Watch Your Back

by Carl Ellenberger, MD

Although this post has little to do with music, the odds are good that some musical readers will find it useful. 

Chronic low back pain is the most common cause of disability and the largest category of medical expenditure in the US healthcare system. The system's response to it is a good example of what is wrong with the system. 

Treatment consumes about $100 billion a year in the US, 9% of total health care costs, not counting the cost of lost work. The fact that more than 200 cures are currently promoted amply shows that only a few can be proven slightly better than no treatment at all -- and only in selected cases.

Most back pain (80-90%) in otherwise healthy people occurs in episodes naturally limited to less than a few weeks that don't need medical attention regardless of severity. When pain remains for more than 3 months, it is called "chronic." That's what we are talking about here. 

If you have had cancer, tuberculosis, HIV, or certain other chronic diseases this doesn't necessarily apply to you. 

In an earlier post I wrote, "...more health problems than you might think can be solved by better understanding than by pills, injections, or surgery." Back pain is one.

So if your back pain is chronic, before having another injection or operation read Watch Your Back by Richard A. Deyo, MD, Professor of Evidence-Based Medicine at Oregon Health and Sciences University who writes with the authority of broad clinical and research experience. Importantly, Deyo does not promote any particular procedure. He writes in a lively style for the general public. 

You may need to revise your thinking about this problem; doing so may change your thinking about other medical problems. Some conventional rules don't apply. For example, when you have pain, you should continue, without fear of harm, the activity that makes it happen, not try to avoid pain by resting. 

A cause in the spine may not be found even by MRI, though if you are an adult, MRI may show more than one abnormality related to normal wear, such as a bulging disk. Know that if you submit to an MRI, you are twice as likely to submit to surgery. If you submit to surgery you are ten times more likely to have more surgery within ten years. Eighty percent of post-operative patients continue to need pain killers, including opioids (aka narcotics), indefinitely.

Deyo argues persuasively that the responsibility for treating low back pain is yours, done by you, not to you, guided by 'providers' who are not invested in what they provide. A typical spinal fusion operation, a current fad done for pain with increasing frequency, distributes its reimbursement of >$100,000 to many "providers" and manufacturers (think $500 screws) but cannot be proved more effective for pain than no treatment at all. Fusion may be necessary to stabilize your spine after an injury. 

Effective treatment involves a long and difficult life-style change but is your best chance of avoiding a lifetime of disability, depression, and reliance on opioids. This treatment changes the "pain module" of the brain, not anatomy of the spine, by means of cognitive-behavioral and exercise therapy. The concept is consistent with new thinking about the brain and its plasticity--the same plasticity that enables learning of a Beethoven sonata and causes dystonia in rare instances.

I hear you saying, "That's easy for you to say, but you haven't experienced the terrible pain that I have every day. It can't be "all in my head." There must be something terribly wrong where it hurts." You're the doctor. Do something! Deyo reminds us that acute pain is a protective sensation to call attention to the location of an injury. When pain becomes chronic, that simple relationship dissolves, the brain continues to falsely signal pain even after the original injury has healed, and the treatment becomes different. It becomes useless to keep trying to repair the original stimulus that created the pain. (That's like changing golf clubs after you have hit a bad shot.) Therapeutic efforts must turn to ways to change networks in the brain, as they must to treat chronic headache or chronic pain anywhere.

So it is not unreasonable to suspect that the epidemic of low back pain in the US has in one sense been created, at least in part, by the health care system. After all, $100,000+ for a back operation provides work and profits for many people, usually excepting the victim of the pain.

Deyo writes:

"...every system is perfectly designed to get the results that it gets. If our health care system generates high costs, promotes ineffective care, and creates avoidable complications, it's because we've inadvertently designed the system to get exactly those results.

In care for back pain, we do this by performing tests when they're unlikely to help and responding to alarming but meaningless results. We do it by prescribing medications and procedures with proven risks but unproven benefits. We do it by by expecting a quick fix from a probe, a pill, or a procedure when real benefits require harder lifestyle changes. We do it with unrealistic expectations of a pain-free life. We do it by responding to financial incentives for more rather than better care. And we do it by ignoring and underfunding the treatments that appear to be most helpful.

For back pain, here are the results: steadily increasing use of imaging tests, opioids, injections, and surgery. Costs that are rising faster than the rest of medical care. And at a population level, worsening patient function and work disability. We've perfectly designed our health care system to produce these results.

It's easier to understand this situation if you remember that the back business is indeed a business. This is the story of too much medical care today. In a for-profit health care system, the first concern is the bottom line rather than the patient's welfare. And too often it follows a business ethos: caveat emptor -- buyer beware."

Full disclosure: I wrote the guideline for use of MRI in low back pain for the American Academy of Neurology in 1994. It recommends limiting MRI to patients who have had pain for over 7 weeks. By then pain has gone in almost 90% of cases. But for some of them knowing for the rest of their lives they have a degenerated, bulging, or herniated disk may not make their lives better. A herniated ("slipped") disk is not like an inguinal hernia. You don't have to repair it.

Addendum, November, 2016: Expert advice from Neurology Today:

After 10 years or more, 44 percent of fusion patients are terribly disabled and are moving onto the Social Security rolls,” he told Neurology Today. “I believe the highest priorities today in back pain are to halt or significantly curtail the use of opioids, stop invasive procedures, and develop protocols for cognitive behavioral therapy and graded exercise.” 

An emerging body of evidence points to coordinated, multidisciplinary rehabilitation focused on teaching patients how to better cope with their pain through cognitive-behavioral therapy, meditation, and other mindfulness techniques, Dr. Franklin said. Programs that combine active physical therapy with cognitive-behavioral therapy have the potential to change how back pain is treated, he said.