The following is a reader take by Ronald Donelson.
I am an orthopedic surgeon who has specialized in and researched the evaluation and non-operative care of low back and neck pain, first in private practice and then for ten years in an academic tertiary spine institute.
For you clinicians who treat patients with acute low back pain (LBP), do you follow clinical guideline recommendations to simply encourage patients to remain active while reassuring them that their pain will likely go away soon? Or do you find most patients seek more care than that and you want/need to provide more?
Meanwhile, most clinicians are unaware of the disparity between what LBP clinical guidelines recommend and what has actually been published in the peer-review literature. Despite claiming to be evidence-based, most guidelines are developed by consensus using a literature review limited to what seems most relevant to panelists’ collective understanding of LBP. The resulting guideline is based on an incomplete literature review resulting in substantial clinician non-compliance and highly variable, often ineffective, sometimes harmful, and frequently very expensive care.
One of the more glaring guideline omissions is the evidence that establishes that most LBP is actually rapidly reversible, i.e. it recovers quickly, and turns out to be fairly simple to treat. Learning how to identify this large reversible subgroup is the first step in helping these individuals speed their recovery/reversal. A unique form of clinical evaluation reveals characteristics of the reversible pain source that guides patients in successfully self-treating by using pain-eliminating exercises and posture modifications.
Unmentioned by guidelines are the multiple studies reporting high inter-examiner reliability for both conducting and interpreting this unique clinical examination and at least eight cohort studies and four randomized clinical trials that all report that these recoveries in this large subgroup occur much faster and more frequently using these patient-specific treatments. This rapidly reversible LBP subgroup is very large, including 70-89% of acute, 50% of chronic LBP, as well as 50% of those with LBP-only or sciatica, even with neural deficits.
Also overlooked are three studies of those determined to be candidates for disc surgery who only then underwent this unique evaluation. Rapidly reversible LBP was found in 32-52%. One study of patients with sciatica and neural deficits who were felt to be disc surgery candidates reported that 52% (N=67) turned out to have a rapidly reversible problem. Every patient (N=34) completely recovered within five days using pain-eliminating exercises identified by their examination findings.
So it is likely that 50% of today’s lumbar disc surgeries (discectomies, fusions, disc replacements) are not only unnecessary, but rapid recoveries are likely, easy, and inexpensive. This only happens however if clinicians and payers are informed about rapidly reversible LBP how easy and inexpensively it can be identified and treated.
Unfortunately, most researchers and guidelines continue to focus on the nearly useless research question: “What is the best treatment for non-specific LBP?” …. an unvalidated diagnosis. We don’t have guidelines focused on chest pain or abdominal, elbow or ankle pain. So how do we justify our persistent focus on non-specific LBP and one-size-fits-all treatments when we can reliably identify subgroups that then have superior outcomes using subgroup-specific treatments?
Meanwhile, millions undergo unnecessary, even detrimental, tests and treatments that push the U.S. LBP cost to an estimated $80-90 billion per year.
Although the context and politics of this topic are complex, the scientific evidence validating rapidly reversible low back pain is substantial and the economic and quality of care implications are immense.
Ronald Donelson is an orthopedic surgeon and author of Rapidly Reversible Back Pain.
Related posts:
- Who monitors clinical guidelines?
- The race to set definitive guidelines
- Pain wars
- Are American guidelines driving up health care costs?
- Overtreating pain
- Chronic pain and the troops
- Chronic pain
{ 15 comments }
Dr. Donelson,
I have not read your book, but I will be doing so. I am curious as to your reaction to Dr. John Sarno’s work and book(s).
And to Kevin MD – thank you for supporting this contribution on your site.
mem
References?
Interesting take, but you have to buy the book to find out more.
A unique form of clinical evaluation reveals characteristics of the reversible pain source that guides patients in successfully self-treating by using pain-eliminating exercises and posture modifications.
Sounds too good to be true.
Doesn’t mean it isn’t, but doesn’t the fact that it’s being promulgated via a self-published book (available on Amazon and Barnes&Noble, among others) instead of the peer-reviewed literature render it somewhat suspect?
Dr. Donelson,
does your book have any information about chronic neck pain?
Dr. Donelson, You assume that most clinicians jump to expensive tests and surgery for back pain. I beleive we are all doing the best that we can in a murky field with no specific treatment modalities that have been proven to be better than another. You seem to have some magic answer…but after reading your post I am no better off as a treating doctor than I was before. I keep up with all of the literature on treatments for LBP and use body work, home exercises and PT whenever possible. What is your magic bullet?
This reads like a teaser on the inside cover of a book jacket. Kevin, I’m surprised this passed your smell test. It’s obviously self-promotion that provides no specific information whatsoever to either practitioners or patients. Please don’t follow this up with similar pieces.
Excellent contribution. I am no expert on back pain except to say that I had an acute episode 13 years ago, undergoing a disc laminectomy. Following the surgery I was fairly disabled for a month or so. Once recovered I continue to have episodes of pain.
Seems to me that 20 bucks is probably less than one office visit or co pay and much less than a presccription for pain medications.
Peer reviewed articles in my mind are overly complex, take a lot of time and effort to publish and unless one is an academic absorb too much effort. An authored book by a competent professional reaches more people. Why is it some feel than authoring a book and selling it is worthless? One can read it and always reject the information. If I believed and practiced everything I read in a journal. I make my own judgments.
Thanks Kevin….I will give up two Starbucks and buy this book.
“I have a simple test to revolutionize LBP care… so buy my book and find out about it” is generally not the way medical research works. That is the sort of approach one expects to see used by purveyors of “the natural cure for all cancer” and energy magnets. Yeesh.
This poster sounds like a real winner. In case he didn’t know, most patients who come in with LBP have actually had it for YEARS! Yeah, we all know the statisitcs about 80% of LBP going way on its own, blah blah blah. They mention thaqt day one of med school (well, maybe day 151, but whatever). These paitnets I see describe RECURRING back pain that is getting WORSE. They all have a history of MVA’s or TRAUMA. The exams are often negative for SLR or spasm. What do you thin kthen, pAL? UIs MRI okay THEN? Are you one of these CAre Core nurses who act as a barrier to getting the test?
“Most clincians…” Give me a break. Its all so vague. And just like Tony Brayer says above.. you seem to have the “magic answer” in your book.
And Health Trai nExpress.. are you a physicina? Because I don’t understand your post. Are you saying your surgeon scammed you b/c your back pain returned?
As someone who has actually READ the book, I feel I can make an intelligent comment on this post. Before you pooh-pooh it, know that Dr. Donelson is not promoting anything HE has invented, nor for which he recieves financial resistution. The book, rather, is a critcial analysis of the literature regarding the treatment of low back pain and forces the reader to make a critical judgement about past randomized controled trials (and even those that aren’t RTCs). His arguement rests mostly on the fact that most RTCs are putting the proverbial cart before the horse as they invesitage techniques and treatments that have yet to establish any relaibility or validity. The discussion of the lack of the A-D (assessment diagnosis link) is being skipped to review the T-O (treatment-outcome link) in so many RTCs is the highlight of his criticism of past literature. He establishes how the MDT paradigm has studied vigerously the A-D link in order to improve the T-O link. Furthermore, he discusses how a good mechanical assessment as directed by the MDT paradigm (of which he is not the creator) has shown such reliability and constuct validity, yet it is frequently overlooked by the healthcare community for other flashier and lucractive treatments and procedures. He discusses the power of the predictive validity of outcomes when the MDT assessment is used.
Dr. Donelson is an orthopedic surgeon who discovered that the vast majority of the patients he sent to physical therapy that, when seen by a practicioner by the name of Greg Silva (who is a diplomate of the MDT program), rarely needed surgery. Furthermore, when he discovered that those seen by Silva were deemed to have an “irreducible derrangement” (a classification that is thought to not be appropriate for conservative treatment) that THOSE people did remarkably well with surgery as compared to those who did not see an MDT credentialed provider. He has now dedicated a great portion of his time to the conservative treatment of low back pain. To this day, he still participates in high quality studies.
I have read some of them, as well as many others by other MDT invetigators such as Werneke, Long, May, etc.
ChristieD, you just gave us more information in your comment than the good doctor did in his entire post! If he had at least given an overview of his content, he would have presented himself with a modicum of credibility.
Mike: Wondering if you are a physician and what specialty. No my comment was not meant to disparage anyone and certainly not my neurosurgeon. When I say I was disabled it was because I could not comfortably sit on a stool to operate and/or see patients in my opthalmology practice…. Generalizing is a dangerous habit, and yes most books on “alternative health” are scams, this one is farily well researched.
I looked at your blog, interesting,
check mine out at http://healthtrain.blogsot.com
Gary L
Ten days ago, a “Reader Take” I authored was posted entitled “Rapidly Reversible Low Back Pain”. Unfortunately, the final attribution failed to state the title of the book I was referencing: “Rapidly Reversible Low Back Pain. An Evidence-Based Pathway To Widespread Recoveries and Statements”. It wasn’t until today that I realized my submission was posted back on May 5 and so I also missed everyone’s subsequent comments. They are greatly appreciated and I apologize for not responding to them.
The wide range of responses was not at all surprising. It’s impossible to write for such a broad audience on such a big topic in just 600 words. With that in mind, it had to be a teaser, obviously offensive for some, to promote the reading of my book. Skepticism is understandable but it is the message in the book that is important. Someone posted that they had already read it and were extremely complementary.
None of the many invited or peer-reviewed research articles I’ve authored over the past 20 years have ever done this topic justice, and they were all much longer than my short posting on this blog. The story of rapidly reversible LBP was just too big, too important, and too fascinating to leave unwritten.
There’s no magic bullet here, but what is not being reported in current consensus-based LBP clinical guidelines that is nevertheless strongly evidence-based will surprise you. The realization that most LBP is rapidly reversible, and how to make that happen, is, or will be, revolutionizing back care around the world. But progress is so slow, so the question is: how can we make such a good thing happen sooner?
An insightful book review has just been published in the Journal of Family Medicine by Joel Heidelbaugh, an academic family practitioner at U. of Mich. The review can be quickly read at the following link by scrolling down the Table of Contents to the book reviews: http://www.stfm.org/fmhub/fm2008/toc.cfm?xmlFileName=fammedvol40issue5.xml
Other published reviews are posted at: http://www.selfcarefirst.com.
I trust this information will be helpful to each of you, and especially to your LBP patients. If it is, perhaps you can help disseminate this “good news” message to your colleagues.
Thanks everyone,
Ron Donelson, MD, MS
Dear Dr. Donelson,
I was very estatic to see your reader take on the Kevin, MD medical weblog. I got a link to this from another physical therapy blogsite. Ironically, most of them happen to be manual therapists while I seem to be the only MDT credentialed therapist on that site. Yet, they recognized your take as a very informative post. While I am not sure if they knew you were a proponent of the MDT paradigm, I was elated to see that they have a link to further investigate, and I hope some of those manual therapists read your book. I am sure you have probably realized the “tension” that exists between the MDT therapy community and the “manual therapy” community. Perhaps this is part of the reason that the APTA fails to recognize the reliability and efficacy of MDT, since the APTA is largely dominated by FAAOMPT and AAOMPT manual therapists. (In the meantime, a survery done by the APTA found that members found Robin McKenzie to be one of the greatest contributor to our profession…yet they still ignore his work)
Your work has done much to further validate and progress our treatment/assessment approaches. If you consider that at the HEART of physical therapy that we are trying to establish increased funciton and, most importantly, INDEPENDENCE, that MDT most accurately compliments our mission. While hands-on, manual technqiues are sometimes needed (even in the MDT approach), when they are used as a first line of defense and without demonstrating to the patient that they, themselves, have the power to reduce or eliminate their pain WITHOUT US or how to PREVENT pain seriously undermines the core of our profession. While it is often hard when patients come into the clinic “expecting” hands on procedures, to be able to show someone that THEY are in control of their problem is a powerful tool. This is where our profession ought to focus…or else we just ought become massage therapists, personal trainers or chiropractors.
Having had an entry level education that focued on manual therapy, I can only wish that I could go back in time and start over with the MDT courses rather than wasting the first several years of my profession trying to perfect palpation and joint specific mobilization which is now show to have a negative kappa value. I wish I could take back all the ultrasounds, electrical stimulation, myofascial releases, “joint specific mobs” and core stabilizations I did; and when they didn’t work, that I said that their condition just dictated that physical therapy was not for them. Why we don’t teach MDT at the entry level is beyond me. As a PT educator myself who is set to enter the Dip. program this summer, I hope to change that.
Thank-you for your tremendous work.
Christie
Hi There,
Great to see someone else promoting this amazing book. I have read Rapidly Reversible Back Pain at least twice. An easy read and so informative that I could harder put it down.
It is true what Ron says that despite all the money spent on research an answer for back pain is no closer.
Yep, there are lots of references of journal articles in the index of the book.
His suggestion for patients to seek a McKenzie mechanical assessment is essential for anyone suffering from muscle or joint pain that has not responded to previous treatment or for people who are looking to take control of their problem. Most people can learn how to treat their own back or neck and understand how to stop it from coming back.
Sandra McFaul
McKenzie Physiotherapist – advanced level
http://www.herniateddiscguide.com
http://www.ataphysiotherapy.com.au
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