Of course, low back pain (LBP) isn’t a diagnosis.  It’s a symptom, and a very non-specific (NS) symptom at that.  Unfortunately, the lumbar spine, with all its complexity, has a very limited vocabulary with which to express itself when some part of it is in trouble.  So LBP can be the result of many different pathologies for which there obviously is no single effective treatment.  Yet we keep conducting research trying to find the best treatment for the 85% or more with this NS symptom.

Let’s for a moment consider fever, which long ago was another NS symptom, but a very serious one.  For centuries, millions with a fever ended up dying, many during pandemics, many others as more isolated cases.  Many treatments were desperately tried hoping to save lives.  The breakthrough came when the microscope was invented that revealed microbes causing what became known as infection.  Culturing techniques and other diagnostic innovations eventually led to the accidental discovery of penicillin and other very effective antibiotics based on their specificity for each microbe.

If the scientists and physicians of that day had simply searched for the best treatment for NS fever, people would have continued dying. Instead, it was a breakthrough in diagnostics that led to saving millions of lives from infections.

What if people were dying from NS-LBP?  How long would we persist in searching for the best treatment for NS-LBP? Wouldn’t we be far more focused on learning something about its cause?

While many LBP treatments likely have value for some types of LBP, they are certainly not one-size-fits-all-treatments as they are commonly delivered and portrayed. Would abdominal or chest pain treatment be dictated primarily by the clinician the patient selects for care? Does every LBP patient simply look like a nail for the hammer(s) each clinician is trained to use?

Instead, as with fever, shouldn’t LBP researchers be focused on learning more about the cause of LBP? Unfortunately our best imaging technology has failed to help us find structural causes.  Knowing that, the Cochrane Back Review Group wrote in 1998: “There is urgent need for good ideas about how to identify homogeneous subgroups. The efficacy of interventions in the subgroups should be studied in randomized controlled trials.”(1)  Their “urgent need” was seventeen years ago!

Five years later, they wrote again: “systematic reviews on the efficacy of preventive and therapeutic interventions can never provide an adequate basis for clinical guidelines.  We clearly need additional systematic reviews of etiological, diagnostic, and prognostic studies.  Only then can the guidelines hope to offer an evidence-based answer to the “Holy Grail”-type questions, such as “which interventions are most effective for which patients?”(2)

Consider further two surveys (1998 and 2013) of international LBP researchers.(3, 4) Both reported that the #1 research priority was: “Can different varieties or subgroups of LBP be identified and, if they can, what criteria can be used to differentiate among them?” One listed twenty and the other twenty-five top research priorities.  The focus of most RCTs and LBP guidelines, i.e.“finding the best treatment for NS-LBP”, was of such low value to the responders that it didn’t appear on either list.

Little clinical research and no LBP clinical guidelines to date offer any insight into which interventions are most effective for which patients.  They contribute little or nothing to the quality of our decision-making when treating an individual with LBP. When will we get the message and shift our research focus?

Identifying and validating subgroups needs to become our top research focus.  But that requires more than RCTs. A new research paradigm(5) is needed that begins with reliability studies to demonstrate that both subgroup members and non-members can be reliably identified. A reliably identified subgroup then feeds subgroup-specific observational cohorts to identify potentially effective treatments.  Only then can the time, effort, and expense of conducting an RCT be justified in hopes of validating that subgroup by identifying a standardized, predictably effective treatment.

Ironically, guidelines have yet to acknowledge the considerable research over the past twenty-five years that has successfully identified and validated some LBP subgroups, most based on clusters of clinical findings. One with considerable support is the “derangement” subgroup in whom “pain centralization” and a “directional preference” are reliably elicited during a standardized baseline mechanical examination. Subgroup-specific observational cohorts, RCTs, and systematic reviews have validated this mechanical diagnosis. But these studies are routinely overlooked by most clinicians, researchers, and every guideline-to-date, constrained by their tunnel vision on finding the best treatment for NS-LBP.

What a great concept: matching treatments to individual patient characteristics!! Sorta like selecting an antibiotic for a specific microbe instead of treating a fever with blood letting.

Of course, for every validated LBP subgroup, the percentage considered to have NS-LBP decreases…..and that’s a good thing.  So why do funders keep funding RCTs focused on NS-LBP?  It was Einstein who defined insanity as “doing the same thing over and over again and expecting different results.”

In summary, it’s deeply troubling that 1-our lack of progress in solving LBP, 2-the large numbers who are disabled by low back conditions, and 3-the increasing amount we spend each year for ineffective care, are insufficient motivation to bring change in either the conventional LBP research paradigm or the focus of clinical guidelines.

How quickly would we change our research focus if people were dying from LBP?

References
1. Bouter L, van Tulder M, Koes B. Methodologic issues in low back pain research in primary care. Spine. 1998;23(18):2014-20.
2. Bouter L, Pennick V, Bombardier C. Cochrane back review group. Spine. 2003;28(12):1215-8.
3. Borkan J, Koes B, Reis S, Cherkin D. A report from the second international forum for primary care research on low back pain:  reexamining priorities. Spine. 1998;23(18):1992-6.
4. Costa L, Koes B, Pransky P, Borkan J, Maher C, Smeets R. Primary care research priorities in low back pain: an update. Spine. 2013;38:148–56.
5. Spratt K. Statistical relevance. In: D.F. Fardon ea, Editors, editor. Orthopaedic Knowledge Update: Spine 2. 2nd ed. Rosemont, Illinois: The American Academy of Orthopaedic Surgeons; 2002. p. 497-505.

Please share your thoughts with me and ask whatever questions come to mind.

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 »

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 »

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 »

Musculoskeletal (MS) conditions account for the majority of lost work and bed days due to health conditions. According to a report by the Bone & Joint Decade commission, they are the leading cause of disability and health care cost, as well as the most common health condition in the U.S.  The total U.S. cost of MS treatment and lost-wages in 2004 was estimated to be $849 Billion, or 7.7% of GDP.

In this large and very expensive MS arena, numerous studies show that many disorders can be resolved quite easily and quickly using some simple-yet-precise movements and positions of the painful joints that somehow actually correct the underlying problem and eliminate the pain.  The really good news is that, if you’re the one in pain, you can usually perform these movements and positions yourself.  But this requires your provider to first determine which movements, if any, will correct the problem and then teach you what to do.  This specific form of self-care, known as Mechanical Diagnosis & Therapy (MDT), empowers you to take control of, and eliminate, your own painful problem.

Unfortunately, these painful conditions are rarely treated in this way. Only a small percentage of individuals with MS conditions are provided the opportunity to be evaluated by a clinician with MDT training. Consequently, the painful conditions too often persist, even worsen, despite undergoing other extensive, expensive, sometimes even risky treatments. But most importantly, these treatments are all unnecessary for those who can recover using self-care first and MDT principles.

I wanted to advocate for this first type of MDT self-care across the spine care community in order to help individuals avoid these other ineffective and expensive treatments. I therefore founded Self-Care First in 2002. This blog is part of that effort. So whether your condition can be eliminated easily with MDT care or not, the best way to find out is to be evaluated by a practitioner trained in MDT.  In other words, first explore the potential and value of self-care.  Therefore…..self-care first.

Exploring self-care first is especially important in the many disorders that do recover, only to recur days, weeks, or months later. Low back and neck pain are common examples of conditions that frequently recur. Many treatments for these conditions are described as “passive”. That means your practitioner performs the treatment on your behalf, doing something TO you.  They may apply ice, heat, ultrasound, or diathermy to your painful area, or use their hands to massage, mobilize or manipulate your spine and other joints. But they are performing the treatment for you.  You are passive.

Even if effective in decreasing your pain, the pain usually returns again soon.  When it does, your experience tells you to return to get that same relief again for that same passive treatment from your practitioner.  So you seek that type of care again, and again, and again, that cycle repeating itself sometimes many times.  But you meanwhile learn nothing about how to treat yourself or how to prevent your own pain from returning.  You instead develop a dependence on your provider and this passive care while gaining no insight into why it keeps returning nor how to prevent it.  Some practitioners will deepen your dependency on them by recommending you return for treatment even after your pain has gone away in order to prevent your painful condition from returning.  But no data has ever shown that such treatment lowers the chance of having another episode.

Alternatively, if you had learned methods of self-care first that enabled you to eliminate your own pain, you would have also learned how to prevent your pain from returning, a necessary part of your recovery from your current episode as well as for preventing it over the weeks and months ahead.  And if or when your pain does return, you already know how to get rid of it by yourself, because what worked before usually works just as well now.  You have been empowered to be independent of your practitioner using the know-how learned earlier to quickly and effectively treat yourself.

There’s one other point that illustrates the importance of pursuing self-care first (MDT care).   In other blog postings, I described studies documenting that as many as 50% of individuals with back pain that had been considered disc surgery candidates, when finally provided this MDT evaluation, found out they had a rapidly and easily reversible problem all this time that would quickly resolve using self-care.  This enabled these individuals to avoid what would have been unnecessary surgery.

The overwhelming message for patients, clinicians, employers and health plans is to pursue MDT and self-care first.  To locate a practitioner near you that is trained to provide you with this form of care, click here.

Here are some books you may wish to read about MDT and self-care for low back, neck, and shoulder pain:

Treat Your Own Back, by Robin McKenzie

Treat Your Own Neck, by Robin McKenzie

Treat Your Own Shoulder, by  Robin McKenzie

Solving the Mystery: The Key to Rapid Recoveries from Most Back and Neck Pain, by Ronald Donelson

Rapidly Reversible Low Back Pain: An Evidence-Based Pathway to Widespread Recoveries and Savings, by Ronald Donelson

Dr. Ron

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

In my book “Solving the Mystery: The Key to Rapid Recoveries from Most Back and Neck Pain”, I included the stories of two individuals, one with disabling neck pain and the other disabling back pain, both persisting for more than two years despite actively seeking care.

I was present when Peter was first examined for his chronic neck and arm pain.  It was a demonstration to attendees at an international spine conference of how the MDT evaluation identifies rapidly reversible conditions and then guides rapid recoveries.  References to “Figures” below pertain to illustrations in the book.

PETER’S HISTORY
Peter is a 38 year-old adventure guide and instructor who was on his honeymoon when the car he was driving was hit from behind while stopped. He passed out at the scene and was taken by ambulance to the hospital where no severe injuries were identified. He was discharged, given Tylenol, and told to see his doctor when he returned home.

Severe headaches soon started that kept him from sleeping at night as well as pain and numbness progressing down his left arm to his hand. His physician at home sent him to physical therapy that he continued for 18 months.

His pain forced him to stop working because he couldn’t rotate his head when kayaking nor look upward when leading rock-climbing groups.

A neck MRI showed bulging/prolapsed discs at his C5-6 and C6-7 levels that were pressing against his nerve causing the pain and tingling in his left arm.

He was referred to a neurosurgeon who offered him surgery to relieve the pressure on the nerve.  He was told there was a 50% chance of improvement, 40% chance of being the same, and a 10% chance of worsening as a result of the surgery. Because he didn’t like those odds, he decided against surgery.

PETER’S MDT EXAMINATION
He was finally given the opportunity to be examined by a physical therapist with extensive training in Mechanical Diagnosis & Therapy (MDT). At that time, he reported he had improved only 10% over his 18 months of physical therapy. He had pain, numbness and tingling into his left palm and fingers as well as tension and tightness in his neck and aching in his left arm. He did report some improvement in those symptoms four months earlier when he changed his job and stopped climbing and kayaking.

Attempts to bend his neck in any direction seemed to increase his neck and arm pain, including bending his head and neck backward. But a special variation of neck extension (bending the neck backward) noticeably decreased the arm and hand tingling that then didn’t return, which he stated was a “huge difference” from his last 18 months. With more neck extension movements, his hand and arm symptoms improved substantially and remained better, which greatly impressed Peter.

PETER’S MDT EDUCATION AND SELF-CARE INSTRUCTIONS
The therapist told Peter that something was pressing on the nerve and they were perhaps learning that that “something” might be able to be withdrawn from the nerve so his pain and tingling would go away.

He was instructed to perform 10-12 repetitions of the cervical extension exercises 5-6 times/day.  He was shown how to perform them standing, sitting and lying down. He was shown how his forward head position when sitting aggravated his condition and was given a lumbar roll to use behind his lower back, especially in the car, to enable him to sit more erectly with his head positioned much better to keep from aggravating his condition while sitting (Fig. 22.6).

FOLLOW-UP
Using this self-care strategy, the tingling in his arm and hand disappeared almost immediately despite having been present for 18 months.  His headache, neck and arm pain progressively decreased over the next four weeks to where he no longer had any pain. He reported three months later that he was pain-free as long as he did his exercises. He admitted to only doing them 1-2 times per day and if he stopped those exercises for more than two days, his headaches would return very slightly which reminded him to return to his exercises.

He was able to return to all of his work and had even taken up snowboarding as a new sport that he could now include in his work.

SUMMARY
In hindsight, Peter had an undiscovered rapidly reversible problem all this time. Like so many with motor vehicle whiplash injuries, his neck and arm pain didn’t begin until many days after his accident. He then underwent 18 months of useless physical therapy and almost accepted an unnecessary surgical procedure because neither he nor his physicians knew his underlying problem was actually rapidly reversible all this time. Fortunately, Peter finally found someone trained to evaluate and treat him using MDT principles of care.

Peter Is Not An Unusual Patient! There are published data indicating that half of chronic back and neck pain patients respond similarly. While not unusual, sudden and rapid recoveries like this are not widely known, which is why I have written my books and created this blog.  Unfortunately, and most importantly, such dramatic recoveries are also unfamiliar to most health care providers, payers and policy makers who do not provide their back and neck patients with this Mechanical Diagnosis & Therapy (MDT) form of evaluation.

From a cost perspective, every one of these patients who have an undiagnosed rapidly reversible condition costs tens, if not hundreds, of thousands of dollars in direct medical costs and lost productivity,……..all unnecessarily! It only requires a thorough MDT evaluation at the outset of their care to identify them early and guide their rapid recovery to avoid nearly all of that unnecessary expense.

Peter’s actual initial MDT evaluation at this conference can be viewed on DVD available at http://www.optp.com/A-Day-with-McKenzie-DVD_914DVD.aspx. The therapist on the DVD who assessed Peter is Robin McKenzie himself, who developed the MDT method of care.

Dr. Ron

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

 

A very common complaint patients with back or neck pain have is that their doctor doesn’t provide them with a clear diagnosis or explanation of their pain.23,79

That complaint is quite understandable because the conventional examination used by most doctors, along with the best imaging procedures available, are unable to identify the precise cause of most back and neck pain. That does not mean there isn’t a cause; it just can’t be found in most cases using those methods of evaluation.

Nevertheless, back and neck pain often go away on their own in a few days or weeks, regardless of what treatment you pursue.21,59,81,82 Therefore, the underlying problem, whatever it is, is somehow often able to recover, even without formal treatment.

Unfortunately, even though it goes away, it often returns a few weeks or months later.21,59,81,82 Each time it returns, it is referred to as a new “episode”. Each episode ends when the pain goes away again for a few more weeks, months, or maybe even years. Unfortunately, it is all too common for back pain to return several times each year and continue to do so for many years.

Many report that, when their pain returns, it’s even worse than before.30,83,84 Perhaps you have had a few episodes.  Is your pain now more intense, more disabling, lasting longer than in your early episodes? Has it now spread into your arm or leg and require more care than in the past? Often, after many episodes, your pain finally just doesn’t recover again. When it persists for three months or more, it is usually referred to as “chronic”. Once symptoms become chronic, the underlying problem is often much more difficult to solve.

Sometimes back or neck pain become so severe that it prevents you from doing things you want and need to do: you can’t work, take care of your home and family, or participate in the fun things in life. If you are just not improving, your doctor may offer a referral to another doctor for spinal injections or to a spine surgeon to consider an operation.

Besides being no fun, these procedures are risky. They are not always successful, may make your pain worse, cause new symptoms, and also limit future treatment choices. In most circumstances, these risks are unlikely, but they are certainly possible. Unfortunately, it is not unusual to end up with long-term, even permanent, disabling pain.

But these procedures can also be helpful for many. But who are they? There is no way to figure that out ahead of time. And unfortunately, even those who improve are often still unable to return to their former level of activity or work.

So are there any better solutions? Yes, thankfully, for most there are.

The above is a chapter excerpted from my book entitled “Solving The Mystery: The Key to Rapid Recoveries for Most Low Back and Neck Pain.”  This book, my first book (“Rapidly Reversible Low Back Pain“), the SelfCare First website, and many posts on this blog are all devoted to spreading the message:  yes, thankfully, there are better solutions.  In fact, most back and neck pain is rapidly reversible using simple-but-specific exercises and posture modifications. Keep reading these resources. (Numbered references in this excerpt cite specific scientific articles listed in this book.)

Dr. Ron

Ronald Donelson, MD, MS
President

SelfCare First, LLC
Blog: blog.selfcarefirst.com

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