NEJM & LBP
JC Smith, MA, DC
Once again Robert Deyo, MD, has struck at chiropractic with another luke-warm appraisal of SMT in his recent NEJM (Feb. 1, 2001) article, “Primary Care: Low Back Pain.” Although he certainly didn’t endorse the traditional medical triage methods of pain pills, muscle relaxers, hot packs, ultrasound, MRI exams all leading up to the inevitable back fusion as is commonly practiced by most MDs, he still failed to mention “joint complex dysfunction” or VSC as the primary cause of most LBP. And he never once mentioned any sacroiliac involvement whatsoever. (For those of us with chronic SI problems, this is a huge oversight)
Arguably, it shows that these researchers have an inherent bias against SMT and JCD, and probably have never personally or professionally dealt with LBP cases. Deyo et al. refuse to discuss the mechanical instability of this pillar of 24 vertebrae sitting on top of 3 pelvic bones, interconnected by 137 joints. This hugely unstable spinal column that is constantly subjected to stresses from daily living as well as micro and macro-traumas throughout our lives is an anatomical phenomenon that medical researchers seem unable to understand.
Rather than a dynamic structural pillar of bones intertwined with ligaments, muscles, cartilage, and joints, they seem focused solely on secondary static elements like the pathoanatomical features of intervertebral disks. And it seems they refuse to acknowledge any neurological significance to spinal subluxations or misalignments as a cause of back pain, reflex spasms or organic dysfunction. For some unknown reason, simple spinal motion/mechanics seems to escape these learned medical men when they investigate our domain. Indeed, it must be difficult to see the truth when one suffers from medical myopia. If this doesn’t smack of junk science, what does?
On the other hand, Deyo did present a more realistic model of LBP than most MDs are willing to admit to, in that not all LBP cases are simply “pulled muscles” or “slipped disks.” He states, “Perhaps 85 percent of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis. The association between symptoms and imaging results is weak. Thus, nonspecific terms, such as strain, sprain, or degenerative processes, are commonly used.”
He even admits that there is “excessive imaging and surgery for low back pain in the United States.” (No shit, Sherlock) He definitely has gone out on a limb with such an honest statement, especially in The New England Journal of Medicine, the conservative voice of the medical establishment. I wonder if his orthopedic colleagues will sue him again as they did after he co-authored the AHCPR guideline on low back pain in adults? Perhaps this latest treatise is simply his attempt to cover his backside among his colleagues.
“About two thirds of adults suffer from low back pain at some time. Low back pain is second to upper respiratory problems as a symptom-related reason for visits to a physician. There are wide variations in care, a fact that suggests there is professional uncertainty about the optimal approach. In addition, there is evidence of excessive imaging and surgery for low back pain in the United States, and many experts believe the problem has been ‘overmedicalized.’
“Low back pain affects men and women equally, with onset most often between the ages of 30 and 50 years. It is the most common cause of work-related disability in people under 45 years of age and the most expensive cause of work-related disability, in terms of workers’ compensation and medical expenses.”
“Overmedicalized” is one way of saying “unnecessary and ineffective medical intervention,” which are nice terms to use instead of “abuse, waste and exploitation of patients and insurance companies.” Let’s be frank about this epidemic of LBP—the medical profession and hospitals have no real interest in doing fewer back surgeries, which now account as the third-leading reason for hospital admissions and the second-leading surgery. And estimates for LBP run in the $50-75 billion range. Not chump change, even in the world of medicine.
Although Deyo and his co-author, James N. Weinstein, are willing to admit the excesses of the medical interventions for LBP, they seem to have great difficulty admitting the actual causes and best treatments for this epidemic. In their Table 1: “Differential Diagnosis of Low Back Pain,” he 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%.
Causes and Epidemiologic Patterns
“Experimental studies suggest that low back pain may originate from many spinal structures, including ligaments, facet joints, the vertebral periosteum, the paravertebral musculature and fascia, blood vessels, the anulus fibrosus, and spinal nerve roots. Perhaps most common are musculoligamentous injuries and age-related degenerative processes in the intervertebral disks and facet joints.
“Perhaps 85 percent of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis. The association between symptoms and imaging results is weak. Strain and sprain have never been anatomically or histologically characterized, and patients given these diagnoses might accurately be said to have idiopathic low back pain.”
What he refers to as “idiopathic low back pain,” we chiropractors know the majority of these cases of “unknown cause” are actually stemming from joint dysfunction in the 137 joints of the spinal column, a proposition Deyo fails to even mention. He does minimize this cause and even rejects SMT as a first-line method as the AHCPR guideline suggests.
“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 unschooled MDs who are mostly idiots when it comes to the management of these cases (their unfounded reliance on drugs and surgery is 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 similar approach to heart attacks, suggesting most are of unknown origin and spontaneously would improve in 3 weeks (if the patient survives, that is)? This medical alibi for non-treatment and delayed chiropractic care seems to be a red herring that only delays proper spinal care via SMT, only to lead to progressive degeneration of tissues, weakening of muscles, and the inevitable relapse as 60% of patients experience within 6 months.
“Let’s just hope it goes away,” seems to be their latest excuse for a diagnosis, rather than admitting that joint dysfunction is the actual cause of 70% of these bouts and that chiropractors’ SMT is the “proven method” as the AHCPR contends. Deyo and his medical researchers just cannot give credit where credit is due, and seem willing to mislead patients just as their surgical counterparts have done for decades.
The Disk Debate
He did debunked disk degeneration as a primary cause of LBP as most surgeons are apt to convince naïve patients of the need for surgery. In order to save face, Deyo is willing to criticize the overuse of imaging in these cases and the over-reliance on the disproven disk theory that remains the mainstream explanation by most all MDs.
“Computed tomography (CT) and MRI are more sensitive than plain radiography for the detection of early spinal infections and cancers. These imaging techniques also reveal herniated disks and spinal stenosis, which plain radiography cannot. Early or frequent use of these tests 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. Incidental findings may lead to overdiagnosis, anxiety on the part of patients, dependence on medical care, a conviction about the presence of disease, and unnecessary tests or treatments.”
I have to give Deyo credit for the above statement that disk abnormalities are “frequently incidental findings,” a fact that every DC knows but somehow escapes the mindset of most primary care physicians and, for sure, most back surgeons. As MRI researcher, Scott Boden, MD, at Emory once suggested, attributing back pain to disk abnormalities is like “finding gray hair” in that everyone has them and they certainly aren’t the cause of LBP.
I daresay from my 20-year experiences with the typical scenario of a LBP patient who mistakenly enters the majority of MDs offices, he will immediately be given a handful of drugs, then railroaded to the MRI center and diagnosed with some type of disk problem. And, of course, the back surgeon will definitely tell the naïve patient they need disk surgery, and to convince them, tell unsuspecting patients to “look right here, I can prove it to you” with cute little pictures from plain x-rays or MRI scans. Despite Deyo’s and Boden’s best intentions, this scam continues to this day and will not cease, just like the medical profession’s negative reaction to the AHCPR guideline which suggested the same facts.
Deyo also must draw the ire the hospital administrators when he suggests not all herniated disks need surgery. Don’t tell that to the hospital administrator who averages $14,000 for each uncomplicated back surgery case. They are the same folks who ignored the AHCPR report that states, “Surgery has been found to be helpful in only one in 100 cases of low back problems.” No doubt Deyo’s latest assertion will fall on deaf ears just as it did before.
“Herniated Intervertebral Disks
“The natural history of herniated disks is also favorable. Improvement is the norm, although it is often slower than improvement in low back pain alone. Only about 10 percent of patients have sufficient pain after six weeks that surgery is considered. Sequential MRI studies reveal that the herniated portion of the disk tends to regress with time, with partial or complete resolution in two thirds of cases after six months.”
“In the absence of the cauda equina syndrome or progressive neurologic deficit, patients with suspected disk herniation should be treated nonsurgically for at least a month. Early treatment resembles that for nonspecific low back pain, although the safety and efficacy of spinal manipulation remain unclear. Narcotic analgesics may be necessary for pain relief, but they should be used only for limited periods. Bed rest does not accelerate recovery. If severe pain or neurologic deficits persist, CT or MRI and consideration of surgery are appropriate.”
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. “
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.
The Best Solution for LBP Patients
Although I must give Deyo credit for attempting to explain to primary care providers the ABCs of LBP, I would be remiss not to suggest to him and his PCP colleagues that they should simply refer these cases to their neighborhood DCs instead of attempting to supplant them by teaching PCPs something their disinterested in anyway. Other studies have shown the weekend classes in SMT to PCPs were a failure, as well as a slap in our faces. Think of it: something we take years to refine, these disinterested MDs think they can learn overnight! Just who are the real quacks now?
What will it take for the likes of Deyo to admit that the chiropractic profession has best managed these cases for over a century now? As Pran Manga, PhD, recommended for the Ontario Ministry of Health, DCs should be gatekeepers for all back pain problems in order to reduce costs and improve patient outcomes. Just as Deyo wouldn’t presume to encroach upon dentists with elementary explanations/treatments of dental problems for PCPs, why do they see themselves needing to manage this area when DCs are more qualified and better trained to help?
It simply shows the medical arrogance that they presume to know what’s best when, in fact, they don’t. They just cannot rein in their egos and admit that DCs and SMT have been right all along in the vast majority (70%) of these mechanical cases of LBP. Nor can they let go of this multi-billion dollar industry that fuels the coffers of surgeons and hospitals alike.
So, what are we to make of Deyo’s latest effort to help PCPs better understand the epidemic of LBP? Another slanted opinion based loosely on facts as seen through the lens of a biased medical researcher? Or, is it a veiled attempt to lead the medical profession closer to accepting the fact that most LBP cases are mechanical in nature and best helped with SMT, after a 3-week delay and with mixed blessings? Perhaps this article by Deyo is another attempt to convince MDs that the disk theory is dead, surgery is unwarranted, and to faintly suggest SMT?
I don’t know; you be the judge, but it seems painfully obvious SMT and the chiropractic profession continues to get short shrift from medical investigators, especially those who the NEJM might publish. Being no friend of our profession, the NEJM would never print a favorable article touting the benefits and accolades of the chiropractic profession.
Health care is just too political with too much money at stake to promote a competing profession, just as they will never give credit to homeopaths, naturopaths, or any non-MD professional. The medical paradigm is very limited and apparently incapable of giving credit where credit is due. Despite the evidence-based guidelines from every impartial government inquiry of late, the AMA still rejects their advice and continues to print misleading articles such as Deyo’s in the NEJM.
But, what do I know? I’m just a country chiropractic who can’t believe half what is written about this epidemic of LBP. If it weren’t so serious, some of their comments are downright funny.