Doubting Dr. Deyo

By

JC Smith, MA, DC

There’s no question that Richard Deyo, MD, is one of the leading experts in the area spinal research. His works have appeared in every major medical journal from the NEJM to Scientific American to the AHCPR federal guidelines. Indeed, whenever there’s an article about spinal problems, Dr. Deyo seems to be the leading author and has become today the foremost authority on this subject.

Dr. Deyo is usually rather upfront with his opinion of the inability of the medical world to handle this epidemic of low back pain. In an article in the Scientific American titled “Low-Back Pain.”[1] He mentions “Calling a physician a back-pain expert, therefore, is perhaps faint praise–medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.” He continues to criticize “Old concepts supported only be weak evidence,” and the reliance on MRI exams to infer disc abnormalities as the cause of back pain, “Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”

Not only does Deyo bash many medical concepts and treatments for back pain, he then mentions chiropractic as a possible solution, “Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.”

In this article, he mentions the initial MRI research by Scott Boden, MD, which dispelled the herniated disc as a cause of back pain inasmuch as asymptomatic patients frequently have these problems.  As Dr. Deyo mentions: “Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disc… only about 10 percent of patients with a symptomatic disk herniation would appear to require surgery…. And because most back pain in not caused by herniated disks, the actual proportion of all back-pain patients who are surgical candidates is only about 2 percent.”

Other myths he questions include passive therapies such as traction (“simply does not work”), TENS (“little if any long-term effect”), and facet joint injections (“cortisone-like drugs appear to be no more effective than injections with saline solution”).Deyo does endorse “exercise as an important part of prevention and treatment of back problems for those suffering from either chronic or acute back pain… chronic back-pain patients substantially improved by exercising even with their pain.”

Deyo admits “The inability of conventional medical practice to ‘cure’ a large percentage of back-pain patients has no doubt led the condition to be major reason patients seeks various forms of alternative treatment, including chiropractic care and acupunture. Chiropractic care is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.”

Dr. Deyo criticizes the over-reliance on imaging for “misleading…incidental findings” of disk abnormalities.

“Early or frequent use of these tests [Computed tomography (CT scans) and MRI] is discouraged, however, because disk and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading.”[2]

A recent article in the New England Journal of Medicine acknowledged that most back pain is “mechanical” in nature, meaning joint dysfunction. According to Dr. Richard Deyo’s article, “Differential Diagnosis of Low Back Pain,” he showed that “Mechanical Low Back or Leg Pain” constituted 97% of these cases, of which “lumbar strain, sprain” accounted for 70% of these cases; “Nonmechanical Spinal Conditions [disc problems] accounted for “about 1%”; “Visceral Disease” [referred pain from a diseased organ] accounted for 2%.”[3]

Dr. Deyo also criticizes the over-reliance on imaging for low back problems.

“Early or frequent use of these tests [Computed tomography (CT) and MRI] is discouraged, however, because disk and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading. Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.””

For example, Richard Deyo and his co-author, James N. Weinstein, published an article a few months ago in The New England Journal of Medicine about Primary Care and LBP. While they were willing to admit the excesses of the medical interventions for LBP, such as surgery based on the fallacy of a diagnosis made solely from imaging scans of abnormal disks, they also seemed to have great difficulty admitting the actual causes and best treatments for this epidemic.

In their Table 1: “Differential Diagnosis of Low Back Pain,” they did show that “Mechanical Low Back or Leg Pain” constituted 97% of these cases, of which “lumbar strain, sprain” accounted for 70% of these cases; “Nonmechanical Spinal Conditions accounted for “about 1%”; “Visceral Disease” accounted for 2%. While Deyo admits that most LBP stems from mechanical problems, he just cannot bring himself to suggest that perhaps the chiropractors have been right all along with their vertebral subluxations / joint dysfunction concepts.

Despite his willingness to reject MDs as experts in LBP as he debunks the “slipped disk” theory as the main cause of back pain, he has great difficulty to admit that the human spine, consisting of 137 joints, is very susceptible to joint dysfunction as the cause of pain. Even his recommendation of SMT is laughable at best, and downright insulting to DCs, and even smacks of malpractice at its worst.

“Spinal manipulation and physical therapy are alternative treatments for symptomatic relief among patients with acute or subacute low back pain, but their effects are limited. In general, we recommend delaying referral for manipulation or physical therapy until an episode of pain has persisted for three weeks, because half of the patients spontaneously improve within this period.”

So, according to Deyo, 70% of LBP is of “idiopathic,” unknown origin and “spontaneously improves within this period” of three weeks. Of course, the root word here, “idio,” is actually short for “idiot.” While the cause of LBP may be unknown to biased MDs who are mostly idiots when it comes to the management of these cases (their unfounded reliance on “slipped disks, pulled muscles, drugs and surgery are testament to that claim), we DCs know the real cause rests in dysfunctional joint play. And his suggestion to withhold SMT for 3 weeks borders on cruelty, if not sheer malpractice. (I wonder if he would recommend a patient with chest pains to wait 3 weeks too?)

Deyo’s Dilemma

While Deyo is forthright that “patients with suspected disk herniation should be treated non-surgically for at least a month,” he still can’t bring himself to recommend SMT as the AHCPR guideline does. He even states that, “the safety and efficacy of spinal manipulation remain unclear.” Unclear to whom, I might ask?  Only to the medical skeptics who refuse to follow the guidelines of every country that has conducted analysis on this epidemic of LBP. This short shrift exemplifies the myopia of medical men who don’t want to be confused with the facts, research, guidelines or recommendations, or so it seems.

“The most popular alternative therapies for low back pain are spinal manipulation, acupuncture, and massage. Massage has rarely been studied, but promising preliminary results of clinical trials suggest that research on massage therapy should be assigned a high priority. There is no evidence from clinical trials or cohort studies that surgery is effective for patients who have low back pain unless they have sciatica, pseudoclaudication, or spondylolisthesis. ”

Obviously it appears that Deyo is fickle in his assessment of SMT. On one hand, he suggests doing nothing for 3 weeks before referral for SMT, then he suggests the safety and efficacy of SMT “remain unclear” despite the many studies showing otherwise, then he argues, “clinical trials suggest that spinal manipulation has some efficacy.” Incredibly, although he admits that massage therapy has not been studied, he suggests, “research on massage therapy should be assigned a high priority.”

So, let’s get this right: Deyo denies the many studies and guidelines from around the world that support SMT for LBP, then he recommends that massage be given a high priority. This exemplifies his inherent medical bias to look favorably on unsubstantiated methods like massage while discounting the vast number of studies supporting SMT. Indeed, it must be difficult speaking out of both sides of one’s mouth, especially after he puts his foot in it with such ludicrous comments.

Deyo gives faint praise of many traditional medical methods for LBP and back surgeries as well.

“Conventional traction, facet-joint injections, and transcutaneous electrical nerve stimulation appear ineffective or minimally effective in randomized trials.

“Diskectomy produced better pain relief than nonsurgical treatment over a period of 4 years, but it is unclear whether there is any advantage after 10 years. The effectiveness of microdiskectomy, which is performed through a small incision with the aid of magnifying lenses, is similar to that of standard diskectomy, but two newer techniques, automated percutaneous diskectomy and laser diskectomy, are less effective than standard diskectomy. “

Prevention

In regards to prevention and maintenance, Deyo had only lip-service to give:

“Exercise programs that combine aerobic conditioning with specific strengthening of the back and legs can reduce the frequency of recurrence of low back pain. The use of corsets and education about lifting technique are generally ineffective in preventing low back problems. Epidemiologic studies suggest that weight loss and smoking cessation may have preventive value, but no intervention trials involving these approaches have been conducted. There are, of course, other compelling reasons to recommend weight loss and smoking cessation. Ergonomic redesign of strenuous job tasks may facilitate return to work and reduce the chronic nature of pain.”

While his advice is certainly logical, it falls very short and never addresses the concept of maintaining joint play, again illustrating his avoidance of the 137 joints that constitute this pillar of vertebrae in the spinal column. Another issue Deyo fails to address is the fact that most mechanical LBP should be viewed as a chronic degenerative disorder that won’t respond to occasional crisis care during flare-ups. Just as it takes years to develop heart disease, the same can be said about most MSDs. And just as a bypass surgery does not cure a patient of heart disease, nor does a back surgery or an injection or a set of adjustments cure the patient of LBP.

If he had asked a seasoned DC who has managed thousands of LBP cases, he might have gained new insight into this epidemic. He might have learned in order to stabilize an injured or deconditioned low back, the patient needs to not only lose weight, but he needs to strengthen back and abdominal muscles with daily torso exercises, plus the patient must do flexibility and decompression-type spinal exercises to counteract the many compression traumas we experience daily (such as sitting on one’s ass in front of a dang computer like I’m doing right now typing this while my mid and low back ache).

And, most importantly, Deyo could have suggested that everyone with a spine ought to have these 137 joints adjusted by a good chiropractor to reduce joint fixations. And he might have added that patients undergo a Back School and participate in a rehab program to improve the weight bearing capacity of these weakened spines. But, to be honest, few in the medical world have rarely suggested, “An ounce of prevention is worth a pound of drugs or surgery.” Until these so-called back researchers liken spinal care to dental care, they will never contain this huge epidemic of back problems.

Apparently the AMA special interest groups were successful in eliminating the messengers who reported the many ineffective and costly medical procedures that have driven up health care costs to the trillion dollar range. A member of the AHCPR panel, Richard Deyo, MD, MPH, University of Washington Medical School, recently co-authored in The New England Journal of Medicine an article, “The Messenger Under Attack–Intimidation of Researchers by Special Interest Groups.” He wrote that “The huge financial implications of many research studies invite vigorous attack… Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care.” [4]

Perhaps Dr. Deyo is feeling the same type of venomous response to the AHCPR’s guideline that the chiropractic profession has felt from other biased reports. Deyo has written many articles dealing with the ineffectiveness of spinal surgeries, especially spinal fusions. In the AHCPR’s Clinical Practice Guideline, the section on Spinal Fusion clearly summarizes the research. “There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation….Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.” [5]