the same, with NS-treatments like advice to keep active and reassurance of likely recovery in time.  Is it not surprising that hundreds of studies of a NS symptom would only yield NS solutions for the average patient? And is everyone truly the same?  Do none of these experts get it that a bell-shape curve and a bimodal curve focused at the two extremes of the population can have the same mean?

Such recommendations also ignore patients’ understandable sense that there is something terribly wrong and terribly painful somewhere in their back.  “Let’s find out what it is” (get an MRI), and ‘I need pain relief!!”  Again, the doctor gets paid the same for the 5 minutes to write a prescription or make a referral as for the 15 minutes required for patient education. And of course compensation is much greater if a treatment is actually provided, especially if it is invasive.  This perverse reimbursement incentive is substantial.  And all this significantly distracts from the fundamental, even essential, need to figure out how to more precisely diagnose and in turn treat these patients.

Incredibly, there is no mention in this article or, in fact, in any guideline, of the importance and value in discovering something more about the underlying pain generator.  In contrast, two different surveys of international LBP researchers spanning the past 15 years both concluded that the #1 research priority is the identification of valid LBP subgroups (Borkan et al/Spine/1998 and Pransky et al/Spine/2011).  Where is that priority in this article?  After all, isn’t that the only way we will ever move spine care toward more individualized, patient-centric, and cost-effective care?

Paul Batalden at Dartmouth has often stated: “Every process is perfectly designed to get the results it gets.” So what is the process that has been so perfectly generating what is acknowledged in this article as this declining spine care system?

As I see it, the research cards are solidly stacked against making progress in improving care.  For example, the highly regarded Levels of Evidence (LOE) hierarchy that has become the basis for spine-related clinical research and evidence-based care ironically de-emphasizes the importance of the most important focus of LBP science: diagnostic subgroup research. The basis for that de-emphasis appears to be the belief that we simply can’t make a good diagnosis in most cases and may never be able to. If our current advanced imaging can’t do it, it’s unlikely we’ll ever be able to identify anything that will uncover the true source of pain.  Of course, theoretical explanations for LBP abound and are offered to most every patient to justify the clinician’s favorite treatment recommendation.

But the LOE construct includes an absurd approach to diagnosis research based on requiring a  “gold standard” in order to produce a credible diagnostic advance.  How can one possibly have a gold standard when 85% have no means of diagnosis?  Those who accept that research construct obviously never expect to see any headway in making a diagnosis in those 85%.

For decades, the evidence-based process in researching spine care has focused on, and been quite content with, seeking the best treatment for the average patient with this NS symptom. But we don’t have guidelines for abdominal pain, elbow pain, or knee pain, obviously because there are subgroups in each of those body regions for which there are subgroup-specific treatments validated with outcomes evidence.  But with LBP, we have entire guidelines focused on a regional symptom!

Guidelines and RCTs make a feeble attempt at subgrouping by focusing on acute vs. chronic LBP with the belief that they are two different clinical entities.  But there is now evidence that many members of those two duration-based subgroups have far more in common than they have differences (Donelson et al: Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica. PM&R Journal. 2012;p667-81).

The Quebec Task Force was the first comprehensive LBP literature review back in 1987.  It tried to shed light directly on this blind spot when it wrote that “the diagnosis is the fundamental source of error….. Faced with uncertainty, physicians become inventive.” But it changed nothing. According to this article, no acknowledged progress has been made.  Our inability to make a precise diagnosis not only remains the fundamental need, it’s importance is our greatest oversight that lies at the heart of our decline in spine care.

There are two other critical parts of the spine care diagnostic blind spot. First is the belief that a LBP diagnosis must be an anatomic one. The second is an entire body of literature ignored by guidelines as well as many researchers and experts that focuses on identifying and validating LBP subgroups based on clusters of clinical findings. I’ve written extensively about that here in prior blog postings and in my first book: Rapidly Reversible Low Back Pain.

Despite the policymakers’ and pundits’ concern about the decline of spine care, and despite over 1,000 RCTs, there are numerous reliability and prospective cohort studies, RCTs, and systematic reviews that strongly validate certain diagnostic subgroups.  But these studies, just like the population-based NH studies, are ignored, even though they: 1-define clinically-relevant characteristics of the large majority of acute and chronic LBP as well as those with axial pain or sciatica; and 2-identify predictably effective subgroup-specific treatments. These studies strongly suggest that acute NS-LBP can be reduced from 85% to 20% or less of the LBP population.  Those two factors alone represent a major advance in spine care that, if widely implemented, would quickly reverse the decline in spine care depicted in this article.

So why does this extremely important blind spot even exist? Why the inability or reluctance to even acknowledge these studies or see any connection between the need for a diagnosis and the perceived current spine care crisis? That discussion is for a different time and place.  But how can we possibly improve care in this huge and expensive population that struggles with this NS regional symptom without addressing and researching the topic of diagnostic subgrouping as a top priority?

What is so frustrating is that theses ignored studies provide answers!!!…..important ones.  In future blogs, I’ll write about those research strategies and discuss just how precise a diagnosis must be in order to identify predictably effective patient-specific care.  And it needn’t be an anatomic diagnosis!

I’ve run way too long, but there is much more to discuss.  I’d love to hear from you.  Please be sure to click on “Like” if this was useful to you, or “Leave a Comment” (click on “Comment” below).  Have a great week everyone.

Recently, Jeffrey Immelt, Chairman and CEO of General Electric and also Chairman of President Obama’s Council on Jobs and Competitiveness, spoke about health care reform at Dartmouth College in New Hampshire: “We’re investing in really neat, high-end technology, but we’re also investing in low-end, low-cost, and low-price technology.”

We don’t often find “technology” and “low-cost” in the same sentence. Read the rest of this entry »

The cartoon showed a doctor in his office talking with his patient, saying: “I’ve just consulted with my accountant and he says you need surgery.” Like most jokes, the humor here is tied to an element of truth. Surgeons are often recognized for their financial conflict-of-interest (shall we say “economic bias”?) as they decide whether or not to recommend surgery.

Read the rest of this entry »

Most neck and low back pain sufferers are unaware that so many can very successfully self-treat and recover quickly. To do so first requires undergoing a standardized mechanical spine assessment that identifies whether or not the underlying spinal disorder has a directional preference (DP); most disorders do. A DP means patients can perform repetitions of a single direction of end-range spinal bending that rapidly centralizes and eliminates their pain, greatly hastening recovery. Read the rest of this entry »

Dr. John Wennberg, Founder and Director Emeritus of The Dartmouth Institute for Health Policy and Clinical Practice, has asked: “If operating on the wrong leg is considered a medical error, what do we call operating on someone who doesn’t need surgery?” Operating on the wrong leg is every surgeon’s (and patient’s) worst nightmare, but Wennberg infers that operating unnecessarily is of even greater concern. Read the rest of this entry »

While the term “McKenzie care” is very familiar to most physicians, it is a greatly misunderstood form of care. Because family physicians and internists play such an important role in initiating care for back and neck pain, it’s important for them in particular to understand just what McKenzie care is. So let me briefly cover ten things that all health care practitioners, but family docs in particular, should know about McKenzie spine care. Read the rest of this entry »

First, I’d like to wish everyone a very Merry Christmas and may 2012 be a year of prosperity: physically, spiritually, emotionally, and financially.

I have advocated the benefits of making a mechanical diagnosis in individuals with back and neck pain since I first learned about how this was done 30 years ago. It was so impressive to see Robin McKenzie use his spinal movement testing methods to identify what proved to me over subsequent years to be very common patterns of pain response. These patterns enabled the classification of most patients into mechanical subgroups for which there were distinct and predictably effective solutions. Read the rest of this entry »

In their excellent book about health care reform entitled “The Innovator’s Prescription”, Christiansen, et al provide some very practical insight into the challenge of diagnosing and treating low back and neck pain. The authors describe three sequential eras or phases of medicine: Intuitive, Empirical, and Precision medicine. Read the rest of this entry »

I just returned from a most enjoyable trip to Warsaw, Poland where I was an invited speaker at the First Polish Conference on Mechanical Diagnosis & Therapy (MDT).  Most of the nearly 500 attendees had had some MDT training and most of those had passed the MDT credentialing examination.

In a discipline dominated by physical therapists, it is remarkable that more than 50 physicians in Poland have completed the entire McKenzie Institute course curriculum and also passed that exam.  I believe that’s primarily because, in Poland, it was an orthopedic surgeon, Dr. Tomasz Stengert, who first recognized 15 years ago the clinical value and effectiveness of MDT and subsequently founded the Polish branch of the McKenzie Institute.  He has personally taught most of the MDT courses that have attracted many physicians as well as physical therapists.  By way of contrast, there are only a handful of MDT-Credentialed physicians in the entire U.S., but then there are no physician McKenzie Institute faculty members teaching the basic training courses.

Meanwhile, over the years, I’ve been a guest speaker at MDT conferences and taught MDT overview courses to physicians in more than a dozen countries.  It always amazes me what conscientious and patient-centric clinicians I meet.  I believe that’s because the MDT paradigm attracts clinicians with the right motives.  There is no great financial reward for investing in the learning of these methods of care as there is in learning most other clinical “procedures”. They are instead attracted to the opportunity to learn how to determine with considerable precision the nature of each patient’s underlying disorder, their “mechanical diagnosis”.  That in turn identifies for most a standardized and predictably effective treatment that directly addresses the underlying cause, and not just the symptom.  If you’ve accurately determined a patient’s mechanical diagnosis, the patient can usually rapidly, and often dramatically, correct it themselves without needing to know the precise anatomic diagnosis.  That’s very satisfying, but also very fortunate since we are unable to make an anatomic diagnosis for most LBP.  And even when we can, i.e. a herniated disc causing sciatica, that anatomic diagnosis is typically insufficient to inform standardized, predictably effective treatment.

I either attend and speak at a number of non-MDT spine conferences each year.  In my 30+ years experience, these are distinctly different from MDT conferences.  They are characterized instead more by a lack of uniformity in how attendees manage their patients.  The focus is often on “one-ups-man-ship”, nearly always regarding the best treatments or the best study of treatment efficacy, rather than learning how to make a more precise diagnosis that then helps identify a more effective treatment for each patient.  While these organizations and societies are portrayed as scientific forums, many or the leaders have significant financial conflicts-of-interest undermining their objectivity in determining what is best for patients.

That’s a big part of what makes these MDT conferences so special.  Most attendees are eager to learn how to better clinically evaluate and diagnosis their patients and the basic science behind why common patterns of pain response occur during their office evaluation.  Indeed, it is very common for invited speakers who have no prior exposure to MDT to comment how uniquely motivated these attendees are to learn and how full the room remains throughout the conference.

A few years ago, the late Alf Nachemson, one of the most famous and leading experts in spine care, was invited to speak at an MDT conference in Ottawa attended by 350-400 clinicians, mostly physical therapists, as I recall.  Over many prior years, he had made some unflattering public statements about Robin McKenzie and “his disciples” and so accepted the invitation with some trepidation.  At the outset of his first presentation that weekend, he facetiously announced to the audience that he had considered bringing some bodyguards with him.  But after spending the weekend interacting with these people, he began his final talk by stating that “I really don’t understand just what it is you people do, but it is clear that you are passionate about it and you have a great deal of fun doing it” (paraphrased).  Acknowledging all his diligent and dedicated work over his long career, when he retired about a year before he died, I told him that I had great regret that he had worked so hard for so very long, including more than 20 years of intermittent exposure to MDT, but he never allowed himself the opportunity to acquire a working understanding of it and to appreciate its immense potential for improving spine care around the world.

This past weekend in Warsaw, I met a lovely married couple, she a rehab physician and he an orthopedic spine surgeon.  He said he merely drove her to her first McKenzie Institute course a few years earlier and stayed to listen for a bit.  He was so intrigued by what he heard that he ended-up taking all four of the McKenzie Institute courses with his wife and now they are both MDT-Credentialed.  He gave two excellent presentations at the conference, one on how MDT methods helped him in selecting his surgical patients.  What is so intriguing is that, on his own, in his busy surgical practice in Poland, he had learned the same valuable things about the very helpful utility of MDT in surgical patient selection that a handful of spine surgeons here in the U.S. have learned.

Again, the consistent uniformity in thinking and clinical experience is fascinating.  Brainwashing?  That’s what some skeptics conclude.  But none of those skeptics have ever taken an MDT course, and some get very nervous around clinicians who are enthused about what they do.

Personally, no matter what country I’m in, these people are the same.  They are happy and eager to learn because there is great satisfaction in knowing how to directly and successfully treat most patient’s underlying pain-generator that then teaches them how to bring about their own rapid recoveries.  Such high-quality care is occurring more and more frequently within the U.S. and in literally dozens of countries around the world, thanks to this growing corps of dedicated clinicians.

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